ATI NCLEX Medical Surgical Assessment 1 A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take?
... [Show More] (select all that apply) A. Monitor peripheral pulses in the affected extremity B. Position weights against the foot of the bed C. Adjust the prescribed weights every 24 hrs D. Examine the skin under the traction bood E. Assess the temperature of the affected extremity A, D, E -- A, closely monitor the neurovascular integrity. Circulation can be compromised from the fracture as well as the traction device B, weights should hang freely away from the foot of the bed to promote proper traction and healing. Hanging freely provides counter traction that diminishes muscle spasms C, Buck's is a short term treatment with weights ranging 2.3-4.5 kg (5-10lb). Nurse does not adjust the weight without a prescription from the provider D, monitor skin integrity at least every 8 hr E, Circulation can be compromised from the fracture as well as the traction device. Check and document color, temperature, distal pulses, capillary refill, movement, and sensation during neurovascular assessment. Monitor 6 P's: pain, pallor, pulselessness, pressure, paresthesia, and paralysis A nurse is reviewing safety measures with the caregiver of a client who has Alzheimer's disease. Which of the following instructions should the nurse include in the teaching A. Lock doors leading to stairways B. Instruct the client not to use the stove C. Place a throw rug in front of the toilet D. Provide a darkened room for the client to sleep A This pt is at an increased risk for falls d/t difficulty with balance and an inability to recognize dangerous situations due to brain damage from the disease -- B, learning and memory are loss impaired, so it is unrealistic to expect this pt to remember instructions long term. Caregiver should remove the knobs or controls on the stove so the pt cant turn it on C, at a high risk for falls, rugs increase risk for slipping D, loss of cognition and recognition of environment. Keeping the room dark will further decrease the ability of the client to gain their bearings and places the client at risk for falls. Use a night-light A nurse is developing a plan of care for a client who has meningitis. Which of the following interventions should the nurse include in the plan A. Keep the client's room dark and quiet B. Perform a vascular assessment for the client every 6 hr C. Maintain the head of the client's bed at 15 degrees at all times D. Place the client on contact precautions A Meningitis often causes photophobia and phonophobia. Reduce stimuli -- B, risk of thrombotic or embolic complications, perform a vascular assessment at least every 4 hours or more often as needed C, head of bed should be elevated to 30 degrees at all times. Remain on bedrest until activity is tolerated D, meningitis needs droplet precautions for the first 24 hr of antibiotic therapy to prevent transmission. If viral meningitis is confirmed diagnosis, the precautions may be removed A nurse is caring for a client who has a right subclavian central venous catheter. Which reconnecting a new intravenous infusion administration set, which of the following actions should the nurse take A. Ask the client to exhale slowly B. Turn the client's head to the right C. Place the client in a semi fowlers position D. use aseptic technique D aseptic= sterile prevents central line related blood infections when disconnecting and reconnecting the new set -- A, ask pt to perform the valsalva maneuver by inhaling, holding their breath, and bearing down to prevent any air from entering the catheter when disconnecting and reconnecting the new set B, turn clients head to the left to facilitate access to the clients catheter, which is located in the right subclavian vein C, the client should lie flat to ensure the catheter exit site is at or below the level of the heart when disconnecting and reconnecting the new set A nurse is educating an older adult client about immunizations. Which of the following immunizations should the nurse include [Show Less]