Nokea
A 20-year-old woman with a fracture of the left femur is placed in Buck's traction with a 7-lb weight. The patient keeps sliding down in bed.
The nurse should
- A. elevate the patient's left thigh on two pillows.
- B. elevate the foot of the bed on blocks.
- C. raise the knee gatch on the bed 30°.
- D. instruct the patient to remain in the middle of the bed.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will not prevent patient from sliding down; may change pull of traction (2) correct-will keep leg straight and counter the pull of the weights (3) will bend the leg and alter the pull of the traction (4) not effective way of preventing the patient from sliding down in bed
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The nurse's neighbor complains to the nurse that he feels tired all the time. Which comment suggests to the nurse that the man may have a serious sleep disorder?
- A. My wife complains because I snore off and on all night.'
- B. I like to nap in the afternoon.'
- C. I wake up early every morning.'
- D. My muscles seem to jerk as I fall asleep.'
Correct Answer: A
Rationale: Snoring may indicate sleep apnea, a serious disorder causing fatigue, unlike napping, early waking, or muscle jerks, which are less concerning.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Heart rate of 80 bpm.
- D. Calcium level of 9.0 mg/dL.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-thyroidectomy complication. Options A, C, and D are normal or expected.
The nurse is caring for a client with a history of peptic ulcer disease who is receiving ranitidine (Zantac) 150 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Mild epigastric discomfort.
- B. Occasional heartburn.
- C. Black, tarry stools.
- D. Nausea after meals.
Correct Answer: C
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious complication in peptic ulcer disease. Options A, B, and D are less urgent.
A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST?
- A. A new mother is breastfeeding her two-day-old infant who was born five days early.
- B. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis.
- C. An elderly woman discharged from the hospital three days ago with pneumonia.
- D. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.
Correct Answer: D
Rationale: symptoms of pulmonary edema; requires immediate attention
The nurse is assessing a client who may be bulimic. What objective finding indicates bulimia?
- A. Low self-esteem
- B. Loss of tooth enamel
- C. Feeling of loss of control
- D. Feeling of social inadequacy
Correct Answer: B
Rationale: Loss of tooth enamel from frequent vomiting is an objective sign of bulimia, distinguishing it from subjective emotional symptoms.