Nokea
The nurse is caring for an adolescent client who just had placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions should the nurse expect to implement when caring for this client? Select all that apply.
- A. Check the pins every 4 hours and turn the bolt clockwise to tighten loose pins
- B. Maintain client on bed rest until the device is removed
- C. Notify the registered nurse immediately of pin site drainage or increased pain
- D. Perform neurovascular checks every 2-4 hours for 24 hours
- E. Perform sterile pin care per institutional policy
Correct Answer: C,D,E
Rationale: Notifying the RN of drainage or pain, performing neurovascular checks, and sterile pin care prevent complications like infection or neurovascular compromise. Tightening pins is not a nursing task, and bed rest is not always required, depending on the care plan.
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The charge nurse has a health care team that consists of 1 practical nurse (PN), 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?
- A. An admission at the change of shifts with atrial fibrillation and heart failure - PN
- B. Client who had a major stroke 6 days ago - PN nursing student
- C. A child with burns who has packed cells and albumin IV running - charge nurse
- D. An elderly client who had a myocardial infarction a week ago - UAP
Correct Answer: A
Rationale: The care for a new admission should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established.
The most suitable diet for the client with Meniere's disease is:
- A. High in animal protein
- B. Restricted in sodium
- C. High in fat-soluble vitamins
- D. Restricted in complex carbohydrates
Correct Answer: B
Rationale: A low sodium diet and nicotinic acid have been shown to be effective in reducing the symptoms of Meniere's disease. Answers A, C, and D are incorrect because they do not relieve the symptoms of Meniere's disease.
Medication bound to protein can have which of the following effects?
- A. enhancement of drug availability
- B. rapid distribution of the drug to receptor sites
- C. less availability to produce desired medicinal effects
- D. increased metabolism of the drug by the liver
Correct Answer: C
Rationale: Protein-bound drugs are less available for receptor binding, reducing their therapeutic effect until unbound. This does not enhance availability, speed distribution, or increase metabolism directly. Pharmacological Therapies
The practical nurse is caring for a client with newly diagnosed infective endocarditis. Which assessment finding by the nurse is the most concerning?
- A. Pain and pallor in one foot
- B. Pain in both knees
- C. Splinter hemorrhages in the nail beds
- D. Temperature of 38.2°C (100.8°F)
Correct Answer: A
Rationale: Pain and pallor in one foot suggest an embolic event, a serious complication of infective endocarditis that could lead to tissue ischemia or infarction, requiring urgent intervention. Knee pain, splinter hemorrhages, and mild fever are less immediately threatening.
The nurse is talking with the family of an 18 months-old newly diagnosed with retinoblastoma. A priority in communicating with the parents is
- A. Discuss the need for genetic counseling
- B. Inform them that combined therapy is seldom effective
- C. Prepare for the child's permanent disfigurement
- D. Suggest that total blindness may follow surgery
Correct Answer: A
Rationale: Discuss the need for genetic counseling. The hereditary aspects of this disease are well documented. While the parents focus on the needs of this child, they should be aware that the risk is high for future offspring.