Nokea
Which nursing observation provides the best indication that the halo-cervical traction device is applied appropriately?
- A. The client has full range of motion in the neck.
- B. The client's neck pain is within a tolerable level.
- C. The client can speak and hear at preinjury levels.
- D. The client reports the ability to see straight ahead.
Correct Answer: D
Rationale: The ability to see straight ahead indicates proper alignment of the halo device, ensuring the cervical spine is stabilized correctly. Full neck motion contradicts the purpose, and pain or speech/hearing are less specific.
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An hour ago the HCP split the client's forearm cast due to severe arm pain, throbbing, and tingling. Which most important action should be taken by the nurse when the client's symptoms return?
- A. Administer an intravenous pain medication.
- B. Notify the health care provider immediately.
- C. Cut the cast padding and spread the cast Men
- D. Elevate the arm on pillows above the heart level.
Correct Answer: B
Rationale: B. The nurse should notify the HCP immediately because these symptoms suggest compartment syndrome, which is a medical emergency.
The physician orders prednisone for a client with rheumatoid arthritis for painful wrists and joints. Which instruction is it essential for the nurse to give the client?
- A. Take the pills with milk or food.'
- B. Be sure to take the medication between meals.'
- C. Stop the pills at once if your face begins to get puffy.'
- D. Your urine may turn pinkish while taking this.'
Correct Answer: A
Rationale: Taking prednisone with food or milk reduces gastrointestinal irritation, a key instruction for safe administration.
Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nursing take?
- A. Take no action because this is the correct procedure for transferring a client.
- B. Instruct the UAPs not to use a transfer board when moving the client.
- C. Tell the UAPs to use the bed scale sling to move the client to the chair.
- D. Request the UAPs to stop and come to the nurse’s station immediately.
Correct Answer: A
Rationale: Using a transfer board is safe and appropriate for bed-to-wheelchair transfers; no action is needed. Other options are incorrect or unsafe.
The nurse, caring for the client who had bilateral THRs 2 days ago, determines that the client will need a referral to manage exercises and stairs when at home. The nurse should plan to initiate a referral with which interdisciplinary team member?
- A. Occupational therapist
- B. Social worker
- C. Physical therapist
- D. Health care provider
Correct Answer: C
Rationale: C. The physical therapist is the team member with expertise to assist in exercises and ambulating with assistive devices.
The nurse teaches the trainers that adolescent soccer players are at increased risk for which abnormality?
- A. Varus knee deformities
- B. Valgus knee deformities
- C. Varus ankle deformities
- D. Valgus ankle deformities
Correct Answer: A
Rationale: Adolescent soccer players are at risk for varus knee deformities due to repetitive stress on the knees.