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The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
- A. It will be alright for your friends to autograph the cast.
- B. Because the cast is made of plaster, autographing can weaken the cast.
- C. If they don't use chalk to autograph, it is okay.
- D. Autographing or writing on the cast in any form will harm the cast.
Correct Answer: A
Rationale: Autographing a fiberglass cast does not compromise its integrity, making it safe.
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The nurse is assisting a client who is to undergo a thoracentesis. Which of the following is the optimal position for the procedure?
- A. Lying prone with arms above head
- B. Side lying on the unaffected side
- C. Side lying on the affected side
- D. Upright position, leaning forward over an over-bed tray table
Correct Answer: D
Rationale: The upright position leaning forward (D) maximizes lung expansion and access to pleural fluid during thoracentesis.
The client presents to the emergency room with a hyphema. Which action by the nurse would be best?
- A. Elevate the head of the bed and apply ice to the eye
- B. Place the client in a supine position and apply heat to the knee
- C. Insert a Foley catheter and measure the intake and output
- D. Perform a vaginal exam and check for a discharge
Correct Answer: A
Rationale: Elevating the head and applying ice reduces intraocular pressure and swelling in hyphema, a bleed in the eye.
Prior to drawing blood for blood gas analysis, the nurse conducts the modified Allen test to ensure there is adequate collateral circulation. The nurse asks the client to extend the wrist over a rolled towel and make a fist. Place the following steps (Roman numerals) in order from first to last.
- A. Ask the client to open and close the hand until the skin blanches.
- B. Palpate the ulnar and radial pulses and apply pressure to both arteries.
- C. Observe the hand for color.
- D. Release the ulnar artery while maintaining pressure on the radial artery.
Correct Answer: A,B,D,C
Rationale: Modified Allen test sequence: Blanch hand (I), compress arteries (II), release ulnar artery (IV), observe color return (III) to confirm collateral circulation.
A client undergoing 'cold-turkey' withdrawal from years of substance abuse is most at risk of serious life-threatening complications with which of the following substances?
- A. Heroin.
- B. Cocaine.
- C. Alcohol.
- D. Marijuana.
Correct Answer: C
Rationale: Alcohol withdrawal (C) can cause life-threatening complications like seizures and delirium tremens. Heroin (A), cocaine (B), and marijuana (D) withdrawal, while uncomfortable, are less likely to be fatal.
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?
- A. The client’s urine test is positive for glucose and acetone.
- B. The client has 1+ pedal edema in both feet at the end of the day.
- C. The client complains of an increase in vaginal discharge.
- D. The client says she feels pressure against her diaphragm when the baby moves.
Correct Answer: A
Rationale: abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency