Nokea
The nurse is caring for a client with a suspected fractured hip. Which intervention is most appropriate?
- A. Encourage ambulation to promote healing.
- B. Apply a warm compress to reduce pain.
- C. Immobilize the leg to prevent further injury.
- D. Administer aspirin for pain relief.
Correct Answer: C
Rationale: Immobilizing the leg prevents further injury and displacement in a suspected hip fracture. Amb
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The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
- A. Reduce his anxiety
- B. Avoid going to psychotherapy
- C. Manipulate the health team members
- D. Increase his self-image by showing higher standards than the fellow clients
Correct Answer: A
Rationale: These behaviors are attempts to relieve anxiety, as compulsive actions often serve as a coping mechanism for severe anxiety.
A 2-year-old toddler is hospitalized with epiglottitis. In assessing the toddler, the nurse would expect to find:
- A. A productive cough
- B. Expiratory stridor
- C. Drooling
- D. Crackles in the lower lobes
Correct Answer: C
Rationale: A productive cough is not associated with epiglottitis. Children with epiglottitis seldom have expiratory stridor. Inspiratory stridor is more common due to edema of the supraglottic tissues. Because of difficulty with swallowing, drooling often accompanies epiglottitis. Crackles are not heard in the lower lobes with epiglottitis because the infection is usually confined to the supraglottic structures.
The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?
- A. Administer epinephrine
- B. Start an IV fluid bolus
- C. Place the client in Trendelenburg position
- D. Administer oxygen via nasal cannula
Correct Answer: A
Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.
During burn therapy, morphine is primarily administered IV for pain management because this route:
- A. Delays absorption to provide continuous pain relief
- B. Facilitates absorption because absorption from muscles is not dependable
- C. Allows for discontinuance of the medication if respiratory depression develops
- D. Avoids causing additional pain from IM injections
Correct Answer: B
Rationale: IM injections are unreliable in burn patients due to fluid shifts into interstitial spaces, leading to poor absorption. IV administration ensures dependable absorption and effective pain relief.
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Reporting any signs of crepitus immediately to the physician
- D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery. To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.