Nokea
The nurse is performing pin-site care on a client in skeletal traction. Which normal finding should the nurse expect to note when assessing the pin sites?
- A. Loose but intact pin sites
- B. Clear drainage from the pin sites
- C. Purulent drainage from the pin sites
- D. Redness and swelling around the pin sites
Correct Answer: B
Rationale: A small amount of clear drainage ('weeping') may be expected after cleaning and removing crusting around the pin sites of skeletal traction. Pins should not be loose; if this is noted, the primary health care provider should be notified. Purulent drainage and redness and swelling around the pin sites may be indicative of an infection.
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The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. Which interventions should the nurse implement? Select all that apply.
- A. Stop movement of the affected part.
- B. Massage the affected part vigorously.
- C. Notify the primary health care provider immediately.
- D. Force movement of the joint supporting the muscle.
- E. Ask the client to stand and walk rapidly around the room.
- F. Place continuous gentle pressure on the muscle group until it relaxes.
Correct Answer: A,F
Rationale: ROM exercises should put each joint through as full a range of motion as possible without causing discomfort. An unexpected outcome is the development of spastic muscle contraction during ROM exercises. If this occurs, the nurse should stop movement of the affected part and place continuous gentle pressure on the muscle group until it relaxes. Once the contraction subsides, the exercises are resumed using slower, steady movement. Massaging the affected part vigorously may worsen the contraction. There is no need to notify the primary health care provider unless intervention is ineffective. The nurse should never force movement of a joint. Asking the client to stand and walk rapidly around the room is an inappropriate measure.
The nurse is caring for a client who sustained a spinal cord injury that has resulted in spinal shock. Which assessment will provide relevant information about recovery from spinal shock?
- A. Reflexes
- B. Pulse rate
- C. Temperature
- D. Blood pressure
Correct Answer: A
Rationale: Areflexia characterizes spinal shock; therefore, reflexes would provide the best information about recovery. Vital sign changes (options 2, 3, and 4) are not consistently affected by spinal shock. Because vital signs are affected by many factors, they do not give reliable information about spinal shock recovery.
The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
- A. Change the drainage bag to a leg collection bag.
- B. Tie the drainage bag to the client's waist while ambulating.
- C. Use a walker to hang the drainage bag from while ambulating.
- D. Tell the client to hold the drainage bag higher than the level of the bladder.
Correct Answer: A
Rationale: The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement, while preventing accidental disconnection or dislodgment. The drainage bag is kept below the level of the bladder. Option 3 presents the risk of tension or pulling on the nephrostomy tube by the client during ambulation.
The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?
- A. Maintain an open airway.
- B. Administer oxygen by face mask.
- C. Assess the maternal blood pressure and fetal heart tones.
- D. Administer an intravenous infusion of magnesium sulfate.
Correct Answer: A
Rationale: Eclampsia is characterized by the occurrence of seizures. If the client experiences seizures, it is important as a first action to establish and maintain an open airway and prevent injuries to the client. Options 2, 3, and 4 are all interventions that should be done but not initially.
To assure the desired results, how should the nurse instruct the client prescribed oral bisacodyl to take the medication?
- A. At bedtime
- B. With a large meal
- C. With a glass of milk
- D. On an empty stomach
Correct Answer: A
Rationale: Bisacodyl is a stimulant laxative that works by stimulating peristalsis in the colon. To ensure its effectiveness, it should be taken at bedtime to produce a bowel movement in the morning, typically 6 to 12 hours after administration. Taking it with a large meal or milk may reduce its effectiveness due to delayed gastric emptying or interaction with food. Taking it on an empty stomach may cause stomach irritation and is not necessary for its action.