Nokea
An 8-year-old girl has a closed transverse fracture of her right ulna.
Which of the following actions, if performed by the nurse before the application of a cast, is MOST important?
- A. Check the radial pulses bilaterally and compare.
- B. Evaluate the skin temperature and tissue turgor in the area.
- C. Assess sensation of each foot while the girl closes her eyes.
- D. Apply baby powder to decrease skin irritation under the cast.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness (2) assessment, temperature indicates decreased circulation, but is subjective and not most important (3) assessment, upper (not lower) extremity fracture (4) implementation, should not be done because it would increase skin irritation
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The nurse is reviewing client assignments on a medical/surgical unit.
The nurse determines that the assignment is appropriate if the nursing assistant is caring for which of the following clients?
- A. A client with AIDS dementia complex who requires a urine specimen.
- B. A client complaining of postoperative pain after repair of a torn rotator cuff.
- C. A client with GI bleeding due to a duodenal ulcer receiving packed cells.
- D. A client with type I diabetes receiving prednisone for a herniated disk.
Correct Answer: A
Rationale: Strategy: Assign clients with standard, unchanging procedures. (1) correct-standard, unchanging procedure (2) assign to the RN (3) assign to the RN (4) assign to the RN
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
- A. Transfer the client to another caregiver
- B. Reassess the goals with the client
- C. Request a longer hospital stay
- D. Role play the current plan with the client
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.
A client is receiving heparin via continuous IV infusion for management of deep vein thrombosis (DVT). The partial thromboplastin time (PTT) is 1.5 times greater than normal.
Which of the following actions by the nurse is MOST appropriate?
- A. Discontinue the heparin infusion.
- B. Slow down the heparin infusion.
- C. Check the prothrombin time (PT) results.
- D. Continue to monitor the client.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each answer. (1) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (2) no reason to discontinue or slow the infusion because the PTT is within a therapeutic range (3) prothrombin time (PT) Test is useful for assessing warfarin (Coumadin) therapy (4) correct-expected result of heparin therapy is a prolonged PTT of 1.5 times the control, without signs of hemorrhage
A client has been brought into the emergency room for treatment of a suspected drug overdose. The client appears to be highly agitated, fearful, and may be hallucinating.
The nurse should anticipate the client's need for
- A. immediate support from family and friends who accompanied her.
- B. a warm, friendly approach to reduce fears.
- C. a quiet, darkened room to decrease sensory stimulation.
- D. an immediate referral to a social service agency.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate at this time because the client is not in contact with reality (2) may agitate the client further (3) correct-sensory stimulation would only increase agitation and could potentially lead to aggressive behavior and injury (4) not the priority at this time
A client is scheduled to undergo a bone marrow aspiration. Which position would the nurse assist the client into for this procedure?
- A. Dorsal recumbent
- B. Supine
- C. High Fowler's
- D. Lithotomy
Correct Answer: A
Rationale: The dorsal recumbent position is used for bone marrow aspiration, typically performed on the iliac crest, allowing access and patient comfort. Supine, High Fowler's, and lithotomy positions are not suitable, so B, C, and D are incorrect.