Nokea
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.
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Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nursing take?
- A. Take no action because this is the correct procedure for transferring a client.
- B. Instruct the UAPs not to use a transfer board when moving the client.
- C. Tell the UAPs to use the bed scale sling to move the client to the chair.
- D. Request the UAPs to stop and come to the nurse’s station immediately.
Correct Answer: A
Rationale: Using a transfer board is safe and appropriate for bed-to-wheelchair transfers; no action is needed. Other options are incorrect or unsafe.
The nurse correctly instructs the client to avoid which type of fluid?
- A. Milk
- B. Alcohol
- C. Cranberry juice
- D. Carbonated drinks
Correct Answer: B
Rationale: Alcohol increases uric acid levels, worsening gout.
In which conditions might the nurse assess for the presence of papilledema?
- A. Eczema
- B. Craniosynostosis
- C. Shaken baby syndrome
- D. Hydrocephalus
- E. Chest trauma
Correct Answer: B,C,D
Rationale: Papilledema, indicating increased intracranial pressure, can be associated with craniosynostosis, shaken baby syndrome, and hydrocephalus.
The nurse is assessing the client immediately following a C5-C6 anterior cervical discectomy. Which potential problem should be the nurse's priority?
- A. Altered breathing pattern
- B. Impaired tissue perfusion
- C. Altered mobility
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Retractors used during surgery can injure the recurrent laryngeal nerve, resulting in the inability to cough effectively to clear secretions. Edema and bleeding can also compromise the airway and compress the spinal cord.
The client is a 73-year-old woman who fell in her home and suffered a right hip fracture. She tells the nurse that she was walking across the kitchen and felt something 'snap' in her hip and this made her fall. What type of fracture is the client most likely to have?
- A. Comminuted fracture
- B. Greenstick fracture
- C. Open fracture
- D. Pathological fracture
Correct Answer: D
Rationale: A 'snap' before falling suggests a pathological fracture, likely due to weakened bone (e.g., osteoporosis) in an elderly woman.