Nursing Elites

1. A client with a cast complains of numbness and tingling in the affected limb. What should the nurse do first?

• A. Check for tightness of the cast
• B. Elevate the limb
• C. Apply ice to the area
• D. Notify the physician

Correct answer: A

Rationale: The correct first action for a client with a cast experiencing numbness and tingling in the affected limb is to check for tightness of the cast. Numbness and tingling can indicate compromised circulation, and a tight cast may be causing this. Checking the cast for tightness is essential to ensure it is not impeding circulation. Elevating the limb, applying ice, or notifying the physician can be subsequent actions depending on the assessment findings after checking the cast. Elevating the limb might help improve circulation, applying ice is not indicated for numbness and tingling, and notifying the physician can be done if the issue persists after addressing the immediate concern of cast tightness.

2. The nurse is caring for a client who is postoperative following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?

• A. Keep the client in a low Fowler's position.
• B. Maintain hip abduction with pillows.
• C. Encourage early ambulation.
• D. Place the client in a prone position.

Correct answer: B

Rationale: Maintaining hip abduction with pillows is the most important intervention to prevent dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and prevents excessive internal rotation, which can lead to dislocation. Keeping the client in a low Fowler's position (Choice A) does not provide the necessary support and stability for the hip joint. While early ambulation (Choice C) is important for preventing complications such as blood clots and promoting circulation, it is not the most crucial intervention for preventing dislocation. Placing the client in a prone position (Choice D) can be harmful and increase the risk of dislocation.

3. The nurse is preparing to administer a subcutaneous injection of heparin. What is the correct angle of insertion?

• A. 15 degrees
• B. 30 degrees
• C. 45 degrees
• D. 90 degrees

Correct answer: C

Rationale: The correct angle of insertion for a subcutaneous injection, such as heparin, is 45 degrees. This angle is appropriate as it helps to ensure proper delivery of the medication into the subcutaneous tissue. Option A (15 degrees) is too shallow for a subcutaneous injection and may result in the medication being deposited into the muscle. Option B (30 degrees) is also too shallow for subcutaneous injections. Option D (90 degrees) is used for intramuscular injections, not subcutaneous injections.

4. A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the nurse provide?

• A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visual deficits
• B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina
• C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyes in the newborn
• D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection

Correct answer: D

Rationale: The correct answer is D because informing about state law emphasizes the legal requirement and public health rationale behind prophylactic eye treatment to prevent serious infections like gonorrheal or chlamydial ophthalmic infection. Choices A, B, and C are incorrect. Choice A focuses on staphylococcus infection, which is not the primary concern addressed by the prophylactic ointment. Choice B mentions a specific infection acquired from the mother's infected vagina, which is not the main reason for the ophthalmic ointment. Choice C discusses tear duct obstruction and dry eyes, which are not the primary concerns addressed by the prophylactic ointment.

5. What skin care measure should the nurse implement for a client who underwent external radiation treatment the previous day?

• A. Cleanse the radiated area with water and pat the skin dry
• B. Lightly massage the radiated skin with a lanolin-based lotion
• C. Rinse the site with normal saline and cover with a sterile towel
• D. Use a soft washcloth to gently remove the skin markings

Correct answer: A

Rationale: The correct measure for skin care after external radiation treatment is to cleanse the radiated area with water and pat the skin dry. This gentle cleansing without harsh chemicals or friction helps protect the integrity of radiated skin, preventing irritation or further damage. Choice B is incorrect because massaging radiated skin can cause further irritation, which should be avoided. Choice C is incorrect as rinsing with normal saline and covering with a sterile towel may not be necessary and could potentially introduce infection due to excessive moisture. Choice D is incorrect as using a soft washcloth to remove skin markings can be too abrasive for radiated skin, risking damage and irritation.

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