Medical surgical proctored examLATEST NEW EXAM!!!

A client returns to the surgical unit from the PACU in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup? - CORRECT ANSWERS-*The weights rest against the foot of the bed. Rationale: Weights that rest against the foot of the bed or on the floor do not apply the traction essential for reducing the fracture and immobilizing the bone. A client who has a lower-leg cast reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take? - CORRECT ANSWERS-*Petal the edges of the cast. Rationale: Petaling the edges of the cast is a procedure that involves cutting strips of tape and applying them in an overlapping fashion around the edge of a cast. This reduces skin irritation from rough edges. A home health nurse is assisting with the plan of care for an older adult client who had cataract surgery recently. Which of the following information should the nurse include in the plan of care? - CORRECT ANSWERS-*Rest in semi-Fowler's position." Rationale: The client should rest in a semi-Fowler's position to prevent increasing intraocular pressure. A nurse assisting with the care of a client who is receiving treatment following a motor vehicle crash. Which of the following actions should the nurse take to determine the client's level of alertness? - CORRECT ANSWERS-*Check the client's eye opening in response to verbal stimuli. Rationale: Checking the client's eye opening response to verbal stimuli is an appropriate method to check alertness. A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse perform first? - CORRECT ANSWERS-*Check the client's temperature. Rationale: The first action the nurse should take using the nursing process is to collect data from the client and check the client's temperature to determine if the client has a fever, as this is a manifestation of meningitis. D. Administer an oral analgesic. Rationale: The nurse should adminis A nurse at an outpatient surgery center is reinforcing discharge teaching with a client's partner following surgical removal of a cataract. Which of the following information should the nurse include in the teaching? - CORRECT ANSWERS- *The client should wear dark glasses while outdoors. Rationale: Following surgical removal of a cataract, the nurse should instruct the client and partner to wear sunglasses when outside until pupil reaction returns. A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities? - CORRECT ANSWERS-*Checking pupillary responses to light Rationale: Cranial nerve III, the oculomotor nerve, is responsible for pupillary responses to light. Indications that intracranial pressure is increasing include lethargy, decreasing consciousness, tachypnea, hypertension, bradycardia, bounding pulse, and changes in the pupils, such as a sluggish response to light and dilation of one or both pupils. A nurse caring for a client who is recovering from a stroke. The client states "I feel like less of a man. My wife says she is thankful I am alive but I'm sure this is not how she expected us to spend our retirement years." Which of the following is an appropriate response? - CORRECT ANSWERS-* "In what ways do you feel like you are less of a man?" Rationale: The nurse should use the therapeutic technique of restating or rephrasing to encourage the client to state his concerns in greater detail. A nurse collecting data from a client who has Meniere's disease? Which of the following is an expected finding for this client? - CORRECT ANSWERS-*Gradual hearing loss Rationale: An expected finding for a client who has Meniere's disease is tinnitus and gradual loss of hearing in one ear. Some clients also have hearing loss in both ears A nurse enters a client's room and finds the client on the floor in the clonic phase of a tonic-clonic seizure. Which of the following interventions should the nurse take? - CORRECT ANSWERS-*Place a pillow under the client's head. Rationale: The nurse should place a pillow or any soft padding under the client's head to protect the client from injury during the seizure. A nurse in a community clinic is collecting data from an older adult client who has a body mass index of 17.5. When evaluating the client for dehydration, the nurse should look for which of the following indications of fluid-volume deficit? - CORRECT ANSWERS-*Dry mucous membranes Rationale: With older adult clients, reliable indicators of dehydration include dry mucous membranes in the nose and mouth, concentrated urine, speech incoherence, and weakness of the extremities. A nurse in a provider's office is collecting data for a 45-year-old client who is having manifestations associated with perimenopause. Which of the following findings should the nurse expect? - CORRECT ANSWERS-*Report of dryness with vaginal intercourse Rationale: Perimenopause includes the years surrounding m