Nokea
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
- A. Use of a fracture bedpan.
- B. Checks for redness over the ischial tuberosity.
- C. Elevation of the head of bed no more than 25 degrees.
- D. Personal hygiene with a complete bed bath.
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.
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The client states she does not understand what causes idiopathic thrombocytopenic purpura (ITP). The nurse provides which of the following explanations?
- A. It is believed that the platelets are coated with antibodies and the spleen sees them as foreign bodies.
- B. It is believed that the liver identifies the platelets as foreign bodies.
- C. It is now believed that the syndrome is related to an underactive immune system.
- D. The cause is unknown.
Correct Answer: A
Rationale: Idiopathic thrombocytopenic purpura (ITP) is an autoimmune condition where antibodies coat platelets, marking them for destruction by the spleen. This leads to a low platelet count. The liver is not primarily involved, ITP is not due to an underactive immune system, and while 'idiopathic' means the exact trigger is unknown, the autoimmune mechanism is well-established.
A 70-year-old male with the diagnosis of claudication has been hospitalized for an evaluation of his increasingly impaired mobility and complaints of pain. The client tells the nurse that he can no longer walk a block without having severe pain in his left calf and foot. Based on these data, which nursing diagnosis would be most appropriate for this client?
- A. Activity intolerance related to decreased blood supply and pain
- B. Self-care deficit related to increased leg pain
- C. Ineffective coping related to chronic pain
- D. Impaired skin integrity related to poor circulation
Correct Answer: A
Rationale: Activity intolerance due to decreased blood supply and pain is the most appropriate nursing diagnosis, as claudication (pain during walking) directly results from inadequate arterial blood flow, limiting mobility. The other diagnoses may apply but are less specific to the described symptoms.
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
- A. Back at the level of the client's scapula.
- B. Back and head that are high.
- C. Seat that is lower than normal.
- D. Seat with firm cushions.
- E. Chair controlled by client's breath.
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
After a subtotal gastrectomy, care of the client's nasogastric (NG) tube and drainage system should include which of the following nursing interventions?
- A. Irrigate the tube with 30 mL of sterile water every hour, if needed.
- B. Reposition the tube if it is not draining well.
- C. Monitor the client for nausea, vomiting, and abdominal distention.
- D. Turn the machine to high suction if the drainage is sluggish on low suction.
Correct Answer: C
Rationale: Monitoring for nausea, vomiting, and abdominal distention is essential to detect complications such as obstruction or ileus. Routine irrigation, repositioning, or increasing suction without medical orders is unsafe.
A client is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery?
- A. Include family members in preoperative teaching sessions.
- B. Encourage the client to ask questions about managing an ileostomy.
- C. Provide a brief, thorough explanation of all preoperative and postoperative procedures.
- D. Invite a member of the ostomy association to visit the client.
Correct Answer: B
Rationale: Encouraging the client to ask questions about managing an ileostomy promotes active engagement, addresses specific concerns, and supports psychological preparation. Including family, providing explanations, or arranging visits are helpful but less directly empower the client's coping process. CN: Psychosocial adaptation; CL: Synthesize