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The nurse is caring for a client with a long leg cast on his right leg. The nurse notes that the right foot is pale and cool to the touch, and the client continues to complain of pain even though an analgesic was administered 45 minutes ago. What is the FIRST action the nurse should take?
- A. Apply a heating pad to the client's right toes.
- B. Repeat the dose of the analgesic stat.
- C. Remove the cast immediately.
- D. Notify the physician immediately.
Correct Answer: D
Rationale: Pale, cool skin and persistent pain suggest compartment syndrome, requiring immediate physician notification. Options A, B, and C are unsafe.
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A woman is seen in clinic with complaints suggesting cholecystitis or cholelithiasis. What teaching should the nurse expect to reinforce?
- A. Sit up after you eat.
- B. Avoid carbonated beverages.
- C. Avoid caffeine.
- D. Avoid fatty foods.
Correct Answer: D
Rationale: Fatty foods trigger gallbladder contraction, worsening pain in cholecystitis or cholelithiasis; avoiding them reduces symptoms. Sitting up, carbonated drinks, or caffeine are less critical.
Which of the actions suggested to the registered nurse (RN) by the practical nurse (PN) during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?
- A. Measure head circumference
- B. Place in airborne isolation
- C. Provide passive range of motion
- D. Provide an over-the-crib protective top
Correct Answer: A
Rationale: Measure head circumference. This monitors for complications like hydrocephalus in meningitis.
The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision.
- A. Which behavior by the LPN/LVN indicates proper wet-to-dry dressing change technique?
- B. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- C. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- D. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- E. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Packing wet gauze into the incision without overlapping onto the skin prevents skin breakdown from prolonged moisture exposure. Cleansing should be from the center outward, dressings should be pre-soaked, and old dressings are removed dry to debride the wound.
The nurse is caring for a client with a history of hyponatremia.
- A. Which intervention is most appropriate for a client with hyponatremia?
- B. Administer hypertonic saline slowly.
- C. Encourage a low-sodium diet.
- D. Restrict fluid intake.
- E. Administer a diuretic.
Correct Answer: A
Rationale: Administering hypertonic saline slowly corrects hyponatremia by raising serum sodium levels, preventing cerebral edema. Low-sodium diets worsen hyponatremia, fluid restriction is for hypervolemic cases, and diuretics are contraindicated.
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range for heparin (60–80 seconds), increasing bleeding risk, requiring immediate adjustment. Options B, C, and D are normal: INR is unaffected, platelet count 150,000/mm^3 is adequate, and hemoglobin 13 g/dL is normal.