Nursing Elites

1. A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?

• A. A weight greater than 10 lbs. should be used.
• B. The line of pull is upward at an angle.
• C. The line of pull is straight
• D. A weight greater than 20 lbs. should be used.

Correct answer: C

Rationale: The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.

2. When administering intravenous electrolyte solution, which of the following precautions should the nurse take?

• A. Infuse hypertonic solutions cautiously.
• B. Mix no more than 60 mEq of potassium per liter of fluid.
• C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
• D. Monitor the client's digitalis dosage for potential adjustments due to IV calcium administration.

Correct answer: C

Rationale: When administering intravenous electrolyte solutions, it is crucial to prevent infiltration of calcium to avoid tissue necrosis and sloughing. Hypertonic solutions should be infused cautiously (Choice A) to prevent adverse effects. The correct amount of potassium to be mixed in a liter of fluid is no more than 60 mEq, making Choice B incorrect. While monitoring the client's digitalis dosage for potential adjustments due to IV calcium administration is important, the statement suggesting an increased dosage is incorrect as IV calcium diminishes digitalis's action, making Choice D incorrect.

3. Which of the following needs immediate medical attention and emergency intervention? The client who:

• A. complains of sharp pain upon taking a deep breath and excessive coughing.
• B. exhibits yellow, productive sputum, low-grade fever, and crackles.
• C. has a shift of the trachea to the left, with no breath sounds on the right.
• D. has asthma and complains of an inability to catch her breath after exercise.

Correct answer: C

Rationale: Choice C is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised, and venous return to the heart is affected. The mediastinal shift is to the unaffected side, indicating a critical situation that requires immediate intervention to prevent further deterioration. This condition can rapidly progress to a life-threatening state, necessitating prompt medical attention. Choices A, B, and D do not present with life-threatening conditions requiring emergency intervention. Choice A mentions symptoms of pleurisy, which may be painful but not immediately life-threatening. Choice B describes symptoms of bronchitis, which may require medical attention but not of an emergent nature. Choice D reflects a common complaint in asthma but does not suggest an immediate life-threatening situation unless severe respiratory distress is present.

4. Which of the following symptoms is most characteristic of a client with lung cancer?

• A. exertional dyspnea
• B. persistent changing cough
• C. air hunger; dyspnea
• D. cough with night sweats

Correct answer: B

Rationale: The most characteristic symptom of lung cancer is a persistent changing cough. This cough may worsen over time and may produce blood-tinged sputum. Exertional dyspnea (Choice A) is more common in chronic obstructive pulmonary disease (COPD) due to airway obstruction. Air hunger and dyspnea (Choice C) are more typical of conditions like asthma. Cough with night sweats (Choice D) is commonly associated with tuberculosis rather than lung cancer.

5. For which adverse effect of the block does the postpartum nurse monitor the woman after receiving a subarachnoid (spinal) block for a cesarean delivery?

• A. Headache
• B. Pruritus
• C. Vomiting
• D. Hypertension

Correct answer: A

Rationale: The correct answer is 'Headache.' Postdural headache is a common adverse effect associated with a subarachnoid block due to cerebrospinal fluid leakage at the site of dural puncture. This headache worsens when the woman is upright and may improve when she lies flat. To manage this headache, bed rest and adequate hydration are recommended. Pruritus, vomiting, and hypertension are not typically associated with subarachnoid blocks. Pruritus, nausea, and vomiting are more commonly linked to the use of intrathecal opioids.

Similar Questions