Nokea
The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the client and the dressing. The nurse should immediately:
- A. Apply a tourniquet
- B. Assess vital signs
- C. Call the physician
- D. Elevate the surgical extremity with a large pillow
Correct Answer: C
Rationale: Blood saturating the dressing post-amputation suggests significant bleeding, a potential emergency. The nurse should immediately call the physician for evaluation and intervention. Applying a tourniquet is extreme and requires an order, assessing vital signs is secondary, and elevating with a pillow may not address the bleeding source.
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The nurse is planning a community health class for older adults. Which topic should the nurse prioritize?
- A. discussing and preventing polypharmacy
- B. strategies to stay physically active
- C. staying socially engaged in the community
- D. recommended immunizations
Correct Answer: A
Rationale: Polypharmacy is a critical issue in older adults, increasing the risk of adverse drug events.
The nurse is planning care for a client with a fractured humerus in a sling. Which intervention should be included?
- A. Encourage shoulder shrugging exercises.
- B. Apply heat to the fracture site.
- C. Keep the arm in a dependent position.
- D. Restrict all arm movement.
Correct Answer: A
Rationale: Shoulder shrugging exercises maintain mobility and prevent stiffness without stressing the fracture.
A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply.
- A. Reduces myocardial oxygen consumption.
- B. Promotes reduction in respiratory rate.
- C. Prevents ventricular remodeling.
- D. Reduces blood pressure and heart rate.
- E. Reduces anxiety and fear.
Correct Answer: A,D,E
Rationale: Morphine reduces pain, which lowers myocardial oxygen demand (A), decreases blood pressure and heart rate through vasodilation and reduced sympathetic response (D), and alleviates anxiety and fear (E). It does not prevent ventricular remodeling or directly reduce respiratory rate in this context.
Which of the following interventions would be most effective in preventing the development of acute respiratory distress syndrome (ARDS)?
- A. Teaching cigarette smoking cessation.
- B. Maintaining adequate serum potassium levels.
- C. Monitoring clients for signs of hypercapnia.
- D. Replacing fluids adequately during hypovolemic states.
Correct Answer: D
Rationale: Adequate fluid replacement in hypovolemia prevents shock, a major ARDS trigger. Smoking cessation, potassium levels, and hypercapnia monitoring are less directly related to ARDS prevention.
The best method to remove cerumen from a client's ear involves:
- A. Inserting a cotton-tipped applicator into the external canal.
- B. Irrigating the ear gently.
- C. Using aural suction.
- D. Using a cerumen curette.
Correct Answer: B
Rationale: Gentle irrigation with warm water or saline is the safest and most effective method to remove cerumen, avoiding trauma to the ear canal or eardrum.