Nokea
The nurse is teaching the client with carpal tunnel syndrome how best to utilize a wrist splint. Which statement is most appropriate for the nurse to include in the teaching?
- A. Leave the splint in place even when bathing.
- B. Wear the splint as tight as can be tolerated.
- C. Remove the splint intermittently throughout the day.
- D. Only wear the splint when doing work that stresses the fingers.
Correct Answer: C
Rationale: C. Although the splint decreases swelling and promotes healing and is necessary in the management of the pain with carpal tunnel syndrome, it should be removed intermittently during the day to exercise the wrist and bathe.
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A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?
Correct Answer: 30
Rationale: Concentration: 20,000 units ÷ 500 mL = 40 units/mL. Rate: 1200 units/hr ÷ 40 units/mL = 30 mL/hr.
What is the most important factor for the nurse to consider when teaching the child who has CP?
- A. Current age
- B. Type of cerebral palsy
- C. Prior illness experience
- D. Developmental level
Correct Answer: D
Rationale: Developmental level is critical to tailor teaching to the child's cognitive and physical abilities.
The nurse writes a concept of 'impaired mobility' for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply.
- A. Request a physical therapy referral.
- B. Administer enoxaparin (Lovenox) subcutaneously.
- C. Utilize a gait belt when ambulating the client.
- D. Assess the client’s pain levels on a 1-to-10 scale.
- E. Provide a high-carbohydrate, high-fat, high-sodium diet.
Correct Answer: A,B,C,D
Rationale: PT referral, enoxaparin, gait belt, and pain assessment promote mobility and prevent complications in hip fracture. High-carb/fat/sodium diet is inappropriate.
The nurse is analyzing the serum laboratory report for the client diagnosed with lung cancer that has metastasized to the pelvic bone. Which specific finding should the nurse anticipate?
- A. Elevated calcium
- B. Decreased hemoglobin
- C. Elevated creatinine (SCr)
- D. Elevated creatine kinase (CK)
Correct Answer: A
Rationale: A. Malignant tumors cause hypercalcemia through a variety of mechanisms, one being an increased release of calcium from the bones.
The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
- A. Help the client with a two (2)-day postop amputation put on the prosthesis.
- B. Request the UAP double-check a unit of blood to be hung.
- C. Change the surgical dressing on the client with a Syme's amputation.
- D. Ask the UAP to take the client to the physical therapy department.
Correct Answer: D
Rationale: Transporting a client to PT is within UAP scope. Prosthesis application, blood verification, and dressing changes require nursing judgment.