The nurse-manager of a perinatal unit is notified that one c...

A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?

A. Blow cool air from a hair dryer under the cast
B. Twist the cast back and forth
C. Shake powder into the cast
D. Push a pencil under the cast edge

Correct Answer: A

Rationale: The correct answer is A: Blow cool air from a hair dryer under the cast. This method helps to relieve itching by providing airflow without causing damage to the cast or skin. It is safe and effective.

Choice B: Twisting the cast back and forth may cause discomfort or injury to the child's arm.

Choice C: Shaking powder into the cast can create a mess and may lead to skin irritation or infection.

Choice D: Pushing a pencil under the cast edge can cause damage to the skin or lead to complications.

What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

A. Bladder palpation
B. Inspection of the mouth
C. Blood glucose monitoring
D. Auscultation of breath sounds

Correct Answer: B

Rationale: The correct answer is B: Inspection of the mouth. Phenytoin can cause gingival hyperplasia as a common untoward effect. By inspecting the mouth regularly, the nurse can assess for signs of this side effect such as swollen or bleeding gums. Bladder palpation (A) is not relevant to monitoring phenytoin side effects. Blood glucose monitoring (C) is not typically associated with phenytoin use. Auscultation of breath sounds (D) is not directly related to monitoring for phenytoin side effects.

The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?

A. Perform passive range of motion to the right leg
B. Remove skeletal weights every shift to assess right leg
C. Turn frequently from prone to supine positions
D. Maintain skeletal pin sites and assess for signs of infection

Correct Answer: D

Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications.

Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process.

Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process.

Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.

A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

A. Ineffective airway clearance
B. Altered nutrition less than body requirements
C. Fluid volume excess
D. Activity intolerance

Correct Answer: A

Rationale: The correct answer is A: Ineffective airway clearance. After a ureter lithotomy, the client may be at risk for respiratory complications due to anesthesia, pain, and immobility. Ineffective airway clearance can lead to hypoxia and respiratory distress, making it the highest priority. Altered nutrition, fluid volume excess, and activity intolerance are important but are secondary to the immediate threat of compromised airway and breathing in the postoperative period. Therefore, addressing airway clearance first is crucial to ensure optimal client outcomes.

The nurse is planning care for a client receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?

A. Administer an antiemetic before meals
B. Provide frequent mouth care
C. Encourage small, frequent meals
D. Offer clear liquids

Correct Answer: A

Rationale: The correct answer is A: Administer an antiemetic before meals. Administering an antiemetic before meals helps prevent and manage nausea associated with chemotherapy by blocking receptors that trigger nausea and vomiting. This intervention targets the root cause of the symptom. Providing frequent mouth care (B) may help with taste changes but does not directly address nausea. Encouraging small, frequent meals (C) and offering clear liquids (D) may be helpful for some clients, but they do not specifically target nausea caused by chemotherapy.

HESI RN CAT Exit Exam

HESI RN CAT Exit Exam Related

Correct Answer: B

You may also like to solve these questions

Correct Answer: A

Correct Answer: B

Correct Answer: D

Correct Answer: A

Correct Answer: A