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Question 1 of 5

A client in Dunlop traction experiences numbness of the thumb and index finger and cannot move the thumb to touch the tips of the other fingers. The capillary refill time is four seconds. Which of the following actions is indicated?

Correct Answer: A

Rationale: Numbness, impaired thumb movement, and delayed capillary refill suggest compression from a tight elastic bandage. Removing and reapplying it loosely (
A) addresses this. Adjusting weights (B,
D) or countertraction (
C) does not address the symptoms.

Question 2 of 5

The nurse is evaluating nutritional outcomes for an elderly client with anorexia nervosa. Which data best indicates that the plan of care is effective?

Correct Answer: D

Rationale: Weight gain is the most direct indicator of effective nutritional intervention in anorexia nervosa.

Question 3 of 5

The nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?

Correct Answer: C

Rationale: The Valsalva maneuver falsely elevates CVP; normal breathing is required.

Question 4 of 5

The nurse is educating the lady's club in self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram, place an X on the Tail of Spence.

Question Image

Correct Answer: A

Rationale: The Tail of Spence is the upper outer quadrant of the breast, where an X should be placed, as most breast cancers occur in this area.

Question 5 of 5

A client with pancreatic cancer has an infusion of TPN (Total Parenteral Nutrition). The doctor has ordered for sliding-scale insulin. The most likely explanation for this order is:

Correct Answer: C

Rationale: TPN is a high-glucose solution, often causing hyperglycemia, necessitating sliding-scale insulin to manage blood glucose levels.

Similar Questions

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A client is to be discharged with a tracheostomy. Which of the following should the nurse most stress when educating the client about home management? Select all that apply.
The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:
The nurse is caring for a client after a laryngectomy. The client is anxious, with a respiratory rate of 32 and an oxygen saturation of 88. The nurse's first action should be to:
A client is upset that the physician has refused to order a stronger pain medication for the client and berates the nurse, calling the nurse 'worthless and stupid' when the nurse brings the prescribed medication. Which of the following ego defense mechanisms is the client exhibiting?

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