hazards of improper splinting include

NCLEX-PN

Nclex Questions Management of Care

1. What are the hazards of improper splinting?

A. Aggravation of a bone or joint injury
B. Reduced distal circulation
C. Delay in transporting a client with a life-threatening injury
D. All of the above

Correct answer: D

Rationale: Hazards of improper splinting can lead to the aggravation of a bone or joint injury, reduced distal circulation, and delay in transporting a client with a life-threatening injury. Choosing 'All of the above' (Option D) is the correct answer as it encompasses all the hazards mentioned. Option A is incorrect because it only addresses one aspect of the hazards. Option B is incorrect as it does not cover all the hazards associated with improper splinting. Option C is incorrect as it focuses on only one hazard and does not account for the others.

2. A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:

A. measure intake and output.
B. check albumin levels.
C. monitor glucose levels.
D. increase enteral feeding.

Correct answer: A

Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.

3. What is the purpose of the hydraulic lift (Hoyer lift)?

A. To assist clients who have had orthopedic surgery.
B. To assist clients who are unable to stand and extremely obese clients.
C. To assist clients of all ages in a hospital setting.
D. To assist clients with special needs.

Correct answer: B

Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.

4. A client with dumping syndrome should _ while a client with GERD should _.

A. lie down 1 hour after meals; sit up at least 30 minutes after meals
B. sit up 1 hour after meals; lie flat 30 minutes after meals
C. sit up after meals; sit up after meals
D. lie down after meals; lie down after meals

Correct answer: A

Rationale: Clients with dumping syndrome should lie down after eating to decrease the symptoms of dumping syndrome, which include rapid gastric emptying leading to various gastrointestinal symptoms. On the other hand, clients with GERD should sit up at least 30 minutes after meals to prevent the backflow of stomach acid into the esophagus. This position helps reduce symptoms by allowing gravity to keep the stomach contents in place, minimizing the chances of reflux. Therefore, the correct answer is to lie down 1 hour after eating for dumping syndrome and to sit up at least 30 minutes after eating for GERD. Choices B, C, and D are incorrect because they do not accurately reflect the appropriate positioning for each condition.

5. In which situation is the nurse upholding the ethical principle of fidelity?

A. Providing complete information regarding treatment options to a client with newly diagnosed cancer
B. Allowing a client to decide when to receive daily hygiene care
C. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion
D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

Correct answer: D

Rationale: Fidelity is the ethical principle of keeping promises made to clients, families, and other healthcare professionals. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan exemplifies fidelity. By advocating for the client's preferences and ensuring their requests are addressed, the nurse demonstrates a commitment to fulfilling promises made to the client. Allowing a client to decide when to receive daily hygiene care relates to respecting autonomy, not fidelity. Inserting a 19-gauge intravenous catheter into a client needing a blood transfusion aligns with beneficence, as it involves taking action to provide necessary treatment. Providing complete information to a client with newly diagnosed cancer about treatment options reflects justice, promoting fairness and equity in healthcare by offering equal access to information and treatment choices.