Nokea
The nurse is caring for a client with a history of a fractured humerus who is in a sling. The nurse should:
- A. Apply ice to the fracture site
- B. Encourage active range of motion
- C. Keep the arm in a dependent position
- D. Massage the arm daily
Correct Answer: A
Rationale: Ice reduces swelling and pain at the fracture site. Active motion is limited, dependent positioning increases swelling, and massage is not recommended.
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The nurse is removing a peripherally inserted central catheter (PICC). The nurse should position the patient in which position?
- A. Fowlers
- B. Right side lying
- C. Left side lying
- D. Trendelenburg
Correct Answer: D
Rationale: Trendelenburg position (head down) is used when removing a PICC line to reduce the risk of air embolism by increasing venous pressure. Fowler’s, right, or left side-lying positions do not provide this protection.
The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?
- A. Monitor fetal heart tones
- B. Administer tocolytics
- C. Place the client in Trendelenburg position
- D. Administer antibiotics
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being. Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.
A client with AIDS has impaired nutrition due to diarrhea. The nurse teaches the client about the need to avoid certain foods.
- A. Tossed salad
- B. Baked chicken
- C. Broiled fish
- D. Steamed rice
Correct Answer: A
Rationale: Raw foods like tossed salad (A) can harbor pathogens, risky for AIDS patients with diarrhea. Baked chicken (B), broiled fish (C), and steamed rice (D) are cooked and safer, indicating further teaching is needed for A.
An expected response to sodium polystyrene sulfonate (Kayexalate) is:
- A. Increase in serum magnesium
- B. Increase in serum HCO3
- C. Decrease in serum potassium
- D. DecreaseWhole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding.
- E. Platelets
- F. Fresh frozen plasma
- G. Packed red blood cells
Correct Answer: A
Rationale: Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding.
A client is admitted to the emergency department with a loss of consciousness with unknown etiology. The nurse expects to perform which laboratory test to assist in determining etiology?
- A. Total cholesterol
- B. Alkaline phosphatase
- C. Serum glucose
- D. Urinalysis
Correct Answer: C
Rationale: Serum glucose is critical to rule out hypoglycemia or hyperglycemia as causes of unconsciousness. Cholesterol (A), alkaline phosphatase (B), and urinalysis (D) are less urgent.