Nokea
The nurse is to administer nafcillin 500 mg intravenously to the client with osteomyelitis. A vial of 1 g of powdered nafcillin is to be reconstituted with 3.4 mL of 0.9% NaCl. How many milliliters should the nurse plan to administer?
- A. 1.7 mL
Correct Answer: A
Rationale: Rationale: 500 mg / 1,000 mg = x / 3.4 mL; x = 1.7 mL. The nurse should prepare 1.7 mL nafcillin (Nallpen).
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Which is the best technique for the nurse to use when applying the elastic bandage to the client's lower extremity?
- A. Making figure-eight turns with the bandage
- B. Making spiral-reverse turns with the bandage
- C. Making recurrent turns with the bandage
- D. Making spica turns with the bandage
Correct Answer: A
Rationale: The figure-eight technique provides even compression and support around the ankle joint, stabilizing it while allowing some flexibility. Spiral-reverse turns are better for cylindrical limbs, recurrent turns are used for stumps, and spica turns are typically for larger joints like the hip or shoulder.
The nurse explains that the primary reason for the client's increased risk for altered skin integrity due to a T12 SCI is which factor?
- A. The inability to perceive extremes in temperature leading to burns
- B. The inability to feel skin irritation such as wrinkled linens or clothing
- C. The increased likelihood of bowel and bladder dysfunction and skin irritation
- D. The circulatory changes that cause vasoconstriction and decreased blood supply
Correct Answer: B
Rationale: Loss of sensation below T12 prevents the perception of skin irritants, increasing the risk of pressure ulcers.
The nurse is caring for the client who had a surgical repair of a right Dupuytren's contracture. Which intervention should the nurse plan?
- A. Elevate the right lower extremity above the level of the heart
- B. Assist the client with bathing, dressing, grooming, and toileting
- C. Instruct about wearing low-heeled and properly fitting shoes
- D. Frequently rewrap the elastic bandage on the right extremity
Correct Answer: B
Rationale: B. Independent self-care is impaired for a few days after surgery because the hand is bandaged. The nurse should plan that the client receive assistance with personal care and ADLs.
The nurse notes during an annual health screening for the 78-year-old client that the client is 1.5 inches shorter than at last year's visit. Which initial screening might the nurse best anticipate for this client?
- A. Bone mineral density (BMD) test
- B. An x-ray of both hips and spine
- C. A bone scan of the hips and spine
- D. A physical check for scoliosis
Correct Answer: A
Rationale: A. BMD testing will best determine if the loss of height is due to osteoporosis, a common finding with aging.
The nurse is caring for the client involved in an MVA who sustained an unstable pelvic fracture. Which HCP order should be the nurse's priority?
- A. Urinalysis and culture and sensitivity
- B. Blood alcohol level and toxicology screen
- C. Computed tomography (CT) scan of the pelvis
- D. Give two units of cross-matched whole blood
Correct Answer: D
Rationale: D. Significant blood loss occurs because the pelvis is a highly vascular area. A type and cross-match must be completed prior to administering blood, which takes time.