The nurse supervises care of a client in Buck's traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)- Nurselytic

Question 1 of 5

The nurse supervises care of a client in Buck's traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

A. The nurse removes the foam boot three times per day to inspect the skin B. The staff turn the client to the unaffected side C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct Answer: C

Rationale: The correct answer is C. Turning the client to the unaffected side helps prevent complications such as pressure ulcers. Dorsiflexion of the foot on the affected leg helps maintain proper alignment and prevent foot drop. The incorrect choices are A and D. Removing the foam boot multiple times per day can disrupt traction, and asking the client to dorsiflex the foot may not be appropriate without ensuring proper alignment and direction from the healthcare provider.

Question 2 of 5

Are M6 practical nurses utilized in field units with patient holding capabilities?

A. Yes B. No C. - D. -

Correct Answer: A

Rationale: Yes, M6 practical nurses are utilized in field units with patient holding capabilities. They play a crucial role in providing care and support in these settings. Choice B is incorrect as M6 practical nurses are indeed utilized in such field units, as stated in the extract. Choices C and D are not applicable as the correct answer is 'Yes.'

Question 3 of 5

The nurse is analyzing laboratory values for the assigned clients. Which finding, based on the client's medical history, indicates the need for immediate follow-up?

A. Client with chronic kidney disease and serum creatinine of 1.6 mg/dL B. Client with diabetes mellitus and a glycosylated hemoglobin A (HbA1c) of 7.0% C. Client with heart failure and a B-type natriuretic peptide (BNP) of 140 pg/mL D. Client who is male and has anemia with hemoglobin of 16.5 g/dL and hematocrit of 45%

Correct Answer: B

Rationale: An HbA1c of 7.0% in a client with diabetes mellitus indicates poor long-term glucose control, necessitating immediate follow-up. Elevated HbA1c levels suggest a higher average blood sugar over the past 2-3 months, increasing the risk of complications associated with diabetes. Choices A, C, and D do not require immediate follow-up based solely on the provided information. A serum creatinine of 1.6 mg/dL in a client with chronic kidney disease, a BNP of 140 pg/mL in a client with heart failure, and hemoglobin of 16.5 g/dL and hematocrit of 45% in a male client with anemia are within acceptable ranges or do not indicate an urgent need for intervention.

Question 4 of 5

The nurse in the pediatric clinic performs a physical assessment of a 13-year-old boy. Which of the following findings by the nurse requires an immediate intervention?

A. The adolescent complains of his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes B. The nurse noted unilateral breast enlargement C. The child's scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass D. The child's scrotum appears enlarged and red. The nurse palpated a thickened and swollen spermatic cord.

Correct Answer: D

Rationale: A swollen and thickened spermatic cord could indicate testicular torsion, which is a surgical emergency.

Question 5 of 5

The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

A. The client who needs both sequential compression devices removed B. The elderly woman who needs assistance ambulating to the bathroom C. The surgical client who needs help changing the gown after bathing D. The male client who needs the intravenous fluid discontinued

Correct Answer: A

Rationale: The correct answer is A because removing sequential compression devices could increase the risk of thromboembolism, making it the priority. Choice B involves assisting with ambulation, which can be done after addressing the urgent need of the client in choice A. Choice C and D involve non-urgent tasks compared to the potential risks associated with not removing sequential compression devices promptly.

Nurselytic

ATI RN

ATI RN

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