NCSBN PRACTICE QUESTIONS 76-90

NCSBN PRACTICE QUESTIONS 76-90 An 18 month-old weighing 22 pounds is admitted to the pediatric unit with a diagnosis of dehydration. A replacement bolus of normal saline at 20 mL/kg is ordered to be administered intravenously over 40 minutes. In mL/hour, what will be the setting for the IV delivery system? - correct answer -300 Using ratio proportion:First, convert 22 pounds to kilograms (22/2.2) = 10 kg20 mL/kg = 20 x 10 kg = 200 mL200 mL/40 minutes = x mL/60 minutes (in an hour)200 x 60 = 12000/40 = 300 mL/hrUsing dimensional analysis:20 mL/kg x 1 kg/2.2 lb x 22 lb x 60 min/hr x 1/40 min = 300 mL/hr The mother of a 2 month-old baby calls a pediatrician's nurse two days after the first DTaP, inactivated polio vaccine (IPV), Hepatitis B and Haemophilus influenzae type B (HIB) immunizations. She reports that the baby feels very warm, cries inconsolably for as long as three hours, and has had several shaking spells. Which immunization would the nurse expect to be primarily responsible with these findings? A. DTaP B. IPV C. Hepatitis B D. HIB - correct answer -A DTaP immunization is a vaccine that protects against diptheria, tetanus and pertussis (whooping cough). The majority of reactions described in this question occur with the administration of the DTaP vaccination. Contraindications to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose, as well as signs of encephalopathy within seven days of the immunization. A client diagnosed with angina has been instructed about the use of sublingual nitroglycerin. Which statement made by the client is incorrect and indicates a need for further teaching? A. "I'll call the health care provider if pain continues after three tablets five minutes apart." B. "I will rest briefly right after taking one tablet." C. "I understand that the medication should be kept in the dark bottle." D. "I can swallow two or three tablets at once if I have severe pain." - correct answer -D Clients must understand that just one sublingual tablet should be taken at a time and placed under the tongue. After rest and a five-minute interval, a second and then eventually a third tablet may be necessary.The nurse is working with victims of domestic abuse. The nurse should understand which of these factors is a reason why domestic violence or emotional abuse remains extensively undetected? A. The expenses due to police and court costs are prohibitive B. Little knowledge is known about batterers and battering relationships C. There are typically many series of minor, vague complaints D. Few people who have been battered seek medical care - correct answer -C Signs of domestic violence or emotional abuse may not be clearly manifested and include many series of a minor complaints such as headache, abdominal pain, insomnia, back pain and dizziness. These may be covert indications of violence or abuse that go undetected. These complaints may be vague and reflect ambivalence about the disclosure of any violence or abuse. The nurse is obtaining an aerobic wound culture from a client with stage two pressure injury. The nurse first removes a gauze dressing and observes a moderate amount of purulent drainage on the dressing and then the nurse performs hand hygiene. What is the next correct step in the procedure? A. Swab the gauze dressing that was removed from the wound B. Irrigate the wound with normal saline C. Obtain a culture by rotating a sterile swab in the open wound D. Remove wound exudate from the wound edges with a cotton tip applicator - correct answer -B After removing the dressing and performing hand hygiene, the wound needs to be irrigated to remove surface pathogens before the nurse can obtain a wound culture. Cultures are not obtained from wound exudate on the dressing or wounds that have not been irrigated since the exudate may be contaminated with normal skin flora. The nurse is caring for a client who is experiencing frightening hallucinations that are markedly increased at night. The client's partner asks to stay a few hours beyond the visiting time, in the client's private room. What would be the best response by the nurse? A. "Yes, staying with the client and orienting the client to the surroundings may decrease any anxiety." B. "No, your presence may cause the client to become more anxious." C. "No, it would be best if you brought the client some reading material that the client could read at night."D. "Yes, would you like to spend the night when the client's behavior indicates that the client is or will be frightened?" - correct answer -A Encouragement of a family member or a close friend to stay with the client in a quiet surrounding cannot only help increase orientation, but can also minimize confusion and anxiety. The visitor could also report to the nurse any unusual findings of the client. This would be the most supportive approach for this client. The RN, who is functioning as the charge nurse, needs to determine shift assignments. How will the charge nurse determine which client assignments are appropriate for the licensed practical nurse (LPN)? A. Ask the LPN about prior experience caring for clients with similar diagnoses B. Determine how many nursing assistants are available to help the LPN with client care C. Refer to the list of technical tasks LPNs are trained to perform D. Review the procedure manual with the LPN prior to making an assignment - correct answer -A The definition of assignment is the routine care, activities and procedures that are within the authorized scope of practice of the RN or LPN/LVN. The RN must determine the needs of the clients and make assignments not only based on scope of practice, but also education, demonstrated competency and skill level. Regardless if the LPN received education and training to perform specific