Nokea
Which client symptom indicates that the nurse should discontinue the medication and notify the physician even if the client's pain is unrelieved?
- A. Vomiting
- B. Dizziness
- C. Drowsiness
- D. Headache
Correct Answer: A
Rationale: Vomiting is a sign of colchicine toxicity, requiring immediate cessation.
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Which assessment finding warrants immediate action by the nurse when a client is in Buck's traction?
- A. The traction weights are hanging above the floor.
- B. The leg is in line with the pull of the traction.
- C. The right is about is to be the two.
- D. The rope is in the groove of the traction pulley.
Correct Answer: A
Rationale: Traction weights must hang freely to maintain proper pull. If they are above the floor (e.g., resting on something), the traction is ineffective, requiring immediate correction to ensure proper alignment and healing.
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: Supine with legs elevated improves venous return in shock.
The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority?
- A. Presence of bruising to the right elbow
- B. Pain level rating on a 0-10 scale
- C. Sensation and pulse of the right forearm
- D. Left-handed or right-handed
Correct Answer: C
Rationale: C. Impairment of the neurovascular system is a priority. The closed reduction could cause further damage, which would be noted distal to the injury. Sensation and pulses are part of a neurovascular assessment to an extremity.
Which level of participation should the nurse expect when assessing a 9-year-old who has mental retardation with an IQ level of 45?
- A. Able to communicate verbally only with two-letter words
- B. Able to read and comprehend simple written instructions
- C. Able to walk independently and perform a simple skill
- D. Able to perform tasks that require careful manual dexterity
Correct Answer: C
Rationale: An IQ of 45 indicates moderate intellectual disability, allowing independent walking and simple tasks.
The HCP's progress note states that the infant with meningitis is in an opisthotonus position. What should the nurse observe when performing an assessment?
- A. Resistance with specific leg movement
- B. Knee or hip flexion with head flexion
- C. A high-pitched cry with neck flexion
- D. Hyperextension of the head and neck
Correct Answer: D
Rationale: Opisthotonus is characterized by severe hyperextension of the head and neck, often seen in meningitis.