Nokea
Nurses' Notes Day 1: Client brought to the emergency department (ED) following a fall that occurred while downhill skiing. Client states they fell when turning to avoid hitting another skier. Client reports feeling a severe, sudden pain of right leg upon falling. Right leg was immobilized at the scene and client transported to the ED.
Client states they were wearing a helmet while skiing. Client reports no headache or loss of consciousness.
Client reports pain as 10 on a scale of 0 to 10 to the right lower leg just below the knee and is unable to bear weight.
Right proximal tibia ecchymotic and swollen below the knee. Area is painful to touch. Open area noted on skin with bone visible. Right knee appears displaced. Left pedal pulses 3+, foot warm with intact movement and sensation. Right pedal pulses 1+, foot cool to palpation with minimal movement and reduced sensation.
The nurse is collecting data on the client. Which of the following findings require follow up? (Ski accident client)
- A. Findings of right lower extremity assessment
- B. Oxygen saturation
- C. Right pedal pulses
- D. Level of consciousness
- E. Temperature
- F. Pain level
- G. X-ray results
Correct Answer: A,C,F,G
Rationale: Right leg swelling, weak pulses, pain, and X-ray (fracture) indicate urgent issues like compartment syndrome.
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A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?
- A. Request a dosage increase if the apical heart rate is less than 60/min.
- B. Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
- C. Administer the medication with an antacid.
- D. Instruct the client to expect increased hair growth.
Correct Answer: B
Rationale: Propranolol is a beta-blocker, and it should be withheld if the systolic blood pressure is below 90 mm Hg to prevent hypotension. A heart rate below 60/min might also warrant withholding, not increasing, the dose, and the other options are unrelated to its administration.
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?
- A. Ask the provider for a prescription for a pureed diet.
- B. Have an assistive personnel feed the client.
- C. Obtain a referral for physical therapy.
- D. Apply foam handles to the client's eating utensils.
Correct Answer: D
Rationale: Chronic arthritis often impairs hand dexterity and grip strength, making self-feeding challenging. Option A, a pureed diet, addresses swallowing issues, not arthritis-related difficulties with utensils, so it's irrelevant here. Option B, having assistive personnel feed the client, undermines independence and dignity without addressing the root issue of utensil handling. Option C, physical therapy, may improve joint function long-term but doesn't provide immediate help for eating. Option D is correct applying foam handles increases utensil girth, improving grip for arthritic hands, promoting self-feeding and autonomy. This intervention directly tackles the physical limitation caused by arthritis, aligning with nursing goals of enhancing quality of life and independence. It's practical, cost-effective, and can be implemented quickly, offering immediate relief while other therapies (like PT) work in the background. Evidence supports adaptive equipment as a first-line strategy for arthritis patients struggling with daily activities, making this the most appropriate and empowering choice.
A nurse is providing first aid for a client who has a minor burn on one hand, which of the following actions should the nurse take? (Select all that apply.)
- A. Maintain skin integrity over the blisters.
- B. Apply ice to the larger blisters.
- C. Administer ibuprofen for pain.
- D. Run cool water over the affected area.
- E. Allow the affected area to remain open to air.
Correct Answer: A,C,D
Rationale: Maintaining blister integrity prevents infection (A), ibuprofen relieves pain (C), and cool water reduces heat and pain (D). Ice can damage tissue, and open air may increase infection risk.
A nurse is reinforcing teaching with the family of a client who has methicillin-resistant Staphylococcus aureus (MRSA) of a leg wound and is on contact precautions. Which of the following statements by a family member indicates an understanding of the teaching?
- A. We should remove gloves before leaving the hospital room.
- B. There is no cure for MRSA.
- C. MRSA only occurs in health care facilities.
- D. We will need to wear masks when we are in the hospital room.
- E. We can touch the client without precautions.
- F. MRSA will resolve without treatment.
- G. We should wash hands after glove removal.
Correct Answer: A
Rationale: Gloves should be removed before leaving to prevent contamination spread; MRSA is treatable, can occur outside facilities, and masks aren't required for contact precautions.
A nurse is preparing to perform tracheostomy care for a client. In which order should the nurse take the following steps?
- A. Ensure a method to communicate during the procedure.
- B. Wear clean gloves to remove the tracheostomy dressing.
- C. Clean the inner cannula using a small brush.
- D. Explain the procedure to the client.
- E. Apply clean tracheostomy ties.
Correct Answer: D,A,B,C,E
Rationale: The sequence is: Explain the procedure (D) to inform the client, ensure communication (A) during the process, remove the dressing with gloves (B), clean the cannula (C), and apply new ties (E). This order ensures safety and client comfort.