Nokea
The nurse is precepting a student nurse who is helping to care for a client with a hip fracture. The client has Buck's traction applied. Which statement by the student nurse indicates a need for further explanation by the primary nurse?
- A. The weight on Buck's traction should be between 5 and 7 pounds.
- B. Buck's traction is a type of skeletal traction that helps in bone realignment.
- C. The weights should hang freely and be checked regularly for correct positioning.
- D. Diligent pin site care is crucial to prevent infection in clients with skeletal traction.
Correct Answer: B
Rationale: Buck’s traction is skin traction, not skeletal traction, which uses pins. The other statements are correct regarding weight, positioning, and pin care (though pin care applies to skeletal traction).
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The nurse is working on a neurological unit. If the following events occur simultaneously, which would receive RN priority?
- A. A client with a cerebral aneurysm complains of sudden weakness on the right side.
- B. A client with a suspected brain tumor complains of a headache.
- C. A client post-op lumbar laminectomy vomits.
- D. A client with Guillain-Barre syndrome has a temp of 99.6°F.
Correct Answer: A
Rationale: Sudden weakness in a client with a cerebral aneurysm suggests possible rupture or neurological deterioration, a life-threatening emergency requiring immediate attention.
The nurse must administer in one syringe a combined dose of two different insulins from two vials. Place the steps (Roman numerals) in the correct order.
- A. Cleanse tops of vials.
- B. Inject air into vial 1.
- C. Withdraw medication from vial 1.
- D. Change needles.
- E. Withdraw medication from vial 2.
- F. Inject air into vial 2.
Correct Answer: A,B,F,C,E
Rationale: The correct order is: Cleanse vials (I), inject air into vial 1 (II), inject air into vial 2 (VI), withdraw from vial 1 (III), withdraw from vial 2 (V). Changing needles (IV) is not standard.
The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects?
- A. Mild nausea.
- B. Hot flashes.
- C. Vaginal bleeding.
- D. Hair thinning.
Correct Answer: C
Rationale: vaginal bleeding is a serious side effect of tamoxifen, as it may indicate endometrial cancer
A pregnant client with a history of alcohol addiction is scheduled for a nonstress test. The nonstress test:
- A. Determines the lung maturity of the fetus
- B. Measures the activity of the fetus
- C. Shows the effect of contractions on the fetal heart rate
- D. Measures the neurological well-being of the fetus
Correct Answer: B
Rationale: A nonstress test measures fetal heart rate in response to fetal movement, assessing fetal activity and well-being.
A client with cancer received platelet infusions 24 hours ago. Which of the following assessment findings would indicate the most therapeutic effect from the transfusions?
- A. Hgb level increase from 8.9 to 10.6
- B. Temperature reading of 99.4°F
- C. White blood cell count of 11,000
- D. Decrease in oozing of blood from IV site
Correct Answer: D
Rationale: Platelet infusions aim to improve clotting. Decreased oozing from an IV site indicates effective platelet function. The other findings are unrelated to platelets.