Nokea
The nurse is talking with the parent of a pediatric client who had a cast applied to the right arm 30 minutes ago. Which of the following statements by the parent would require follow-up?
- A. I understand that my child may feel tingling or burning underneath the cast for the first few days.
- B. I can use a hair dryer to blow cool air underneath the cast if my child experiences itching.
- C. I will call the clinic if my child experiences pain that is not relieved with medication.
- D. I should keep my child's arm elevated while resting for the first few days.
Correct Answer: A
Rationale: Tingling or burning may indicate neurovascular compromise or pressure on nerves, requiring immediate evaluation, not dismissal as normal.
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A newborn had a bowel resection with temporary colostomy for Hirschsprung disease. The practical nurse should alert the supervising registered nurse about which postoperative finding?
- A. Moderate amount of blood-tinged mucus from the stoma on postoperative day 2
- B. Small amount of non-formed stool in the colostomy bag on postoperative day 6
- C. Stoma bleeds a small amount during colostomy bag change on postoperative day 3
- D. Stoma is gray-tinged at the edges but pink at the center on postoperative day 5
Correct Answer: D
Rationale: A gray-tinged stoma suggests ischemia or poor perfusion, which is a critical finding requiring immediate reporting to assess for stoma viability.
A nurse finds a client unresponsive and is unable to palpate a pulse. Resuscitation is initiated and continued by the rapid response team. The nurse then finds a do not resuscitate (DNR) prescription in the client's chart. What is the appropriate action by the nurse?
- A. Complete resuscitation as life support measures have already been started
- B. Continue resuscitation until DNR status is verified with health care provider
- C. Immediately have the rapid response team stop resuscitation measures
- D. Verify with a family member if life-saving measures should be continued
Correct Answer: C
Rationale: A DNR order indicates the client's wish to avoid resuscitation. Once discovered, resuscitation should be stopped immediately to respect the client's directive, unless there is clear evidence the order is invalid.
A child's burn is debrided each day with hydrotherapy to remove the eschar. The child's parents ask why this immersion is necessary. What is the most appropriate response for the nurse to make?
- A. By removing the scab or crusting daily in the special bath, we help prevent infection and then the healthy tissue may be covered by skin grafts.'
- B. By submersion in a whirlpool bath, we can better exercise her limbs to prevent contractures.'
- C. This is a cleansing bath given so that fresh dressings may be applied to the burn areas.'
- D. We decrease her chance of infection by immersion in antibiotic solutions with each debriding bath.'
Correct Answer: A
Rationale: Hydrotherapy removes eschar to prevent infection and prepare for grafting, accurately explaining the procedure's purpose.
The nurse on the telemetry unit is preparing client medications in the medication room. Which of the following actions should the nurse perform to be consistent with client safety practices related to medication administration? Select all that apply.
- A. Confirm the client's identity, medication, dosage, time, and route prior to medication administration
- B. Do not administer any medication that is damaged or has an unreadable label
- C. Place all medications in a dispensing cup before taking them to a client's room
- D. Review laboratory values before administering anticoagulants
- E. Wear gloves when handling transdermal medication patches
Correct Answer: A,B,D,E
Rationale: These actions align with safe medication administration practices: verifying the 'five rights' (A), ensuring medication integrity (B), checking relevant lab values for anticoagulants (D), and using gloves to prevent absorption of transdermal medications (E).
A nursing assistant assigned to care for a client with a radium implant tells the nurse, 'I don't want to be assigned to that radioactive patient.' The best action for the nurse to take is to:
- A. Tell the nursing assistant that the client's body acts as a shield.
- B. Point out that her behavior is uncaring.
- C. Instruct her regarding the use of a lead-lined apron.
- D. Ask the nursing assistant why she is afraid of the client.
Correct Answer: D
Rationale: Asking why the nursing assistant is afraid addresses her concerns and allows education. Claiming the body shields radiation is inaccurate. Calling her uncaring is unprofessional. Lead aprons are not typically used for implants.