Nokea
Which material added by the nurse is best for covering the tips of the pin to prevent injuries while the client is in skeletal leg.
- A. Gauze squares
- B. Cotton balls
- C. Cork blocks
- D. Rubber tubes
Correct Answer: C
Rationale: Cork blocks securely cover pin tips, preventing injury to the client or staff while maintaining stability. Gauze and cotton are less durable, and rubber tubes may not fit securely.
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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.
When planning the client's discharge, the nurse must help the client obtain which essential piece of equipment for home care?
- A. A wheelchair
- B. A hospital bed
- C. A raised toilet seat
- D. A mechanical lift
Correct Answer: C
Rationale: A raised toilet seat maintains hip angles below 90 degrees, preventing dislocation during toileting, which is essential for safe home care post-hip replacement.
The clinic nurse assesses a client with complaints of pain and numbness in the left hand and fingers. Which question should the nurse ask the client?
- A. Do you smoke or use any type of tobacco products?'
- B. Do you have to wear gloves when you are out in the cold?'
- C. Do you do repetitive movements with your left fingers?'
- D. Do you have tremors or involuntary movements of your hand?'
Correct Answer: C
Rationale: Repetitive movements are a primary cause of carpal tunnel syndrome, causing pain and numbness. Smoking, cold sensitivity, and tremors are unrelated.
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 50-year-old female client is being evaluated for osteoporosis. Which data should the nurse assess? Select all that apply.
- A. Family history of osteoporosis.
- B. Estrogen or androgen deficit.
- C. Exposure to secondhand smoke.
- D. Level and amount of exercise.
- E. Alcohol intake.
Correct Answer: A,B,C,D,E
Rationale: Family history, hormonal deficits, smoking, exercise, and alcohol are all risk factors for osteoporosis, requiring comprehensive assessment.