skills, the RN needs to determine the LPN's experience with caring for clients with similar diagnoses. While the RN is responsible for ensuring an assignment given to a delegatee is carried out completely and correctly, the LPN must be able to perform the skills or tasks independently. The nurse is caring for a school-aged child with a diagnosis of secondary hyperparathyroidism after treatment for chronic renal disease. Which serum lab data should receive priority attention by the nurse? A. Osmolality and sodium B. Blood urea nitrogen and magnesium C. Calcium and phosphorus D. Glucose and potassium - correct answer -C The parathyroid regulates the calcium and phosphorus serum levels. Calcium and phosphorous levels will be elevated in hyperfunction of this gland until the client is stabilized. To recall this information think of a see-saw. Associate that calcium is first in the alphabet and thus calcium follows the direction of the abnormality - hyper or hypo function - of the parathyroid. Put the calcium on one side and the phosphorus on the other side of the see-saw.The nurse is caring for a client who just had a central venous catheter line inserted at the bedside. Which of these assessments requires immediate attention by the nurse? A. Pallor in the extremities B. Increased temperature by one degree C. Involuntary coughing spells D. Dyspnea at rest - correct answer -D Complications of central catheter insertion include pneumothorax and hemothorax. Air embolism is another potential complication. Dyspnea, shallow respirations, sudden sharp chest pain that worsens with coughing or deep breathing are indications of pneumothorax. Other potential complications of central catheters may include thrombosis, local or systemic infection, or even cardiac tamponade (if the central line perforates the heart). When considering the options listed, the client who is dyspneic after central line insertion would be the greatest concern for the nurse. The nurse is providing preprocedural education to the client preparing for a barium enema. What statement made by the client indicates a need for further education? A. "I will need to drink plenty of fluids and eat foods high in fiber after the procedure." B. "I will use the prescribed laxative before the procedure." C. "I will not eat or drink anything after midnight before the procedure." D. "A barium enema is used to examine the upper and lower GI tracts." - correct answer -D A barium enema involves filling the large intestine (lower GI tract) with diluted barium liquid while xray images are taken. After the procedure, a small amount of barium will be immediately expelled and the remainder will be excreted in the stool. Because barium liquid may cause constipation, clients should eat foods high in fiber and drink plenty of fluids to help expel the barium from the body. A client admitted with heart failure is experiencing severe shortness of breath and states, "I feel like something is terribly wrong!" The client is restless and begins to cough up large amounts of pink frothy sputum. The client's skin is a dusky grayish color and the oxygen saturation levels have decreased from 92% to 76% in the last hour. What is the first action the nurse should take? A. Check vital signs B. Administer the PRN ordered oxygen C. Call the health care provider D. Place the bed in high Fowler's position - correct answer -BWhen dealing with a medical emergency, the rule is to assess airway first, then breathing, and then circulation. Starting oxygen is the priority. The other actions should also be implemented as quickly as possible, including activation of the rapid response team. The client is experiencing an acute episode of fulminant pulmonary edema, likely as a result of a new and severe cardiac event and possible cardiogenic shock. Emergency assessment and intervention is indicated to prevent cardiac arrest and possible death. There is an order for a continuous lidocaine infusion at a rate of 4 mg/minute to treat PVCs. The IV solution contains 2 grams of lidocaine in 500 mL of D5W. The infusion pump delivers 60 microdrops/mL. What rate in microdrops/minute would deliver 4 mg of lidocaine/minute? Report the response using a whole number. - correct answer -60 Dimensional analysis (DA): Remember in DA, you always want to start your equation with what's called for in the solution. In this case, you want to know microdrops/drops/minute = 4 mg/min X 1 g/1000 mg X 500 mL/2 g X 60 microdrops/mL = 4 X 500 X 60/1000 X 2 = 120000/2000 = 60 microdrops/mLAnother way to solve for X:What you have: 2 grams (2000 mg) lidocaine in 500 mL AND you are using a microdrip set (60 microdrops/mL)What you want/need: 4 mg lidocaine to infuse/minute4 mg/min X 500 mL/2000 mg X 60 (microdrops)/min = 60 microdrops/minute The nurse is reviewing client assignments at the beginning of the shift. Which task could be safely assigned to an unlicensed assistive person (UAP)? A. Stay with a client during the self-administration of insulin B. Clean and apply a dressing to a small pressure ulcer on the leg C. Empty a client's colostomy bag D. Monitor a client's response to passive range of motion exercises - correct answer -C If the UAP has demonstrated competency in the task, s/he may empty a client's colostomy bag. This is an uncomplicated, routine task with an expected outcome. The other tasks involve one or more parts of the nursing process and cannot be assigned to an UAP. The school nurse is screening the children for scoliosis. At what time of development should the nurse expect to see early findings of scoliosis? A. During the years when children begin to run and jump B. During a preadolescent growth spurt C. In early infancy before 8 months of age D. When a child begins to play competitive sports - correct answer -BIdiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt. It is more common in females than in males. The home care nurse is admitting a new client with a diagnosis of COPD, atrial fibrillation and gout. After reviewing the client's medication list, the nurse would arrange for periodic monitoring of blood drug levels for which of the following medications? (Select all that apply.) A. Beclomethasone inhaled (Qvar) B. Digoxin (Lanoxin) C. Theophylline (Elixophyllin, Theo-24, Uniphyl) D. Allopurinol (Aloprim, Zyloprim) E. Glipizide (Glucotrol) - correct answer -B,C It is necessary to monitor blood levels for the client taking theophylline and digoxin to prevent the client from developing toxicity. The nurse is working with clients who are diagnosed with eating disorders. Which eating disorder would the nurse expect to cause the greatest fluctuation in serum potassium levels? A. Dysthymic disorder B. Anorexia nervosa C. Binge eating disorder D. Bulimia nervosa - correct answer -D Hypokalemia can be caused by overuse of laxatives and by prolonged fasting and starvation. But the greatest fluctuation in potassium levels is associated with bulimia, due to the purging process that causes dehydration and potassium loss. Low potassium levels can cause weakness, abdominal cramping and irregular heart rhythms. Dysthymic disorder is associated with poor appetite or overeating. The nurse has an order to insert an indwelling urinary catheter for a male client. What is the best reason for lubricating the tip of the catheter prior to insertion? A. Reduce the friction within the urethra B. Diminish the leakage of urine around the catheter C. Minimize risk for infectionD. Prevent bladder distention - correct answer -A Due to the somewhat long length of the male urethra, lubrication reduces potential discomfort and localized tissue irritation as the catheter is passed. A client asks the nurse about including her 2 year-old and 12 year-old sons in the care of their newborn sister. Which response is an appropriate initial statement by the nurse? A. "Focus on your sons' needs during the first days at home." B. "Suggest that your partner spend more time with the boys." C. "Tell each child what he can do to help with the baby." D. "Ask the children what they would like to do for the newborn." - correct answer -A In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn. The nurse is caring for a client who is exhibiting a panic attack. What should the nurse do for this client? A. Assist the client to describe the experience in detail B. Develop a trusting relationship C. Maintain safety for the client D. Teach the client to control behaviors - correct answer -C Clients who display signs of severe anxiety in the form of a panic attack need to be supervised closely until the anxiety is lessened. They may harm themselves or others because during panic attacks perception is narrowed and thinking is flawed. The nurse is to review the topic of caring for clients with Guillain-Barré syndrome with other staff members at a monthly meeting. Which of these findings should the nurse include in the discussion? (Select all that apply.) A. Weakness, tingling or loss of sensation in legs and feet occur first B. Rapidly progressive ascending paralysis of the legs, arms, respiratory muscles and face C. Difficulty with bladder control or intestinal functions D. Hypertension E. Difficulty with eye movement, facial movement, speaking, chewing or swallowingF. Numbness, tingling, prickling sensation or moderate pain throughout the body - correct answer - A,B,C,E,F Guillian-Barré is an autoimmune disease. The symptoms of weakness or tingling sensation begins in the legs and progresses to the arms and upper body, resulting in almost complete paralysis. The client is often put on a ventilator during the worst part of the disease to assist breathing. The client may have low blood pressure or poor blood pressure control. A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? A. Use aseptic technique during dressing changes B. Check results of liver enzyme tests C. Maintain central line catheter integrity D. Monitor serum glucose levels - correct answer -D Hyperglycemia may occur during the first day or two as the child adapts to the high-glucose load of the TPN solution. Thus, a priority nursing responsibility is blood glucose testing. The nurse is teaching diet restrictions to a client diagnosed with Addison's disease. The client indicates an understanding of the dietary restrictions when making which of these statements? A. "I will increase fluids and restrict sodium and potassium." B. "I will increase sodium and fluids and restrict potassium." C. "I will increase sodium, potassium and fluids." D. "I will increase potassium and sodium and restrict fluids." - correct answer -B The manifestations of Addison's disease (also called adrenal insufficiency or hypocortisolism) are due to mineralocorticoid deficiency that results in renal sodium wasting and potassium retention. Other findings are dehydration, hypotension, hyponatremia, hyperkalemia and metabolic acidosis. A nurse is working in an inpatient psychiatric setting. The nurse understands what reason touching clients should be limited to a quick handshake? A. A handshake allows the use of therapeutic touch while maintaining boundaries. B. Touching a client, other than a handshake, can set off a violent episode. C. Refraining from touching signals the termination of the nurse-client relationship.D. A handshake will not be misinterpreted as an invitation to more sexual behavior. - correct answer -A The therapeutic use of touch is a basic part of the nurse-client relationship. However, in a psychiatric setting, the extent of physical contact should be limited to handshakes. Some facilities may even have a no-touch policy, especially