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Questions 158

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Question 1 of 5

The nurse is caring for a client with diabetes mellitus. Which instruction should be given to the client?

Correct Answer: D

Rationale: Numbness and tingling in the feet and toes may indicate diabetic neuropathy a serious complication requiring prompt reporting. Avoiding stairs reducing sodium or daily weighing are not specific to diabetes management unless indicated.

Question 2 of 5

The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:

Correct Answer: B

Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.

Question 3 of 5

A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?

Correct Answer: D

Rationale: Digoxin's therapeutic level is 0.8-2.0 ng/mL. Digoxin's toxic level is >2.0 ng/mL.

Question 4 of 5

The client is admitted with a diagnosis of abruptio placenta. Which diagnostic test is most likely to be ordered?

Correct Answer: C

Rationale: Ultrasound can confirm placental separation in abruptio placenta and fetal heart monitoring assesses for distress due to hypoxia. Both tests are critical for diagnosis and management.

Question 5 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.

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