Nokea
The nurse receives a client from the postanesthesia care unit who has had skeletal traction applied in the operating room. The nurse should take immediate action to correct which problem with the traction setup when it is noted?
- A. Knots are secured tightly.
- B. There are weights at both ends of the bed.
- C. Weights are resting against the foot of the bed.
- D. Pin site is exposed to air without any dressing.
Correct Answer: C
Rationale: The traction setup is checked to ensure that weights are hanging freely from the ropes and knots are tied securely. The weights should not be resting on the bed. Countertraction is commonly supplied by the client's body weight or by weights pulling in the opposite direction. Therefore, there can be weights at both ends of the bed. Pin-site care varies but usually includes regularly removing exudate with half-strength hydrogen peroxide, rinsing pin sites with sterile saline, and drying the area with sterile gauze; the pin site is left open to air. If any problems are noted, they should be fixed immediately.
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You have been asked to teach an inservice class for nurses in your facility about ethics. Which of the following should you consider during the planning of this educational activity?
- A. Planning a way to evaluate the effectiveness of the class by seeing a decrease in the amount of referrals to the facility's Ethics Committee
- B. Establishing educational objectives for the class that reflect the methods and methodology that you will use to present the class content
- C. The need to exclude case studies from the class because this would violate client privacy and confidentiality
- D. Some of the most commonly occurring bioethical concerns including genetic engineering into the course content
Correct Answer: B
Rationale: When planning an educational activity, establishing clear educational objectives is essential to define the content, methods, and expected outcomes of the class, ensuring effective learning.
A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). The nurse should teach the client to avoid which of the following foods?
- A. Green leafy vegetables.
- B. Citrus fruits.
- C. Whole grains.
- D. Lean meats.
Correct Answer: A
Rationale: Green leafy vegetables are high in vitamin K, which can reduce warfarin's anticoagulant effect.
The nurse is caring for a client post-thyroidectomy. Which finding indicates a potential complication?
- A. Hoarseness
- B. Incisional pain
- C. Mild swelling at the site
- D. Thirst
Correct Answer: A
Rationale: Hoarseness post-thyroidectomy may indicate recurrent laryngeal nerve damage, a serious complication requiring immediate reporting.
A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instruction in the medication and the importance of monitoring his heart rate. An expected outcome of the education program will be:
- A. A return demonstration of palpating the radial pulse.
- B. A return demonstration of how to take the medication.
- C. Verbalization of why the client has atrial fibrillation.
- D. Verbalization of the need for the medication.
Correct Answer: A
Rationale: Teaching the client to monitor their radial pulse ensures they can detect irregularities or bradycardia, a critical aspect of managing digoxin therapy.
When cleaning the skin around an incision and drain site, which of the following procedures should the nurse follow?
- A. Clean the incision and drain site separately.
- B. Clean from the incision to the drain site.
- C. Clean from the drain site to the incision.
- D. Clean the incision and drain site simultaneously.
Correct Answer: A
Rationale: Cleaning separately prevents cross-contamination between the incision and drain site, reducing infection risk.