when working with clients who have a history of sexual trauma. Even reassuring touching can be misinterpreted by the client. Upon completion of the admission documents, the nurse identifies that an elderly client does not have an advance directive. What action should the nurse take? A. Document this information on the chart B. Refer this issue to the nurse manager and the risk manager C. Give the client written information about advance directives D. Assume that the client wishes full resuscitation efforts - correct answer -C For each admission, nurses should request a copy of a client's current advance directive. If there is none, the nurse must provide written information about what an advance directive implies. It is then the client's choice to sign the forms. Note that a standard is for non-direct care providers to witness these forms; a social worker or other health care professional would need to witness a client's signature. The clinic nurse is examining a 15 month-old child with suspected otitis media. Which group of findings should the nurse anticipate? A. Vomiting, pulling at ears and pearly white tympanic membrane B. Periorbital edema, absent light reflex and translucent tympanic membrane C. Diarrhea, retracted tympanic membrane and enlarged parotid gland D. Irritability, rhinorrhea, and bulging tympanic membrane - correct answer -D Clinical manifestations of otitis media include irritability, rhinorrhea, bulging tympanic membrane, and pulling at the ears. The client is diagnosed with a large spontaneous pneumothorax and will have a chest tube inserted. The nurse understands that the chest tube is needed for which of the reasons listed below? A. Increase intrathoracic pressure to allow both lungs to expand equally B. Drain the purulent drainage from the empyema that caused the problemC. Prevent an accumulation of blood and other drainage into the pleural cavity D. Drain air from the pleural cavity and restore normal intrathoracic pressure - correct answer -D There are no clinical signs or symptoms in primary spontaneous pneumothorax until a cyst or small sac (bleb) ruptures. When air enters the pleural space, the pressure in the space equals the pressure outside the body; the vacuum is lost and the lung collapses. This causes acute onset chest pain and shortness of breath. A small pneumothorax without underlying lung disease may resolve on its own. A larger pneumothorax requires aspiration of the free air and/or placement of a chest tube to evacuate the air. A nurse practicing in a maternity setting has a client whose fetus is post-mature. The nurse recognizes that the fetus is at risk due to what factor? A. Excessive fetal weight B. Low blood sugar levels C. Progressive placental insufficiency D. Depletion of subcutaneous fat - correct answer -C The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long-term effects may be related to hypoxia. These newborns are typically meconium stained. A client is scheduled for a transesophageal echocardiogram (TEE). Prior to the procedure, which activity could be delegated to the unlicensed assistive person (UAP)? A. Assess the client's psychological state B. Provide basic instructions about the procedure C. Obtain a signed consent D. Remove the pitcher of water from the bedside table - correct answer -D Removing the water pitcher would be an appropriate task because the client would be NPO. The health care provider is responsible for instructions about the procedure and needs to address client questions or concerns. The nurse is typically responsible to obtain a signed consent form and to assess the client both physically and psychologically before the procedure. The nurse and a student nurse are discussing the health issues related to a laboring HBsAg-positive client. Which of these comments by the student is incorrect and indicates a need for further instruction? A. "The infant will receive the hepatitis B vaccine within 12 hours after birth."B. "The HBsAg-positive mother should be reported to the state or local health department." C. "The HBsAg-positive mother should not breastfeed her baby." D. "The infant will receive the hepatitis B immune globulin within 12 hours after birth." - correct answer -C All persons with HBsAg-positive laboratory results should be reported to the state or local health department. The newborn should receive the hepatitis B immune globulin and hepatitis B vaccine within 12 hours after birth, using different sites (the second vaccine is given between 1 and 2 months; the last vaccine is given between 6 and 18 months). HBV is not spread by breastfeeding, kissing, hugging, coughing, or casual contact. The nurse is planning care for a 12 year-old child diagnosed with sickle cell disease who is in a vasoocclusive crisis of the elbow. Which intervention should be included in the plan of care? A. Passive range of motion exercise B. Pain management C. Cold compresses to elbow D. Fluid restriction - correct answer -B Management of a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, patient-controlled analgesia promotes maximum comfort. Fluid are usually increased and range of motion exercises are avoided in the acute phase of the crisis. Cold is avoided because it constricts the vessels and may result in increased pain. A nurse is assessing the growth of children during their school-age years. What would the nurse expect to see during this assessment? A. Decreasing amounts of body fat and muscle mass B. Little change in body appearance from year to year C. Yearly weight gain of about 5 1/2 pounds per year D. Progressive height increase of 4 inches each year - correct answer -C School-age children gain about 5 1/2 pounds each year and increase about 2 inches in height. The nurse is assessing a child with suspected lead poisoning. Which assessment should a nurse expect to find? A. Auditory wheezes with expirationB. Numbness and tingling in feet C. Excessive perspiration D. A history of difficulty sleeping - correct answer -B A child who has unusual neurologic complaints, such as neuropathy or footdrop that cannot be attributed to other causes, may be affected by lead poisoning. This may occur when a child ingests or inhales paint chips from lead-based paint or dust during remodeling in older buildings. Other findings of lead poisoning are appearance of bluish gum line, hyperactivity and developmental delays. