Nokea
The nurse is preparing communication for a provider. The client is experiencing
acute pain greater than the severity of the fracture. Distal to the injury, he is
experiencing a 'pins and needles' sensation. The pulse is weak and thready but
is bounding on all unaffected extremities. What emergent condition does the
nurse suspect?
- A. Ischial tuberosity
- B. Compartment syndrome
- C. Broken arm syndrome
- D. Pulmonary embolism
Correct Answer: B
Rationale:
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The nurse will be using the Braden Scale with each admit to the long-term care
center. Which of these will NOT be utilized in a Braden Scale Assessment?
- A. Mental state
- B. Friction and shear
- C. Nutrition
- D. Sensory perception
Correct Answer: A
Rationale:
A nurse is providing oral hygiene for an unconscious client. What is the priority
nursing intervention?
- A. Position the client on one side with the head turned towards you
- B. Handle dentures with care
- C. Use gentle brushing and flossing techniques for clients with fragile mucosa
- D. Have a suction apparatus ready at the bedside
Correct Answer: A
Rationale:
A client is in skeletal traction. With the nurse's assessment, it is noted that the
pairs appear red, swollen and there is purulent drainage. What action does the
nurse take first?
- A. Collect a culture of the purulent fluid
- B. Cleanse the skin around the pins
- C. Administer an antibiotic
- D. Instruct the client to complete exercise of the affected extremity
Correct Answer: A
Rationale:
A nurse assesses an area of skin over a bony prominence. What finding would
be most concerning?
- A. Redness
- B. Non-blanching
- C. Blanching
- D. Warmth
Correct Answer: A
Rationale:
A client has cellulitis on his left arm. What statement by the client indicates
understanding of symptom management?
- A. "I can use tight bandages on my arm."?
- B. "I should not apply heat to my arm."?
- C. "I can use a warm, moist towel on my arm."?
- D. "I should use a cold, dry source on my arm."?
Correct Answer: C
Rationale: