a client with a fractured femur is placed in skeletal traction what action should the nurse prioritize
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Nursing Elites

HESI RN

HESI Exit Exam RN Capstone

1. A client with a fractured femur is placed in skeletal traction. What action should the nurse prioritize?

Correct answer: A

Rationale: The correct action the nurse should prioritize when a client is placed in skeletal traction for a fractured femur is to ensure that the weights are freely hanging. This is crucial to maintain proper alignment of the bone and prevent complications. Placing pillows under the client's knees (Choice B) is not a priority in skeletal traction. Adjusting the weights to alleviate discomfort (Choice C) should not be done without proper orders from the healthcare provider. Ensuring that the traction ropes are free of knots (Choice D) is important but ensuring the weights hang freely is the priority to maintain traction effectiveness.

2. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

3. The nurse is developing an educational program for older clients discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics?

Correct answer: D

Rationale: The correct answer is D, 'All of the above.' When developing educational materials for older clients with new antihypertensive medications, it is essential to include characteristics such as using pictures to illustrate complex ideas, providing a list with definitions of unfamiliar terms, and using common words with few syllables. These features help enhance understanding and medication adherence, especially for older adults who may have challenges with health literacy. Choices A, B, and C collectively address the need for simplicity, visual support, and clarification of terms in educational materials, making them crucial for effective patient education.

4. A client in labor who received epidural anesthesia experiences a sudden drop in blood pressure. What action should the nurse take first?

Correct answer: D

Rationale: In a client experiencing a sudden drop in blood pressure after epidural anesthesia, the first action the nurse should take is to place the client in a lateral position. This position helps improve venous return and cardiac output by relieving aortocaval compression. Administering oxygen via nasal cannula may be necessary if the client shows signs of respiratory distress, but it is not the first priority in this situation. Administering an intravenous fluid bolus can help stabilize blood pressure, but repositioning the client takes precedence. Preparing the client for an emergency cesarean section is not indicated solely based on a sudden drop in blood pressure after epidural anesthesia; this step would be considered if other complications arise.

5. The client is being taught about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?

Correct answer: A

Rationale: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs can increase the risk of bleeding in clients taking Coumadin, which is an anticoagulant medication. Avoiding NSAIDs helps prevent potentially dangerous interactions with Coumadin. Choices B, C, and D are incorrect. Cough medicines with guaifenesin, histamine blockers, and laxatives containing magnesium salts do not typically have significant interactions with Coumadin therapy. Therefore, they are not the over-the-counter medications that the client needs to avoid while on Coumadin.

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