Nokea
Which intervention should the nurse implement for a client with a fractured hip in Buck’s traction?
- A. Assess the insertion sites for signs and symptoms of infection.
- B. Monitor for drainage or odor from under the plaster covering the pins.
- C. Check the condition of the skin beneath the Velcro boot frequently.
- D. Take weights off for one (1) hour every eight (8) hours and as needed.
Correct Answer: C
Rationale: Checking skin under the Velcro boot prevents irritation or breakdown in Buck’s traction. Insertion sites and plaster are for skeletal traction, and weights must remain constant.
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The nurse knows that elevated findings on which laboratory test typically validate a diagnosis of gout?
- A. Creatinine clearance
- B. Blood urea nitrogen
- C. Serum uric acid
- D. Serum calcium
Correct Answer: C
Rationale: Elevated serum uric acid confirms gout, as it causes crystal formation.
Which interventions are appropriate for an adolescent experiencing a seizure?
- A. A tongue blade inserted into the adolescent's mouth during a seizure can cause injury.
- B. Padding protects the adolescent's limbs from injury against the hard side rails during a seizure.
- C. Airway obstruction can occur during or after the seizure. An oropharyngeal airway should be available but should not be inserted during the seizure. If the seizure has commenced, nothing should be forced into the adolescent's mouth.
- D. The etiology is unknown. Only if an airborne or droplet infectious disease were suspected as the cause would droplet precautions be considered.
- E. Suctioning equipment may be needed to clear secretions after the seizure.
Correct Answer: B,C,E
Rationale: Padding protects limbs from injury, an oropharyngeal airway should be available but not inserted during a seizure, and suctioning equipment may be needed post-seizure to clear secretions.
The nurse would be correct to request a consultation with a dietitian if the client chooses a meal that includes which food?
- A. Nuts
- B. Milk
- C. Eggs
- D. Liver
Correct Answer: D
Rationale: Liver is high in purines, which increase uric acid levels, worsening gout. Nuts, milk, and eggs are low-purine foods, suitable for a gout diet, necessitating a dietitian consultation for education.
A cast has just been applied to a client's left forearm, and he has 10 lbs of Russell's traction on his left leg. Which of the following nursing concerns takes priority in the care of this client?
- A. The casted extremity may swell, and the cast will become a tourniquet.
- B. Heat conduction from the wet cast can cause burning to the skin below.
- C. Muscle atrophy of the areas involved can lead to decreased muscle tone.
- D. Skin irritation from the cast edges can cause abrasions.
Correct Answer: A
Rationale: Swelling in a newly casted extremity can cause the cast to act as a tourniquet, compromising circulation, which is the priority concern. Heat from a wet cast does not burn skin, muscle atrophy is a long-term issue, and skin irritation is less urgent.
Which statement to the nurse indicates a good understanding by the client of the use of methotrexate and cyclosporine?
- A. I am having an exacerbation of symptoms so two medications are needed.
- B. Cyclosporine is given to enhance the effect of the methotrexate.
- C. Methotrexate and cyclosporine together decrease unwanted side effects.
- D. My symptoms are severe enough to indicate the use of two strong medications.
Correct Answer: D
Rationale: Severe symptoms may necessitate combination therapy with methotrexate and cyclosporine, both potent immunosuppressants, to control rheumatoid arthritis. Cyclosporine does not enhance methotrexate, and side effects are not necessarily reduced.