Nokea
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient’s left leg is externally rotated. The nurse should
- A. place a trochanter roll on the outer aspect of the thigh.
- B. perform resistive range of motion of the left leg.
- C. adduct and internally rotate the left leg.
- D. instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee
You may also like to solve these questions
The nurse has just received the change of shift report. Which client should the nurse assess first?
- A. A client with a supratentorial tumor awaiting surgery
- B. A client admitted with a suspected subdural hematoma
- C. A client recently diagnosed with akinetic seizures
- D. A client transferring to the neuro rehabilitation unit
Correct Answer: B
Rationale: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment to prevent deterioration.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed?
- A. The child is placed in a private room.
- B. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- D. The staff uses standard precautions.
Correct Answer: A
Rationale: contact precautions required for diapered or incontinent clients
An 18-month-old is being discharged following hypospadias repair. Which instruction should be included in the nurse's discharge teaching?
- A. The child should not play on his rocking horse.
- B. Applying warm compresses will decrease pain.
- C. Diapering should be avoided for 1-2 weeks.
- D. The child will need a special diet to promote healing.
Correct Answer: A
Rationale: Avoiding straddling activities like rocking horses prevents strain on the surgical site post-hypospadias repair.
The nurse is caring for a client receiving Capoten (captopril). The nurse should be alert for adverse reactions to the drug, which include:
- A. Increased red cell count
- B. Decreased sodium level
- C. Decreased white cell count
- D. Increased calcium level
Correct Answer: C
Rationale: Captopril, an ACE inhibitor, can cause agranulocytosis, leading to a decreased white cell count, which should be monitored.
A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is to:
- A. Check the blood pressure
- B. Monitor the temperature
- C. Evaluate the urinary output
- D. Check the specific gravity of the urine
Correct Answer: A
Rationale: Blood pressure monitoring is critical post-adrenalectomy, as the adrenal gland regulates blood pressure through hormone production, and surgery may cause instability.