Nokea
Which client should the nurse call first?"
- A. Client with a left humerus fracture reporting stiffness and limited range of motion in the left shoulder
- B. Client with a left shoulder sling due to a fractured clavicle reporting vomiting after taking oxycodone
- C. Client with a right leg cast applied yesterday for a fractured ankle reporting itching in the right foot
- D. Client with fibromyalgia reporting unresolved burning pain and prescribed amitriptyline 1 week ago
Correct Answer: C
Rationale: Itching in a new cast may indicate skin irritation or an allergic reaction, requiring prompt assessment to prevent complications. Stiffness in a fracture or unresolved fibromyalgia pain are less urgent.
You may also like to solve these questions
The most common cause of injury from a house fire is:
- A. explosion.
- B. falls from second-story windows.
- C. thermal damage to skin and body surfaces.
- D. inhalation injury.
Correct Answer: D
Rationale: Inhalation injury, from smoke and toxic gases, is the most common cause of house fire injuries, often leading to respiratory compromise. Thermal damage is also significant but less frequent. Accident Prevention
In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding?
- A. Age 40 years
- B. Lactose intolerance
- C. Family history of breast cancer
- D. Use of cocaine on weekends
Correct Answer: D
Rationale: Use of cocaine on weekends. Cocaine use is harmful to the breastfed infant, even with intermittent use.
A young couple asks the nurse what method of contraception they should use. What information is most important for the nurse to have before giving an answer?
- A. The exact age of the couple
- B. The sexual history of both partners
- C. The method they find most acceptable
- D. How soon they want to start a family
Correct Answer: C
Rationale: The couple's preferred contraceptive method ensures adherence and satisfaction, guiding the nurse's recommendations. Age, sexual history, or family planning timeline are secondary.
The nurse enters the room of an adult who is having a grand mal seizure. Which initial action is appropriate?
- A. Put a padded tongue blade in the client's mouth.
- B. Restrain the client.
- C. Turn the client's head to the side.
- D. Call the physician immediately.
Correct Answer: C
Rationale: Turning the head to the side during a seizure prevents airway obstruction by saliva or vomit, prioritizing safety, unlike tongue blades (risk injury), restraints, or immediate physician calls.
The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?
- A. Crackles in the lungs
- B. Confusion and restlessness
- C. Distended neck veins
- D. Use of accessory muscles
Correct Answer: B
Rationale: Confusion and restlessness. Neurological changes, including impaired mental status, are early signs of inadequate oxygenation.