Nokea
The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication?
- A. Presence of crusts around the pin insertion site.
- B. Serous drainage on the dressing.
- C. Pin moves slightly at insertion site.
- D. Client does not feel pain at insertion site.
Correct Answer: C
Rationale: A moving pin indicates instability, a complication risking infection or poor healing. Crusts and serous drainage are normal, and lack of pain is not a complication.
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A client tells the nurse that he is going to harm his brother-in-law, who called the police on him for threatening to hurt his ex-wife. The nurse should notify which of the following persons? Select all that apply.
- A. Agency administrators.
- B. Ex-wife.
- C. Police.
- D. Intended victim.
- E. Social service department.
Correct Answer: C,D
Rationale: The nurse has a duty to warn the intended victim (brother-in-law) and notify the police due to the credible threat of harm. Notifying administrators or social services may be secondary, and the ex-wife is not the current target.
A client with a history of migraine headaches is prescribed sumatriptan (Imitrex). The nurse should instruct the client to:
- A. Take the medication at the onset of a migraine.
- B. Take the medication daily to prevent migraines.
- C. Avoid taking the medication with food.
- D. Stop the medication if nausea occurs.
Correct Answer: A
Rationale: Sumatriptan is most effective when taken at the onset of a migraine to abort the attack.
A client with a diagnosis of nephrotic syndrome states to the nurse, 'Why should I even bother trying to control my diet and the swelling? It doesn't really matter what I do if I can never get rid of this kidney problem anyway!' Which potential client problem should the nurse address based on the client's statement?
- A. Anxiety
- B. Difficulty coping
- C. Feeling powerless
- D. Negative body image
Correct Answer: C
Rationale: Feeling powerless is a problem when the client believes that personal actions will not affect an outcome in any significant way. Anxiety occurs when the client has a feeling of unease with a vague or undefined source. Difficulty coping indicates that the client has impaired adaptive abilities or behaviors in meeting the demands or roles expected from the individual. Negative body image occurs when the way the client perceives body image is altered.
The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first?
- A. Apply oxygen.
- B. Administer morphine sulfate.
- C. Start an intravenous (IV) line.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.
A client with a history of deep vein thrombosis is prescribed enoxaparin (Lovenox). Which laboratory value does not require routine monitoring?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Hemoglobin
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, does not require routine PT monitoring, unlike warfarin, as it primarily affects anti-factor Xa activity.