Exam (elaborations) Nursing 11456

Review 1. A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return D: Improve venous return. Elevating the leg both improves venous return and reduces swelling. Client comfort will be improved as well. 2. The nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? A) Clean the meatus, begin voiding, then catch urine stream B) Void a little, clean the meatus, then collect specimen C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine A: Clean the meatus, begin voiding, then catch urine stream. A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it’s best to just slip the container into the stream. Other responses do not reflect correct technique 3. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16-year-old who had an open reduction of a fractured wrist 10 hours ago B) 20-year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72-year-old recovering from surgery after a hip replacement 2 hours ago D) 75-year-old who is in skin traction prior to planned hip pinning surgery. C: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first. The 16-year-old should be seen next because it is still the first post-op day. The 75-year-old is potentially vulnerable to age-related physical and cognitive consequences in skin traction should be seen next. The client who can safely be seen last is the 20-year-old who is 2 weeks post-injury. 4. A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glasgow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glasgow Coma Scale 13, no ventilator required B: Glasgow Coma Scale 8, respirations regular. The Glasgow Coma Scale provides a standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose provides too much room for interpretation and is not very precise. 5. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug? A) Bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time C: Prothrombin time. Coumadin is ordered daily, based on the client’s prothrombin time (PT). This test evaluates the adequacy of the extrinsic system and common pathway in the clotting cascade; Coumadin affects the Vitamin K dependent clotting factors.