Nokea
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
- A. Two finger widths are noted between the axilla and the top of the crutch.
- B. The client bears weight on his hands when ambulating.
- C. The crutches and the client's feet move alternately.
- D. The client bears weight on his axilla when standing.
Correct Answer: D
Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
You may also like to solve these questions
The nurse is caring for a client with a history of a tracheostomy. Which intervention is most important when suctioning the tracheostomy?
- A. Using sterile technique
- B. Applying suction for 20 seconds
- C. Instilling saline before suctioning
- D. Using a large-diameter catheter
Correct Answer: A
Rationale: Sterile technique during tracheostomy suctioning prevents infection, a critical concern. Suctioning should last 10-15 seconds, saline is optional, and catheter size should be appropriate.
A client has just received an epidural block. She is laboring on her right side. The nurse notes that her blood pressure has dropped from 132/68 to 78/42 mm Hg. The nurse's first action would be to:
- A. Call the physician immediately and give dopamine IM
- B. Turn her on her left side and recheck her blood pressure in 5 minutes
- C. Administer oxytocin (Pitocin) immediately and increase the rate of IV fluids
- D. Increase the rate of IV fluids and start O2 by mask
Correct Answer: D
Rationale: Nursing measures to support fetal oxygenation and promote maternal blood pressure would precede calling the physician. Systolic pressures below 100 mm Hg or a reduction in the systolic pressure of >30% necessitate treatment. Assessing the blood pressure in 5 minutes may allow for further fetal and/or maternal compromise. Turning the client on her left side will promote uteroplacental perfusion and is appropriate. Oxytocin (Pitocin) increases the strength of uterine contractions and may cause maternal hypotension; thus it is an inappropriate drug for use in this clinical situation. IV fluids would be increased to expand the circulating blood volume and promote increased blood pressure. Turning the mother to her left lateral side promotes uteroplacental perfusion. IV fluids are administered to increase the circulating blood volume, and O2 is administered to promote fetal oxygenation and decrease the nausea accompanying the hypotension.
Before administering intravenous chemotherapy to the patient being treated, the nurse should:
- A. Administer a bolus of IV fluid
- B. Administer pain medication
- C. Administer an antiemetic
- D. Allow the patient a chance to eat
Correct Answer: C
Rationale: Chemotherapy often causes nausea and vomiting, so administering an antiemetic prophylactically is standard to improve patient comfort. Fluid boluses, pain medication, or eating are not routine pre-chemotherapy steps unless specified.
The client is diagnosed with pancreatitis. Which laboratory value is most indicative of this condition?
- A. Elevated amylase
- B. Decreased bilirubin
- C. Elevated hemoglobin
- D. Decreased white blood cell count
Correct Answer: A
Rationale: Elevated amylase is a key indicator of pancreatitis, as it is released from damaged pancreatic tissue. Bilirubin, hemoglobin, and white blood cell counts are less specific, though leukocytosis may occur.
The nurse is caring for a client with a diagnosis of chorioamnionitis. Which diagnostic test is most likely to be ordered?
- A. Complete blood count
- B. Amniotic fluid analysis
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Chorioamnionitis requires a complete blood count to assess for infection (e.g. elevated white blood cells) and amniotic fluid analysis to confirm infection. Both tests are commonly ordered.