Nokea
The nurse is caring for a client with a history of a fractured femur who is in a cast. The client complains of swelling. The nurse should:
- A. Apply ice to the cast
- B. Elevate the leg
- C. Massage the leg
- D. Notify the physician immediately
Correct Answer: B
Rationale: Elevating the leg reduces swelling in a casted femur by improving venous return. Ice is helpful, massage is contraindicated, and notification is needed if swelling persists.
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Nursing assessment of early evidence of septic shock in children at risk includes:
- A. Fever, tachycardia, and tachypnea
- B. Respiratory distress, cold skin, and pale extremities
- C. Elevated blood pressure, hyperventilation, and thready pulses
- D. Normal pulses, hypotension, and oliguria
Correct Answer: A
Rationale: Fever, tachycardia, and tachypnea are the classic early signs of septic shock in children. Respiratory distress, cold skin, and pale extremities are later signs of septic shock. Elevated blood pressure, hyperventilation, and thready pulses are later signs of septic shock. Normal pulses, hypotension, and oliguria are not early signs of septic shock.
The client is prescribed methotrexate for rheumatoid arthritis. Which instruction should the nurse include?
- A. Take the medication with milk to prevent stomach upset.'
- B. Report any signs of infection immediately.'
- C. Avoid exposure to sunlight.'
- D. Take the medication only when joint pain is severe.'
Correct Answer: B
Rationale: Methotrexate causes immunosuppression, increasing infection risk, so reporting signs of infection is critical. Milk does not prevent GI upset, photosensitivity is not a primary concern, and methotrexate is taken regularly, not as needed.
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
- A. Must use the least restrictive measure possible to control the behavior
- B. Should put the client in seclusion until he promises to behave appropriately
- C. Should apply full restraints until the behavior is under control
- D. Should allow other clients to observe the acting out so that they can learn from the experience
Correct Answer: A
Rationale: This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take 'time-out' before placing the client in seclusion, giving medication as necessary, or restraining. This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D Seniors) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting-out behaviors.
The client is admitted to the intensive care unit following a coronary artery bypass graft. The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure of 70/40, and respiration of 32 breaths per minute. The nurse suspects hypovolemic shock. Which assessment tools would contribute to a diagnosis of hypovolemic shock?
- A. Hemoglobin of 5 g
- B. Central venous pressure of 2 mm of mercury
- C. Pulmonary artery wedge pressure of 16 mm of mercury
- D. Hematocrit of 22%
- E. Troponin (T 1) level of 4 mcg/L
Correct Answer: A, B, D
Rationale: Hypovolemic shock involves low blood volume, reflected by low hemoglobin (5 g, A), low central venous pressure (2 mmHg, B), and low hematocrit (22%, D). Normal pulmonary artery wedge pressure (16 mmHg, C) suggests no left heart failure. Elevated troponin (E) indicates myocardial damage, not volume status.
The nurse is caring for a client with acquired immunodeficiency syndrome. Which finding should be reported to the doctor immediately?
- A. Temperature of 100.2°F
- B. White patches on the tongue
- C. Weight loss of 10 pounds
- D. Respiratory rate of 26 breaths per minute
Correct Answer: D
Rationale: A respiratory rate of 26 breaths per minute suggests respiratory distress, a critical issue in AIDS due to possible opportunistic infections like Pneumocystis pneumonia, requiring immediate reporting.