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Questions 149

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Question 1 of 5

The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip. If a diagnosis of unilateral dislocation of the right hip is made, which of the following symptoms will the nurse observe?

Correct Answer: B

Rationale: folds and creases will be longer and deeper on affected side

Question 2 of 5

A client admitted with transient ischemia attacks has returned from a cerebral arteriogram. The nurse performs an assessment and finds a newly formed hematoma in the right groin area. What is the nurse's initial action?

Correct Answer: A

Rationale: Applying direct pressure to a hematoma at the arteriogram site controls bleeding and prevents further complications, making it the initial action.

Question 3 of 5

A client with advanced Alzheimer's disease has been prescribed haloperidol (Haldol). What clinical manifestation suggests that the client is experiencing side effects from this medication?

Correct Answer: B

Rationale: Haloperidol, an antipsychotic, can cause extrapyramidal side effects like tremors, which are common and indicate a neurological side effect.

Question 4 of 5

The nurse is inserting an intravenous line into the right arm and has identified a potential insertion site. Place the steps (indicated in Roman numerals) of venipuncture in the proper sequential order.

Order the Items

Source Container

Palpate vein.
Cleanse skin
Apply tourniquet.
Perform venipuncture.

Correct Answer: C,A,B,D

Rationale: Venipuncture sequence: Apply tourniquet (III), palpate vein (I), cleanse skin (II), perform venipuncture (IV).

Question 5 of 5

A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:

Correct Answer: D

Rationale: Sulfamylon (mafenide acetate) causes a burning sensation upon application, which should be explained to the client.

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