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The nurse is developing a plan of care for a patient who has a halo vest immobilizer (halo brace) following a cervical spine fracture. Which of the following should the nurse include in the patient's plan of care?
- A. Pin care every shift
- B. Neck flexion and extension exercises
- C. Taping the wrench to the vest
- D. Report loosening of the pins
- E. Use straws when providing liquids
Correct Answer: A, D, E
Rationale: Pin care prevents infection, reporting loose pins ensures stability, and straws aid safe drinking. Neck exercises are contraindicated as they risk spinal injury, and taping the wrench is standard but not always required unless specified.
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The nurse is teaching a client scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. Which of the following information should the nurse include?
- A. Do not eat or drink 6-8 hours prior to your test.'
- B. You will feel flushing as you receive the intravenous contrast.'
- C. The scan takes several hours to complete.'
- D. Please remove all metallic objects before this exam.'
Correct Answer: D
Rationale: Removing metallic objects prevents interference with the DEXA scan, which measures bone density. Fasting and contrast are not required, and the scan typically takes 10-30 minutes.
The nurse is caring for a client on bed rest for a week following a right hip fracture. Which of the following findings, if noted in the client, would indicate signs of complications due to immobility?
- A. An area of the client's sacrum is unable to be blanched
- B. The skin and the sclerae are yellow
- C. Crackles in the bases of the client's lungs
- D. Swelling and tenderness in the left calf
- E. The client is using the bedpan to void
Correct Answer: A, C, D
Rationale: Non-blanchable sacral skin indicates pressure injury, crackles suggest pneumonia or fluid from immobility, and calf swelling/tenderness may signal deep vein thrombosis. Jaundice and bedpan use are not directly immobility-related.
The nurse is caring for a client with myasthenia gravis who is six hours postoperative following a thymectomy. Which item should the nurse have at the bedside?
- A. Calcium gluconate
- B. Bag-valve mask
- C. Tracheostomy kit
- D. Atropine sulfate
Correct Answer: B
Rationale: Myasthenia gravis can cause respiratory muscle weakness, and post-thymectomy risks respiratory compromise. A bag-valve mask is critical for emergency ventilation. Calcium gluconate, tracheostomy kits, and atropine are not directly related.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 62-year-old female client.
Item 1 of 1
Triage Note
1211: The client was brought to the ED by her neighbor, who was concerned about her increasing pain and immobility. The client's neighbor reported that the client called her a few hours ago, asking her to go to the ED because of increasing pain and the inability to perform her activities of daily living. History of osteoporosis, hypertension, and gout. She reports that she recently started seeing a rheumatologist because of persistent fatigue, low-grade fevers, and lack of appetite. Vital signs: T 99.7° F (37.6° C), P 82, RR 16, BP 134/76, pulse oximetry reading 98% on room air. Pain rated 7/10 on the Numerical Rating Scale, which is described as throbbing of both feet, especially in her toes. She also reports having stiffness in her wrists and fingers that starts in the morning and persists throughout the day. Triage assessment: the client is alert and fully oriented to person, place, and situation. Peripheral pulses 2+. Clear lung sounds bilaterally. Swollen, errythemic toes that are warm and tender to touch. She does not recall her weight but reports significant weight loss over the past three months.
For each assessment finding below, click to specify if the finding is consistent with the disease process of osteoarthritis, acute gout flare, or rheumatoid arthritis. Each finding may support more than 1 disease process.
- A. Low-grade fever
- B. Weight loss
- C. Redness and warmth of the affected joint
- D. Morning joint stiffness in the wrists that lasts throughout the day
- E. Pain with movement in the affected joint
- F. Reduced range of motion in the affected joint
- G. Pain level
Correct Answer: A: Rheumatoid Arthritis, Acute Gout Flare, B: Rheumatoid Arthritis, C: Rheumatoid Arthritis, Acute Gout Flare, D: Rheumatoid Arthritis, E: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare, F: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare, G: Osteoarthritis, Rheumatoid Arthritis, Acute Gout Flare
Rationale: Seen in inflammatory conditions; not typical in osteoarthritis. Chronic systemic inflammation may lead to unintentional weight loss. Indicates joint inflammation; osteoarthritis does not usually present with warmth or redness. Stiffness >1 hour, especially in small joints, is classic for RA. Movement worsens pain in all these conditions, though the cause differs. All limit ROM due to stiffness, inflammation, or damage. Pain is a shared feature, though severity and timing vary.
The nurse is caring for a client with a newly applied plaster cast. The nurse should
- A. Use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable.
- B. Expedite drying by using a hot blow dryer on the cast.
- C. Let the cast hang below the heart to promote blood flow.
- D. Handle the cast with the palms of the hands.
Correct Answer: D
Rationale: Handling a wet plaster cast with the palms prevents denting, which could cause pressure points. Scratching inside risks skin damage, hot dryers can burn, and a dependent position increases swelling.