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.
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The nurse suspects that a child may have ingested a caustic substance. Which comment by the child would be of greatest concern to the nurse?
- A. Ask the child if the mouth is burning or throat pain is present.'
- B. I feel sleepy and my stomach hurts.'
- C. My tongue feels funny and I’m thirsty.'
- D. Has the child had vomiting, diarrhea or stomach cramps?'
Correct Answer: A
Rationale: Local irritation of tissues indicates a corrosive poisoning. Burning in the mouth or throat pain suggests ingestion of a caustic substance, requiring immediate attention.
A patient asks a nurse the following question. Exposure to TB can be identified best with which of the following procedures? Which of the following tests is the most definitive of TB?
- A. Chest x-ray
- B. Mantoux test
- C. Breath sounds examination
- D. Sputum culture for gram-negative bacteria
Correct Answer: B
Rationale: The Mantoux is the most accurate test to determine the presence of TB.
After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is
- A. abdominal x-ray
- B. auscultation
- C. flushing tube with saline
- D. aspiration for gastric contents
Correct Answer: A
Rationale: abdominal x-ray. Placement should be verified by radiograph to determine that the tube is in the stomach or intestine rather than in the airways.
The nurse is teaching the client with a latex allergy about home and personal safety. Which information should the nurse emphasize? Select all that apply.
- A. Remove items in the home made from synthetic materials.
- B. Keep emergency telephone numbers readily accessible.
- C. Have someone remove any latex balloons and rubber bands.
- D. Avoid foods such as kiwi, bananas, avocados, and chestnuts.
- E. Certain plants, such as poinsettia plants, help remove allergens.
Correct Answer: B,C,D
Rationale: B: Emergency numbers are critical for anaphylaxis. C: Latex items like balloons and rubber bands must be removed to avoid exposure. D: Certain foods can trigger cross-reactive allergic reactions. A and E are incorrect as synthetic materials are safe, and poinsettias can cause reactions.
The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?
- A. hepatitis A
- B. hepatitis B
- C. hepatitis C
- D. hepatitis D
Correct Answer: A
Rationale: Hepatitis A does not produce a carrier state. It is transmitted via contaminated water or food via the oral-fecal route and is not blood borne.