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? A. Catch a ball B. Ride a bicycle C. Skip on alternate feet D. Stand on one foot - correct answer -D At this age, gross motor development allows a child to balance on one foot. A client has a history of chronic obstructive pulmonary disease (COPD). The nurse enters the client's room to find that the nasal cannula is in proper position with the oxygen set at 6 liters per minute, the client's color is flushed and the respirations are 8 per minute. What should the nurse do first? A. Remove the nasal cannula for at least five minutes B. Lower the oxygen's flow rate C. Place client in a higher sitting position D. Check the client's pulse for strength and rate - correct answer -A The client has findings of oxygen toxicity so the nurse should first remove the cannula for a least five minutes. Then the nurse should perform these next sequence of actions: pulse assessment, change of position and then lower the oxygen flow rate and reapply if respirations are within normal parameters. A higher concentration of supplemental oxygen removes the hypoxic drive to breathe and leads to increased hypoventilation, respiratory decompensation, and the development or worsening of respiratory acidosis. A client who is 12 hours postop becomes confused and says: "Giant sharks are swimming across the ceiling." Which assessment is necessary by the nurse to adequately identify the source of this client's behavior?A. Peripheral glucose stick B. Cardiac rhythm strip C. Pupillary response D. Pulse oximetry - correct answer -D A sudden change in mental status in any postop client should trigger a nursing intervention directed toward evaluation of the client's respiratory status. Pulse oximetry would be the initial assessment. If available, arterial blood gases would be better. Acute respiratory failure is the sudden inability of the respiratory system to maintain adequate gas exchange, which may result in hypercapnia and/or hypoxemia. Clinical findings of hypoxemia include these finding, which are listed in order of initial to later findings: restlessness, irritability, agitation, dyspnea, disorientation, confusion, delirium, hallucinations, and loss of consciousness. While there may be other factors influencing the client's behavior, the first nursing action should be directed toward maintaining oxygenation. Once respiratory or oxygenation issues are ruled out, then significant changes in glucose would be evaluated. A client continuously calls out to the nursing staff when anyone passes the client's door and asks them to do something in the room. The charge nurse should take which approach for this client? A. Reassure the client that a staff person will check frequently to see if the client needs anything B. Arrange for each staff member to go into the client's room to check on needs every hour on the hour C. Keep the client's room door cracked to minimize the distractions of people passing by the room D. Assign a nursing staff member to visit the client at regular intervals - correct answer -D Regular, frequent, planned contact by a designated staff member is the best approach to provide a continuity of care and communicate to the client that care will be available as needed. A nurse working at a clinic is reviewing a client's blood sugar log and recognizes that the client is not consistently monitoring blood sugar. Which of the following diagnostic tests would assist the nurse in evaluating the client's overall management of diabetes? A. Hemoglobin B. Fasting blood sugar C. Hemoglobin A1C D. White blood cell count - correct answer -CThe hemoglobin A1C is the best indicator of glycemic control because it reflects an average of the blood sugar over the life of a red blood cell (approximately 90 to 120 days). The fasting blood sugar will only evaluate the client's blood sugar at that specific testing time. Hemoglobin and a white blood cell count are not used to determine blood sugar levels. A client who has returned from surgery reports feeling nauseated and later has an emesis. The nurse administers promethazine per standing orders. In addition to relief from nausea, what other effects of this medication does the nurse expect? (Select all that apply.) A. Dry mouth B. Sedation C. Pinpoint pupils D. Heart palpitations E. Runny nose - correct answer -A,B,D Promethazine (Phenergan) is used as an antihistamine, sedative and antiemetic. It produces anticholinergic effects, such as dry mouth and nasal congestion, dilated pupils and urinary retention. Although promethazine is a sedative, the nurse should understand that it can cause some people to have heart palpitations and to feel restless and unable to sleep. The nurse suspects that the client is in cardiogenic shock. Which of the following findings supports this information? A. Bradycardia B. Increased cardiac output C. Decreased or muffled heart sounds D. Bounding pulses - correct answer -C Cardiogenic shock involves decreased cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume; it is the leading cause of death in acute MI. Findings of cardiogenic shock include hypotension, rapid and faint peripheral pulses, distant-sounding heart sounds, cool and mottled skin, oliguria and