a nurse is caring for a client with a broken femur who is in a traction splint in bed all of the following interventions are part of care of this clie a nurse is caring for a client with a broken femur who is in a traction splint in bed all of the following interventions are part of care of this clie
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Nursing Elites

NCLEX NCLEX-RN

Health Promotion and Maintenance NCLEX RN Questions

1. A client with a broken femur is in a traction splint in bed. Which of the following interventions is NOT part of caring for this client?

Correct answer: C: Turning the client to a side-lying position

Rationale: When caring for a client with a broken femur in a traction splint, turning the client to a side-lying position is not recommended. This client is at risk of skin breakdown and complications due to the injury, making it important to prevent unnecessary movement that may increase the risk of injury or discomfort. Palpating the temperature of both feet helps in assessing circulation, evaluating pulses bilaterally ensures perfusion to the extremities, and relieving heel pressure by placing a pillow under the foot helps in reducing pressure points and preventing complications like pressure ulcers. Therefore, the correct answer is turning the client to a side-lying position as it is not a recommended intervention in this scenario.

2. The mitral valve is synonymous with the term:

Correct answer: Bicuspid valve

Rationale: The mitral valve, also known as the bicuspid valve, is located between the left atrium and the left ventricle, regulating blood flow from the left atrium into the left ventricle. The term 'bicuspid' refers to the valve's two cusps or leaflets. This distinguishes it from the tricuspid valve (Choice D), which has three cusps, making Choice D incorrect. The left ventricle (Choice A) and right atrium (Choice B) are not synonymous with the mitral valve. Therefore, the correct answer is C: Bicuspid valve.

3. The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

Correct answer: Skin will remain intact and without redness during hospital stay

Rationale: The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.

4. A client undergoing presurgical testing before a total abdominal hysterectomy says to the nurse, 'After I have this surgery I know my husband will never come near me again.' Which response would the nurse give?

Correct answer: You're concerned about how your husband will respond to your surgery.

Rationale: The correct response acknowledges the client's expressed concern about her husband's reaction to the surgery, encouraging further discussion without imposing the nurse's assumptions. Choice A reframes the client's concern to focus on the husband's response, aligning more closely with the client's stated worry. Choice B makes an assumption about the client's concerns regarding sexual relations, which may not be the primary focus of her statement. Choice C shifts the attention to how others perceive the client, deviating from the client's specific reference to her husband's reaction, thus not addressing the client's main concern.

5. A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?

Correct answer: Focus on your sons' needs during the first days at home.

Rationale: It is essential for the nurse to guide the client on the initial steps in involving her 2 and 12-year-old sons in the care of their newborn sister. The most appropriate response is to 'Focus on your sons' needs during the first days at home.' In an expanded family, parents should prioritize reassuring older children that they are loved and as important as the newborn. This response acknowledges the importance of ensuring the well-being and emotional adjustment of the older siblings during the transition period. Choices B, C, and D are less appropriate as they do not directly address the emotional needs and adjustment of the older children during this significant family change.

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