Nokea
What should the nurse do after noting serosanguineous drainage on the cast of a child with myelodysplasia post-TEV repair?
- A. Cut a window where the drainage is seeping through the cast.
- B. Petal the cast to minimize skin irritation and decrease leakage.
- C. Measure the area of drainage on the cast and document this.
- D. Telephone the surgeon to report the serosanguineous drainage.
Correct Answer: C
Rationale: Measuring and documenting the drainage allows monitoring without compromising the cast's integrity.
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When preparing the client for cast application, which statement by the nurse is most accurate?
- A. The cast will feel tight as it's applied.
- B. Your arm will feel warm as the wet plaster sets.
- C. You can expect a foul odor until the cast is dry.
- D. You may feel itchy while the cast is wet.
Correct Answer: B
Rationale: Wet plaster generates heat as it sets, causing a warm sensation, which is a normal part of the process. Tightness may indicate a problem, odors are not typical, and itching is more common as the cast dries.
Which area of health teaching is essential to include in the discharge instructions for a client who has undergone a total hip replacement?
- A. Modifying ways of donning clothing
- B. Using special equipment for bathing
- C. Taking vigorous daily walks
- D. Receiving a daily stool softener
Correct Answer: A
Rationale: Modifying clothing application (e.g., avoiding bending or crossing legs) prevents hip dislocation, making it essential for discharge teaching. Vigorous walks are contraindicated, and the other options are less critical.
The nurse is to give the client with gout one tablet of colchicine every hour until relief or toxicity occurs. Which of the following is an indication for stopping the colchicine?
- A. Ringing in the ears
- B. Nausea and vomiting
- C. A rash on the client's hips
- D. A temperature of 101°F
Correct Answer: B
Rationale: Nausea and vomiting are signs of colchicine toxicity, indicating the need to stop the medication.
If the client is in shock, how should the nurse position the client while continuing to assess and provide care?
- A. Prone with the arm supported
- B. In Fowler's position with the knees flexed
- C. Supine with the legs elevated
- D. Lateral with the back extended
Correct Answer: C
Rationale: In shock, positioning the client supine with legs elevated improves venous return and cerebral perfusion, stabilizing blood pressure. Other positions are less effective or contraindicated.
The client in the rehabilitation hospital refuses to participate in physical therapy following surgery for repair of a fractured right femur sustained in a motor-vehicle accident (MVA). The client also fractured the left forearm. Which should the nurse implement first when encouraging the client to participate in therapy?
- A. Medicate the client for pain 30 minutes prior to the therapy.
- B. Have the health-care provider make the client go to therapy.
- C. Explain that insurance will not pay if the client does not participate in therapy daily.
- D. Determine why the client refuses to participate in therapy sessions.
Correct Answer: D
Rationale: Understanding the refusal reason (e.g., pain, fear) guides interventions to encourage therapy participation. Pain medication, HCP orders, and insurance threats are secondary.