Nokea
The nurse is caring for a client with a newly applied long leg cast. Which of these actions should the nurse take first to prevent complications from the cast?
- A. Check pedal pulses bilaterally
- B. Elevate the leg on pillows
- C. Apply ice to the cast
- D. Instruct the client to wiggle toes hourly
Correct Answer: A
Rationale: Checking pedal pulses bilaterally is the first action to ensure adequate circulation and detect potential complications like compartment syndrome early.
You may also like to solve these questions
The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments?
- A. Focus on the child's needs and recovery
- B. Explain the cause of the child's illness
- C. Acknowledge that early care would have been better
- D. Accept their feelings without judgment
Correct Answer: D
Rationale: Accept their feelings without judgment. Parents often blame themselves for their child's illness. Feeling helpless and angry is normal and these feelings must be accepted.
The nurse confides to a coworker that when reporting a change in the client's condition to the HCP, the HCP stated, "It seems that every time you work, there is some catastrophe. Can't you problem-solve earlier so this doesn't happen!" What is the coworker's best response?
- A. "This HCP responds to everyone the same. You did everything right; don't feel bad."
- B. "You should obtain our hospital policy and initiate the steps to report the HCP."
- C. "Let the nurse manager know; I think our manager is already dealing with the HCP."
- D. "Let's go to the medical director, who should be told about this HCP's angry response."
Correct Answer: B
Rationale: Reporting the HCP's uncivil behavior per hospital policy is the best response to address and document the issue appropriately.
A patient has experienced a severe third degree burn to the trunk in the last 36 hours. Which phase of burn management is the patient in?
- A. Shock phase
- B. Emergent phase
- C. Healing phase
- D. Wound proliferation phase
Correct Answer: A
Rationale: The shock phase is considered the first 24-48 hours in burn wound management.
A client states, 'People think I'm no good, you know what I mean?' Which of these responses would be most therapeutic?
- A. Well people often take their own feelings of inadequacy out on others.'
- B. I think you're good. So you see, there's one person who likes you.'
- C. I'm not sure what you mean. Tell me a bit more about that.'
- D. Let's discuss this to see the reasons you create this impression on people.'
Correct Answer: C
Rationale: I'm not sure what you mean. Tell me a bit more about that.' This therapeutic communication technique elicits more information, especially when delivered in an open, non-judgmental fashion.
A power outage occurs at a hospital, and a backup generator supplying power to a telemetry unit fails. After obtaining a flashlight, what is the nurse's next best action?
- A. Call the nursing supervisor
- B. Assess the most critically ill clients
- C. Obtain oxygen tanks for clients on oxygen
- D. Delegate which clients the NA should monitor
Correct Answer: C
Rationale: Obtaining oxygen tanks is the priority, as room oxygen sources fail during a power outage, and clients on oxygen are at immediate risk.