Nokea
Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- A. Utilizes a Steinman pin
- B. Requires that both legs be secured
- C. Utilizes Kirschner wires
- D. Is used primarily to heal the fractured hips
Correct Answer: A
Rationale: Balanced skeletal traction commonly uses a Steinman pin to stabilize fractures.
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A 15-year-old client was involved in an auto accident and requires emergency surgery to control bleeding, but both parents are out of town and unable to sign the consent form. Which of the following is the most appropriate action?
- A. The client signs the consent form.
- B. The parents give telephone consent with two witnesses listening.
- C. The parents give email consent.
- D. The physician operates without consent because of the emergency situation.
Correct Answer: D
Rationale: In an emergency where a minor requires life-saving surgery and parents are unavailable, the physician can proceed without consent (D) to save the client's life. Client consent (A), telephone consent (B), or email consent (C) are not appropriate in this urgent situation.
The doctor is preparing to remove chest tubes from the client's left chest. In preparation for the removal, the nurse should instruct the client to:
- A. Breathe normally
- B. Hold his breath and bear down
- C. Take a deep breath
- D. Sneeze on command
Correct Answer: B
Rationale: Holding breath and bearing down (Valsalva maneuver) prevents air entry into the pleural space during chest tube removal.
A 28-year-old woman pregnant with twins comes in for her prenatal appointment. She tells the nurse that she has two children at home (ages 4 years and 16 months), and she had one abortion 6 years ago when she was 8 weeks along in the pregnancy. The nurse charts
- A. gravida 4, para 2.
- B. gravida 4, para 3.
- C. gravida 5, para 2.
- D. gravida 5, para 3.
Correct Answer: C
Rationale: Gravida counts all pregnancies (2 children, 1 abortion, current twin pregnancy = 5). Para counts deliveries after 20 weeks (2 children = 2). Twins count as one delivery.
Which of the following pediatric clients is at greatest risk for latex allergy?
- A. The child with a myelomeningocele
- B. The child with epispadias
- C. The child with coxa plana
- D. The child with rheumatic fever
Correct Answer: A
Rationale: Children with myelomeningocele are at higher risk for latex allergy due to repeated exposure to latex products during medical procedures.
The nurse is reviewing the lab reports on several clients. Which one should be reported to the physician immediately?
- A. A serum creatinine of 5.2 mg/dL in a client with chronic renal failure
- B. A positive C reactive protein in a client with rheumatic fever
- C. A hematocrit of 52% in a client with gastroenteritis
- D. A white cell count of 2,200 cu/mm in a client taking Dilantin phenytoin
Correct Answer: D
Rationale: A white cell count of 2,200 cu/mm indicates severe leukopenia, a serious side effect of Dilantin, requiring immediate reporting.