Nokea
The nurse is monitoring a client with a fracture to the left arm. Which sign observed by the nurse is consistent with impaired venous return in the area?
- A. Increasing edema
- B. Weakened distal pulse
- C. Pallor or blotchy cyanosis
- D. Continued pain despite medication
Correct Answer: A
Rationale: Impaired venous return is characterized by increasing edema. In the client with a fracture, this is most often prevented by elevating the limb. The other options identify signs of arterial damage, which can occur if the artery is contused, thrombosed, lacerated, or becomes spastic.
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A client with a history of type 1 diabetes mellitus is prescribed insulin aspart (NovoLog). The nurse should explain that this insulin:
- A. Provides a steady basal insulin level.
- B. Is administered immediately before meals.
- C. Should be mixed with long-acting insulin.
- D. Is taken once daily at bedtime.
Correct Answer: B
Rationale: Insulin aspart is a rapid-acting insulin administered immediately before meals to control postprandial glucose.
The nurse manager is developing a 'read-back' procedure to reduce medication administration errors. Which of the following are purposes of the 'read-back' requirement? Select all that apply.
- A. To prohibit orders and test results from being communicated verbally or by telephone.
- B. To ensure that orders and test results that are communicated verbally or by telephone are clear to the receiver of the information.
- C. To make sure that orders and test results that are communicated verbally or by telephone are confirmed by the individual giving the information.
- D. To minimize the risk of non-authorized personnel from giving orders which are communicated verbally or by telephone.
- E. To encourage the use of electronic medical records.
Correct Answer: B,C,D
Rationale: Read-back ensures clarity, confirmation, and authorized communication of verbal orders, reducing errors. It does not prohibit verbal orders or mandate electronic records.
A client experiencing low back pain asks the nurse which type of exercise will strengthen the lower back muscles. Which exercise should the nurse encourage the client to participate in to best strengthen the lower back muscles?
- A. Tennis
- B. Diving
- C. Canoeing
- D. Swimming
Correct Answer: D
Rationale: Walking and swimming are very beneficial in strengthening back muscles for the client with low back pain. The other options involve twisting and pulling of the back muscles, which is not helpful to the client experiencing back pain.
The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate?
- A. 45 mm Hg
- B. 50 mm Hg
- C. 60 mm Hg
- D. 80 mm Hg
Correct Answer: D
Rationale: The normal Po2 level is 80 to 100 mm Hg. The remaining options are low values and do not indicate adequate oxygen levels.
A client with a history of cirrhosis is admitted with jaundice. The nurse should include which of the following in the plan of care?
- A. Monitor for signs of bleeding.
- B. Encourage a high-fat diet.
- C. Administer vitamin C.
- D. Restrict protein intake.
Correct Answer: A
Rationale: Jaundice in cirrhosis indicates liver dysfunction, increasing bleeding risk due to impaired clotting factor production.