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Questions 158

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Question 1 of 5

A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:

Correct Answer: A

Rationale: Skeletal traction is the application of traction directly to bone with the use of pins and wires or tongs for the purpose of providing a strong, steady, continuous longitudinal pull on the bone. It is indicated for preoperative immobilization and positioning of hip and femur fractures. A type of skeletal traction (balanced suspension with a Thomas splint and Pearson attachment) uses a sling to support the extremity, but it also uses weights to provide a strong, steady continuous pull on the extremity. A sling is used instead of pins. Pelvic traction provides an intermittent pull over the pelvis and bone, whereas skeletal traction is continuous. Pelvic traction does not use pins. Skeletal traction uses weights at the end of the bed to provide a continuous pull on long bones. Weights are not applied to both ends of the bed.

Question 2 of 5

A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?

Correct Answer: A

Rationale: Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. Hemoglobin is the main component of RBCs. Its main function is to carry O2 from the lungs to the body tissues and to transport CO2 back to the lungs. RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. PT is used to monitor the effects of oral anticoagulants, e.g., coumarin-type anticoagulants.

Question 3 of 5

A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:

Correct Answer: A

Rationale: Adrenalectomy can disrupt cortisol and aldosterone production leading to blood pressure instability (e.g. hypotension from adrenal insufficiency). Monitoring blood pressure is critical to detect and manage these changes promptly.

Question 4 of 5

A client with a history of a ventricular tachycardia is receiving Amiodarone (Cordarone). The nurse should monitor the client for:

Correct Answer: D

Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring monitoring for cough or dyspnea. Hypotension is possible but less specific, and hyperglycemia/hypokalemia are unrelated.

Question 5 of 5

A client with a history of pancreatitis is admitted with complaints of nausea. The nurse should give priority to:

Correct Answer: A

Rationale: Antiemetics relieve nausea in pancreatitis, improving comfort and preventing dehydration.

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