Nokea
The nurse is caring for the client involved in an MVA who sustained an unstable pelvic fracture. Which HCP order should be the nurse's priority?
- A. Urinalysis and culture and sensitivity
- B. Blood alcohol level and toxicology screen
- C. Computed tomography (CT) scan of the pelvis
- D. Give two units of cross-matched whole blood
Correct Answer: D
Rationale: D. Significant blood loss occurs because the pelvis is a highly vascular area. A type and cross-match must be completed prior to administering blood, which takes time.
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Which antiepileptic medication is associated with gingival hyperplasia?
- A. Gingival hyperplasia (overgrowth of gum tissue) is unique to phenytoin (Dilantin) among antiepileptic medications. About 20% of people taking phenytoin have gingival hyperplasia. This can be minimized with thorough oral care.
- B. Valproic acid (Depakote) does not have a side effect of gingival hyperplasia.
- C. Gingival hyperplasia is not a side effect of carbamazepine (Tegretol).
- D. Gingival hyperplasia is not a side effect of phenobarbital (Luminal).
Correct Answer: A
Rationale: Phenytoin (Dilantin) is uniquely associated with gingival hyperplasia, which can be mitigated with good oral hygiene.
The client, who is diagnosed with CA, tells the clinic nurse about the inability to ambulate and about staying on bedrest due to hip stiffness. In addition to teaching the client measures to reduce joint stiffness, which referral for the client should the nurse plan to discuss with the HCP?
- A. Psychiatrist
- B. Social worker
- C. Physical therapist
- D. Arthritis Foundation
Correct Answer: C
Rationale: C. The nurse should plan to discuss a referral to a physical therapist (PT). The PT can assist the client in adopting self-management strategies and teach isometric, postural, and aerobic exercises that prevent joint overuse.
The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively?
- A. Keep an abduction pillow in place between the legs at all times.
- B. Cough and deep breathe at least every four (4) to five (5) hours.
- C. Turn to both sides every two (2) hours to prevent pressure ulcers.
- D. Sit in a high-seated chair for a flexion of less than 90 degrees.
Correct Answer: A
Rationale: An abduction pillow prevents hip dislocation post-THR, a critical complication. Coughing, turning, and chair positioning are important but secondary.
The occupational health nurse is planning health promotion activities for a group of factory workers. Which activity is an example of primary prevention for clients at risk for low back pain?
- A. Teach back exercises to workers after returning from an injury.
- B. Place signs in the work area about how to perform first aid.
- C. Start a weight-reduction group to meet at lunchtime.
- D. Administer a nonnarcotic analgesic to a client complaining of back pain.
Correct Answer: C
Rationale: Weight reduction reduces spinal stress, a primary prevention strategy for low back pain. Post-injury exercises are secondary, first aid signs are tertiary, and analgesics treat symptoms, not prevent.
The nurse working on a medical-surgical floor feels a pulling in the back when lifting a client up in the bed. Which should be the first action taken by the nurse?
- A. Continue working until the shift is over and then try to sleep on a heating pad.
- B. Go immediately to the emergency department for treatment and muscle relaxants.
- C. Inform the charge nurse and nurse manager on duty and document the occurrence.
- D. See a private health-care provider on the nurse's off time but charge the hospital.
Correct Answer: C
Rationale: Reporting and documenting the injury ensures workplace safety protocols and workers’ compensation processes are followed. Continuing work risks further injury, ED is premature, and private care is secondary.