altered mental status. The client is admitted with a pressure ulcer that's two inches in diameter with no tunneling. It is a shallow open ulcer with loss of dermis and a red/pink wound bed. The nurse observes some serous drainage. What intervention does the nurse anticipate will be ordered to treat this wound? A. Hydrogel dressingB. Whirlpool treatment and debridement C. Alginate dressing with silver added D. Alternating pressure pad overlay for the bed - correct answer -A This ulcer is a partial thickness wound. These types of wounds heal by tissue regeneration, which is why the nurse would expect a gel dressing to be ordered. This dressing will keep the wound moist, provide protection from infection and promote healing; also, the cool sensation provided by the gel offers pain relief. Pink/red wound edges are considered normal in the inflammatory stage of healing; the wound does not require debridement. There is nothing to indicate that there's an infection, which is why the alginate with silver is not needed; also, alginate dressings are better for wounds with moderate-to-heavy drainage and are good for filling cavities or tracts. An alternating pressure pad overlay would not treat the wound. The nurse is evaluating a stage III pressure ulcer while performing a dressing change. Which wound assessment findings indicate that the prescribed treatment is appropriate to support wound healing? (Select all that apply.) A. The wound base is moderately moist, shiny and red B. Clumps of soft yellow tissue adhere to the wound bed C. The size of the wound is decreasing D. The periwound texture is moist and soft E. The edge of the wound appears rolled or curled under F. A fruity odor is noted on the dressing - correct answer -A,C A wound base that's moist, shiny and "beefy" red indicates good blood flow, new tissue growth and healing. Slough is clumps or strings of moist and soft tissue and can be yellow, tan or green in color - slough will impede healing. A fruity odor indicates infection. Soft and denuded tissues in the periwound indicate tissue breakdown due to excessive moisture from wound drainage. Curled or rolled wound edges (epibole) prevents epithelial cells from migrating to close the wound. A client with anemia has a new prescription for ferrous sulfate. When teaching the client about diet and iron supplements, what should the nurse emphasize about taking an iron supplement? A. Lie down for about 10 minutes after taking the pill B. Take the iron tablet with a glass of orange juice C. Take an antacid with the iron supplement to reduce stomach upset D. Take the iron tablet with a glass of low-fat milk - correct answer -BIron is best taken on an empty stomach, one hour before or two hours after meals, with a full glass of water or orange juice (ascorbic acid enhances the absorption of iron.) The client should not take the medication with antacids, dairy products, coffee or tea because these will decrease the effectiveness of the medicine. The client should not lie down for at least 10 minutes after taking the medicine. A client has been given a prescription for alendronate. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) A. "I will notify the health care provider if I have any difficulty swallowing." B. "I will take the pill immediately preceding weight-bearing exercise." C. "I will swallow it with 8 ounces of water." D. "I will stand or sit quietly for 30 minutes after taking it." E. "I will always eat breakfast before taking it." - correct answer -A,C,D Alendronate (Fosamax) can cause esophagitis or esophageal ulcers unless precautions are followed. The client must be able to sit upright or stand for at least 30 minutes after taking the tablet. The client should take the tablet first thing in the morning, with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. A nurse, who is assigned for five days to a client who has exhibited manipulative behaviors, becomes aware of feeling reluctance to interact with the client. The nurse should take what action next? A. Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours B. Develop a behavior modification plan for the client that will promote more functional behavior within the next week C. Limit contacts with the client to avoid reinforcement of the manipulative behavior during the work times D. Talk with the client about the negative effects of manipulative behaviors on other clients and staff within the next few days - correct answer -A The nurse who experiences stress in a therapeutic relationship can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of positive and negative actions. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship in positive and negative ways. A nurse is reviewing the nutritional needs for a child diagnosed with cystic fibrosis. The nurse should anticipate that this client would be deficient in which vitamins?A. B12, D and K B. A, D and K C. A, C and D D. A, B1 and C - correct answer -B The uptake of fat-soluble vitamins, A, D and K, is decreased in children with cystic fibrosis. Vitamin B12 is deficient in clients who have had bariatric surgery or various degrees of a gastrectomy. Vitamin B1 is often deficit in clients who have an alcohol addiction. These clients are given a thiamine (B1) injections daily times three to prevent Korsakoff syndrome. Vitamin D may be deficient in people who do not get at least 10 to 15 minutes of sunlight on the arms each day. Vitamin C deficit is associated with less than the needed intake of foods with vitamin C. An older adult client, admitted after a fall at home, begins to seize and loses consciousness. What action by a nurse is appropriate to do next? A. Stay with client and monitor the condition B. Collect pillows and pad the side rails of the bed C. Place an oral airway in the mouth and suction