Nokea
The nurse is caring for a client with a newly applied plaster cast. The nurse should
- A. Use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable.
- B. Expedite drying by using a hot blow dryer on the cast.
- C. Let the cast hang below the heart to promote blood flow.
- D. Handle the cast with the palms of the hands.
Correct Answer: D
Rationale: Handling a wet plaster cast with the palms prevents denting, which could cause pressure points. Scratching inside risks skin damage, hot dryers can burn, and a dependent position increases swelling.
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The nurse is caring for a client in Buck traction. The nurse plans on elevating the head of the bed to
- A. 15 degrees.
- B. 90 degrees.
- C. 60 degrees.
- D. 45 degrees.
Correct Answer: A
Rationale: Elevating the head to 15 degrees maintains alignment in Buck traction while allowing comfort. Higher angles (60 or 90 degrees) may disrupt traction, and 45 degrees is less optimal.
A nurse is caring for a client admitted to the emergency department with suspected rhabdomyolysis. Which of the following findings would the nurse anticipate in a client with this condition?
- A. Elevated creatinine kinase (CK) levels
- B. Decreased serum potassium levels
- C. Hypertension and bradycardia
- D. Clear urine output
Correct Answer: A
Rationale: Rhabdomyolysis causes muscle breakdown, releasing creatinine kinase (CK) into the blood, elevating levels. Potassium levels typically rise, blood pressure and heart rate vary, and urine is dark from myoglobin.
A nurse is caring for a client who recently had a cast placed on their right lower extremity. Which statement from the client should be of the greatest concern to the nurse?
- A. I've been having pain in my right calf.'
- B. My right leg feels really itchy.'
- C. I have not been keeping my leg elevated while in bed.'
- D. My hands and arms support my body weight while using crutches.'
Correct Answer: A
Rationale: Pain in the calf may indicate compartment syndrome or deep vein thrombosis, both serious complications requiring urgent attention. Itching is common, elevation is helpful but less urgent, and crutch use is expected.
The nurse is caring for a client diagnosed with osteomalacia. The nurse is correct in characterizing osteomalacia as
- A. Bone softening from insufficient levels of vitamin D.
- B. Invasion of bacteria into the bone.
- C. Decreased bone mass caused by a deficiency of calcium.
- D. A bone fracture caused by minimal trauma.
Correct Answer: A
Rationale: Osteomalacia is bone softening due to inadequate vitamin D, impairing calcium absorption and mineralization. Bacterial invasion is osteomyelitis, decreased bone mass is osteoporosis, and minimal trauma fractures are not osteomalacia.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 17-year-old male client.
Item 1 of 1
History and Physical
1722: The client has had an external fixation on the left wrist for the past two weeks. Today, he noticed swelling, increased pain, fever, and reports purulent drainage from the pin sites. The client reports poor adherence to performing pin care at home. On exam, the client is febrile and has an oral temperature of 103.4° F (39.7° C). The left wrist is erythemic, swollen, and tender to the touch.
The nurse has reviewed the history and physical. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
- A. Obtain a prescription for an antibiotic
- B. Culture the pin sites
- C. Apply a pressure dressing over the pins
- D. Obtain a prescription for analgesia
- E. Position the client's wrist so it is extended
Correct Answer: A: Indicated, B: Indicated, C: Not Indicated, D: Indicated, E: Not Indicated
Rationale: A: Antibiotics treat infection suggested by fever and drainage. B: Cultures identify the organism. C: Pressure dressings may damage pins or tissue. D: Analgesia addresses pain. E: Extension may worsen swelling and pain.