Nokea
A 20-year-old client has a cast applied for a fracture of the right femur. Three hours later, the client complains that it is hot and painful under his cast.
Which of the following is the MOST appropriate action for the nurse to take?
- A. Assess the cast for wet spots and increase air circulation in the room.
- B. Check the circulation in his casted extremity and change the client's position.
- C. Take the client's temperature and observe him for other signs of infection.
- D. Medicate the client for pain and notify the physician of his complaint.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) heat is sign of pressure (2) correct-heat is sign of pressure, pressure limits circulation (3) too early to see signs of infection (4) all complaints must be investigated, medication would mask signs of pressure, assessment first step
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The nurse is caring for a client with a new colostomy.
- A. What is the most appropriate teaching point for a client with a new colostomy?
- B. Change the appliance every morning.
- C. Empty the pouch when it is one-third full.
- D. Use a mild soap to cleanse the peristomal skin.
- E. Apply a skin barrier only if irritation occurs.
Correct Answer: C
Rationale: Using a mild soap to cleanse the peristomal skin prevents irritation and maintains skin integrity. Changing the appliance daily is unnecessary, emptying at one-third full prevents leaks, and a skin barrier should be used routinely to protect the skin.
A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
- A. Regulate the neonate's temperature using a radiant heater
- B. Withhold feedings while under the phototherapy
- C. Provide water feedings at least every 2 hours
- D. Protect the eyes of neonate from the phototherapy lights
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
- A. Avoid brushing his teeth until the ulcers heal.
- B. Rinse his mouth frequently with normal saline.
- C. Rinse his mouth frequently with hydrogen peroxide.
- D. Cleanse his teeth and mouth with lemon and glycerin swabs.
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a fractured mandible with wiring, in case of emergency airway obstruction. Oral airway , pliers , and tracheostomy set are not standard.
The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:
- A. Decreased urinary output
- B. Hypersomnolence
- C. Absence of knee jerk reflex
- D. Decreased respiratory rate
Correct Answer: B
Rationale: Hypersomnolence is an expected side effect of magnesium sulfate due to its sedative properties, so B is correct. Decreased urinary output , absence of knee jerk reflex , and decreased respiratory rate are signs of toxicity, not expected effects.