The nurse is caring for a client who has a fiberglass long leg cast on the right leg. Which nursing
actions should be implemented in the cast care of
... [Show More] this client? SATA
a) Smelling the cast and feeling for the presence of hot spots on the cast.
b) Checking neurovascular status of the right exposed foot and toes every four hours.
c) Using a soft cotton-tipped 6-inch swab to help scratch beneath the cast.
d) Placing the nurse's finger in the client's cast while performing cast care.
e) Covering the perineal area of the cast with plastic before client uses the fracture bedpan.
a) Smelling the cast and feeling for the presence of hot spots on the cast.
b) Checking neurovascular status of the right exposed foot and toes every four hours.
d) Placing the nurse's finger in the client's cast while performing cast care.
e) Covering the perineal area of the cast with plastic before client uses the fracture bedpan.
Rationale
Cast care should include ensuring the cast is not too tight, by placing a finger between the client's
skin and cast; by protecting the cast from being soiled by placing a protective plastic covering in
the perineal area before the client uses a bedpan; by smelling for a foul odor coming from the
cast; by palpating for hot spots on the cast every shift; and by performing neurovascular checks
distal to the cast every four hours. Nothing should be placed in the cast to facilitate scratching
beneath the cast.
The nurse is caring for an older client being treated for a cardiac condition who has developed
"dry eyes". Which medication may be contributing to this condition?
a) Procainamide (Procanbid).
b) Iron supplements.
c) Atenolol (Tenormin).
d) Lipitor (Atorvastatin). c) Atenolol (Tenormin).
Rationale
Dry eyes is an annoying side effect of some medications that can cause a client to feel like they
have something in their eye or a continuous scratchy sensation. This condition can cause eye
strain and discomfort to a client. Clients prescribed Atenolol for hypertension are at risk of
developing dry eyes as a side effect of the medication.
The UAP is assisting a client getting into the shower. The charge nurse answers a call from the
cast clinic to immediately send the UAP's other assigned client to the clinic. Which action should
the nurse take?
a) Ask the UAP to find another team member to take the client to the clinic.
b) Notify the delegating nurse of the current request from the cast clinic.
c) Instruct the UAP to take the client to clinic after helping the other client taking a shower.
d) While the client is showering the UAP should take the other client to cast clinic.
b) Notify the delegating nurse of the current request from the cast clinic.
Rationale
The charge nurse should notify the delegating nurse of the situation. The third principle of
delegation is "The person to whom the assignment was delegated cannot delegate that
assignment to someone else... the delegating nurse needs to be notified and reassign the task..."
During a literature review for a research study, the nurse discovers a separate study has already
proved the proposed hypothesis to be true. Which action should the nurse take regarding the
proposed research study?
a) Discontinue the research.
b) Revise the hypothesis of the current study so it is unique.
c) Perform the current study as a replication study.
d) Contact the authors of the original study for permission to continue.
c) Perform the current study as a replication study.
Rationale
Because of inherent scientific error that may exist within all research studies, hypotheses require
more than one test to support their accuracy. A critical weakness with nursing research is a lack
of replication. Retesting a hypothesis that has been shown to be true strengthens the findings of
the earlier study and supports the use of those findings to influence clinical practice.
In assessing the scrotum of a male client, which finding would need to be reported to the
healthcare provider?
a) Asymmetric appearance.
b) Taut appearance of skin surface.
c) Deeper pigmentation of the underside.
d) Presence of sebaceous cysts. b) Taut appearance of skin surface.
Rationale
The skin surface of the scrotum should appear coarse, rather than taut, which may indicate
swelling or edema and should be reported to the healthcare provider.
Which nursing intervention should the nurse implement when caring for a child with nephrotic
syndrome?
a) Take vital signs every 2 hours.
b) Restrict the number of visitors.
c) Reposition the client every 2 hours.
d) Monitor fluid intake and urine output. d) Monitor fluid intake and urine output.
Rationale
Due to the pathophysiology of nephrotic syndrome, decreased colloidal osmotic pressure in the
capillaries is decreased, resulting in overall body edema. Treatment usually includes infusion of
25% albumin and use of diuretics to help pull fluids out of the interstitial tissues back into the
vascular system. Fluid intake and urine output should be carefully monitored to prevent
hypervolemia and edema and monitor the efficacy of the medical interventions.
A six-year-old client, who received a kidney transplant presents with signs including fever,
decreased urine output, and tenderness over the transplanted organ. Laboratory results reveal an
elevated serum creatinine level. This presentation is likely due to which cause?
a) Immunosuppression medications.
b) Obstructive uropathy.
c) Transplant rejection.
d) Nephrotic syndrome. c) Transplant rejection.
Rationale
Transplant rejection is caused by the recipient's immune system response to foreign tissue. Signs
that may alert the nurse to rejection of a kidney transplant include fever, tenderness over the graft
area, decreased urine output, and elevated serum creatinine.
A child recently treated for strep throat presents with gross hematuria, facial swelling, and
elevated blood pressure. Laboratory tests reveal proteinuria and azotemia. Which condition
should the nurse suspect?
a) Acute pyelonephritis.
b) Acute glomerular nephritis.
c) Nephrotic syndrome.
d) IgA nephropathy. b) Acute glomerular nephritis.
Rationale
Acute glomerulonephritis (GN) usually manifests after strept throat or other streptococcal
infection. Typical signs of acute GN include gross hematuria, facial edema, hypertension, and
proteinuria.
A child who is recovering from surgery for removal of a Wilms tumor develops abdominal pain
and distension, absence of bowel sounds, and vomiting. Which complication should the nurse
suspect?
a) Intestinal obstruction.
b) Abdominal peritonitis.
c) Pyloric stenosis.
d) Infectious gastritis. a) Intestinal obstruction.
Rationale
Surgical intervention for Wilms tumor involves removal of the tumor, which requires either a
partial or radical nephrectomy. Small bowel obstruction is one of the most common
postoperative complications following removal of a Wilms tumor.
A child diagnosed with Wilms tumor is being treated with dactinomycin. What class of drug is
this medication?
a) Mitotic inhibitor.
b) Antitumor antibiotic.
c) Corticosteroid.
d) Alkylating agent. b) Antitumor antibiotic.
Rationale
Dactinomycin, also known as actinomycin D, is an anti-tumor antibiotic used in the treatment of
a variety of cancers, including Wilms tumor.
The nurse is reviewing medication education with a client who was prescribed triamcinolone
(Dermasorb) for the treatment of eczema. Which statement by the client indicates the client
misunderstands safe administration?
a) Apply to affected areas, avoiding contact with the eyes.
b) Continue to apply medication for a few days after area has cleared.
c) Cover weeping or denuded areas with an occlusive dressing after medication application.
d) Affected areas treated with the medication can burn easily with sunlight exposure. c)
Cover weeping or denuded areas with an occlusive dressing after medication application.
The nurse explains to a new staff member that the goals of the therapeutic milieu for eating
disorder are designed to help a client establish more adaptive behavioral patterns and develop
normal eating habits. [Show Less]