D. Announce a cardiac arrest and plan to assist with intubation - correct answer -A For the client's safety, remain at the bedside and observe respirations, the movements of the extremities and level of consciousness. Prepare to clear the airway or suction if obstructed. If suction equipment is not at the bedside, request that someone else get it for you, rather than leaving the client. Do not place anything in the client's mouth. For safety, do not leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure. In response to a call for assistance by a client in labor, the nurse notes that a loop of the umbilical cord is protruding from the vagina. What is the priority action? A. Put the client into a knee-chest position B. Apply oxygen by mask C. Check for a fetal heart beat D. Call the health care provider - correct answer -A Immediate action is needed to relieve pressure on the cord to prevent the risk of fetal hypoxia. A Trendelenburg or knee-chest position accomplishes this. The exposed cord should be covered with saline soaked gauze and not reinserted. The fetal heart rate should be checked rapidly, the health care provider should be called immediately and the client should be prepared for immediate vaginal or C-section birth. A prolapsed umbilical cord is a medical emergency, which can result in brain damage or death to the fetus if not treated promptly and properly. A client is admitted directly from surgery in skeletal traction for a fractured femur. Which of these nursing interventions should be the priority? A. Maintain proper body alignment B. Apply an overhead trapeze to assist with movement in bed C. Inspect the pin sites for evidence of drainage or inflammation D. Perform frequent neurovascular assessments of the affected leg - correct answer -D The priority postoperative action is to assess the neurovascular status of the leg after a fracture. Nursing management of a client in skeletal traction also includes assessing and caring for pin sites, and educating the client and family about skeletal traction. The overhead trapeze helps the client move in bed and proper body alignment is important, but these are not the priority. If a client is stated to have a dual diagnosis. The nurse should understand that this indicates a substance abuse problem as well as what other type of problem? A. Medical problem B. Mental disorder C. Disorder of any type D. Cross addiction - correct answer -B A dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical dependence. The nurse notes cloudy drainage two days post-insertion of an abdominal catheter for peritoneal dialysis. What other data does the nurse need to collect before reporting this finding to the provider? A. Breath sounds B. Bowel sounds C. Temperature D. Urine output - correct answer -CCloudy drainage may indicate a peritoneal infection, so it is essential to evaluate the client's temperature before notifying the health care provider. In a client on dialysis for renal failure little to no urine output would be an expected finding. A nurse is educating parents on accidental poisoning in children. Which type of accidental poisoning is expected to occur in children under age six? A. Topical contact B. Oral ingestion C. Inhalation D. Eye splashes - correct answer -B The greatest risk for young children is from oral ingestion. While children under age six may come in contact with other poisons or inhale toxic fumes, these are not as common. A 2-year-old child has just been diagnosed with cystic fibrosis. The child's parent asks the nurse what the most important concerns are at this time. Which is the appropriate response from the nurse? A. "Thick, sticky secretions from the lungs are a constant challenge." B. "Cystic fibrosis results in nutritional concerns that can be dealt with." C. "You will work with a team of experts and have access to a support group." D. "There is a high probability of life-long complications." - correct answer -A The primary factor, and the one responsible for many of the clinical manifestations of cystic fibrosis, is mechanical obstruction caused by the increased viscosity of mucous gland secretions.Because of the increased viscosity of bronchial mucus, there is greater resistance to ciliary action (probably secondary to infection and ciliary destruction), a slower flow rate of mucus and incomplete expectoration, which also contributes to the mucus obstruction. This retained mucus serves as an excellent medium for bacterial growth. Reduced oxygen-carbon dioxide exchange causes variable degrees of hypoxia, hypercapnia and acidosis.In severe cases, progressive lung involvement, compression of pulmonary blood vessels and progressive lung dysfunction frequently lead to pulmonary hypertension, cor pulmonale, respiratory failure and death. Pulmonary complications are present in almost all children with cystic fibrosis, but the onset and extent of involvement are variable. A nursing assistant is taking care of a 2 year-old child with Wilm's tumor. The assistant asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN. Which statement by the nurse would be the best response?A. "Touching the abdomen could cause cancer cells to spread." B. "Pushing on the stomach might contribute to a bowel obstruction." C. "Examining the area would be painful." D. "Placing any pressure on the abdomen may cause the tumor to rupture." - correct answer -A Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully. The nurse manager identifies that time spent charting is excessive. