Nokea
The nurse is discharging the client home with a plaster of Paris cast to the lower leg. Which self-care recommendation should the nurse include?
- A. Sprinkle powder in the cast to decrease moisture from sweating.
- B. Direct cool air from a hair dryer into the cast to relieve itching.
- C. Cover the cast with a plastic wrap before you bathe in a tub.
- D. Use hot, soapy water to wash the cast if it becomes very soiled.
Correct Answer: B
Rationale: B. Cool air from a hair dryer helps to control itching on the skin within a cast. Hot air is not recommended because it could burn the skin.
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The day after an amputation, the client begins to hemorrhage from his stump. What action should the nurse take first?
- A. Apply a pressure dressing to the stump
- B. Place a tourniquet above the stump
- C. Notify the physician
- D. Apply an ice pack to the stump
Correct Answer: A
Rationale: Applying a pressure dressing is the first action to control hemorrhage, followed by notifying the physician.
The nurse is teaching a class to pregnant teenagers. Which information is most important when discussing ways to prevent osteoporosis?
- A. Take at least 1,200 mg of calcium supplements a day.
- B. Eat foods low in calcium and high in phosphorus.
- C. Osteoporosis does not occur until around age 50 years.
- D. Remain as active as possible until the baby is born.
Correct Answer: D
Rationale: Staying active (weight-bearing exercise) during pregnancy builds bone density, preventing future osteoporosis. Calcium supplements are secondary, low-calcium diets are harmful, and age misconception ignores prevention.
Which intervention should the nurse implement for a client with a fractured hip in Buck’s traction?
- A. Assess the insertion sites for signs and symptoms of infection.
- B. Monitor for drainage or odor from under the plaster covering the pins.
- C. Check the condition of the skin beneath the Velcro boot frequently.
- D. Take weights off for one (1) hour every eight (8) hours and as needed.
Correct Answer: C
Rationale: Checking skin under the Velcro boot prevents irritation or breakdown in Buck’s traction. Insertion sites and plaster are for skeletal traction, and weights must remain constant.
Which material added by the nurse is best for covering the tips of the pin to prevent injuries while the client is in skeletal leg.
- A. Gauze squares
- B. Cotton balls
- C. Cork blocks
- D. Rubber tubes
Correct Answer: C
Rationale: Cork blocks securely cover pin tips, preventing injury to the client or staff while maintaining stability. Gauze and cotton are less durable, and rubber tubes may not fit securely.
The nurse knows that elevated findings on which laboratory test typically validate a diagnosis of gout?
- A. Creatinine clearance
- B. Blood urea nitrogen
- C. Serum uric acid
- D. Serum calcium
Correct Answer: C
Rationale: Elevated serum uric acid confirms gout, as it causes crystal formation.