Nokea
Which is the best material for the nurse to place under a wet cast immediately after application?
- A. Synthetic sheepskin
- B. A vinyl sheet
- C. An absorbent pad
- D. Several pillows
Correct Answer: D
Rationale: Several pillows elevate the casted extremity, promoting venous return and reducing swelling while the cast dries, without absorbing moisture or causing pressure points. Sheepskin and vinyl are less effective, and absorbent pads may retain moisture.
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The nurse is analyzing the serum laboratory report for the client diagnosed with lung cancer that has metastasized to the pelvic bone. Which specific finding should the nurse anticipate?
- A. Elevated calcium
- B. Decreased hemoglobin
- C. Elevated creatinine (SCr)
- D. Elevated creatine kinase (CK)
Correct Answer: A
Rationale: A. Malignant tumors cause hypercalcemia through a variety of mechanisms, one being an increased release of calcium from the bones.
Which finding should the nurse report as a sign of increased intracranial pressure (ICP)?
- A. While an increasing temperature may be associated with ICP, it may also be due to an infection. It is more important for the nurse to report the widened pulse pressure as a sign of increased ICP.
- B. A widened pulse pressure (increased systolic BP and a decreased diastolic BP) is one of the signs of Cushing's triad and is indicative of ICP.
- C. Bradycardia (not tachycardia) is associated with ICP.
- D. An increased systolic BP (not decreased systolic BP) is another sign of Cushing's triad.
Correct Answer: B
Rationale: Widened pulse pressure is a hallmark of Cushing's triad, indicating increased ICP.
Which interventions should the nurse implement for a child with a newly applied fiberglass hip-Spica cast?
- A. Use a hair dryer on a low setting to help dry the cast.
- B. Place on a Bradford frame for elevation off the bed.
- C. Place pillows to support the child's lower extremities.
- D. Turn the child every 2 hours and monitor the CMS.
- E. Petal the perineal area and other edges of the cast.
Correct Answer: C,D,E
Rationale: Pillows provide support, turning prevents pressure sores, and petaling protects skin around cast edges.
The nurse is teaching the client with carpal tunnel syndrome how best to utilize a wrist splint. Which statement is most appropriate for the nurse to include in the teaching?
- A. Leave the splint in place even when bathing.
- B. Wear the splint as tight as can be tolerated.
- C. Remove the splint intermittently throughout the day.
- D. Only wear the splint when doing work that stresses the fingers.
Correct Answer: C
Rationale: C. Although the splint decreases swelling and promotes healing and is necessary in the management of the pain with carpal tunnel syndrome, it should be removed intermittently during the day to exercise the wrist and bathe.
The 10-year-old, who is Chinese, is scheduled to receive methotrexate to treat IRA. Which information in the medical record of a 10-year-old Chinese child scheduled to receive methotrexate for JRA should prompt the nurse to withhold the dose and contact the HCP?
- A. H&P documentation
- B. Laboratory findings
- C. Vital signs abnormalities
- D. Physical assessment findings
Correct Answer: B
Rationale: Abnormal laboratory findings, such as liver or kidney dysfunction, may contraindicate methotrexate administration.