Nokea
The unlicensed assistive personnel (UAP) reports a client with a fractured femur has 'fatty globules' floating in the urinal. What intervention should the nurse implement first?
- A. Assess the client for dyspnea and altered mental status.
- B. Obtain an arterial blood gas and order a portable chest x-ray.
- C. Call the HCP for a ventilation/perfusion scan.
- D. Instruct the UAP keep the client on strict bedrest.
Correct Answer: A
Rationale: Fatty globules in urine suggest fat embolism syndrome; assessing for dyspnea and altered mental status (respiratory/neurological signs) is the priority. Diagnostics and bedrest follow.
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The nurse is teaching the client with carpal tunnel syndrome how best to utilize a wrist splint. Which statement is most appropriate for the nurse to include in the teaching?
- A. Leave the splint in place even when bathing.
- B. Wear the splint as tight as can be tolerated.
- C. Remove the splint intermittently throughout the day.
- D. Only wear the splint when doing work that stresses the fingers.
Correct Answer: C
Rationale: C. Although the splint decreases swelling and promotes healing and is necessary in the management of the pain with carpal tunnel syndrome, it should be removed intermittently during the day to exercise the wrist and bathe.
What interventions should the nurse implement for a child who sustained a twisting injury of the right arm?
- A. Elevate the arm and apply ice at the site of the child's injury.
- B. Wrap the child's arm with an elastic bandage.
- C. Telephone the child's parent to discuss the injury.
- D. Call the health care provider identified by the child.
- E. Make arrangements to obtain an x-ray of the child's arm.
- F. Meet with the student who caused the child's injury.
Correct Answer: A,B,C
Rationale: Elevation, ice, and wrapping reduce swelling; contacting the parent ensures proper follow-up.
Which nursing observation provides the best indication that the halo-cervical traction device is applied appropriately?
- A. The client has full range of motion in the neck.
- B. The client's neck pain is within a tolerable level.
- C. The client can speak and hear at preinjury levels.
- D. The client reports the ability to see straight ahead.
Correct Answer: D
Rationale: The ability to see straight ahead indicates proper alignment of the halo device, ensuring the cervical spine is stabilized correctly. Full neck motion contradicts the purpose, and pain or speech/hearing are less specific.
A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply.
- A. The client requests pain medication to sleep.
- B. The client has eupnea and normal sinus rhythm.
- C. The client has petechiae over the neck and chest.
- D. The client has a high arterial oxygen level.
- E. The client has yellow globules floating in the urine.
Correct Answer: C,E
Rationale: Petechiae and yellow globules suggest fat embolism syndrome, requiring immediate intervention. Pain medication, normal breathing, and high oxygen are not urgent.
A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?
Correct Answer: 30
Rationale: Concentration: 20,000 units ÷ 500 mL = 40 units/mL. Rate: 1200 units/hr ÷ 40 units/mL = 30 mL/hr.