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem and then report on this at the next staff meeting." What is the nurse manager's leadership style? A. Affiliative B. Autocratic C. Transformational D. Dynamic - correct answer -C A transformational style of management involves staff members in the decision-making processes. Staff members review current policies and provide feedback to their leader in the pursuit of the common good. A nurse is caring for a 4 year-old two hours after a tonsillectomy and adenoidectomy. Which of these assessments must be reported immediately? A. Complaints of throat pain B. Apical heart rate of 110 C. Increased restlessness D. Vomiting of dark emesis - correct answer -C Increased restlessness with increased respiratory and heart rates are often early signs of active bleeding. The other options are expected findings at this time in the postop period for this surgery. The dark emesis indicates old blood that most likely was swallowed during surgery. The client had an open reduction and internal fixation (ORIF) of a femur fracture. During a routine assessment 36 hours after surgery, the nurse finds the client disoriented, short of breath and warm to the touch. The client's temperature is 102.4 F (39 C). What assessment should the nurse perform next?A. Measure oxygen saturation using a pulse oximeter B. Assess orientation to time, person and place C. Remove the splint and inspect the incision D. Perform a neurologic check of bilateral distal extremities - correct answer -A Based on the client's history and assessment findings, the nurse should suspect fat embolism syndrome (FES). Neurologic changes and respiratory distress are two of the classic findings of FES (the third finding is a characteristic petechial rash.) The nurse should activate the rapid response team. While waiting for the team, the nurse will measure the client's SpO2, as well as pulse and blood pressure, and auscultate the lungs. The nurse will also administer supplemental oxygen and ensure venous access. A hospitalized child has a seizure while the family is visiting. The nurse notes the child's whole body is rigid, followed generalized jerking movements of the extremities. The child vomits immediately after the seizure. What is a priority nursing diagnosis for the child at this time? A. Risk for airway obstruction related to aspiration B. Fluid volume deficit related to vomiting C. Risk for infection related to vomiting D. Altered family processes related to chronic illness and hospitalization - correct answer -A The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for this child is from airway obstruction due to aspiration of the vomit. A nurse is caring for a client with left ventricular heart failure with an ejection fraction (EF) of 40%. Which assessment finding is an early indication of inadequate tissue perfusion? A. Use of accessory muscles B. Crackles in the lungs C. Distended jugular veins D. Confusion and restlessness - correct answer -D Neurological changes, including impaired mental status, are early signs of inadequate tissue perfusion and decreased oxygenation of the brain tissues. Other signs of low EF are shortness of breath, dependent edema and arrhythmias. The low EF indicates that this client has severe damage to the left ventricle (normal EF is about 55-70%). A nurse is caring for a client who is receiving procainamide intravenously. It is important for the nurse to monitor which of these parameters?A. Serum potassium levels B. Hourly urinary output C. Continuous ECG readings D. Neurological signs - correct answer -C Procainamide is used to suppress cardiac arrhythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring. A Hispanic couple confide in the nurse about their concern with staff giving their newborn the "evil eye." What should the nurse communicate to the other personnel who are involved in the care of this family? A. Avoid touching the infant above the waist B. Talk very slowly while speaking to him C. Look only at the parents and not the newborn D. Touch the baby after looking at him - correct answer -D In many cultures, an "evil eye" is cast when looking at a person without touching. Thus, the spell is broken by touching while looking or assessing. Remember that quotations in the stem of the question are often the most important content in the question (evil eye). You should make the association between the words "looking" and "seeing"(eye). Also note that the answer needs to refer to the newborn, not the parents ("give the newborn the evil eye"). To only look at the parents is an unrealistic approach. The client returns from the post anesthesia care unit (PACU) in stable condition following abdominal surgery. While planning immediate postoperative care, the nurse identifies the nursing diagnoses listed below. Prioritize these diagnoses by placing them in order of importance (with 1 being the most important). A. Impaired mobility related to invasive equipment B. Acute pain related to surgical procedure C. Risk for ineffective airway clearance related to anesthesia D. Risk for imbalanced nutrition: less than body requirements related to NPO satus - correct answer - C,B,A,D Airway is the highest priority, especially in the immediate postoperative period. Pain control is the next priority because this client will most likely experience significant pain. Although impaired mobility is expected, it does increase the client's risk for postoperative complications. The client's risk for nutrition imbalance is the lowest priority and is to be expected for a client who has had abdominal surgery; hydration is provided intravenously. The nurse who is caring for clients over the age of 70, implements a teaching plan about diet. Using knowledge based on age-related changes, the nurse will emphasize which of the following factors? A. Add high protein supplements to your diet B. Make at least half your grains whole grain C. Follow the DASH eating plan D. Look for foods fortified with iron and other minerals - correct answer -B Anyone, regardless of age, should eat a balanced diet of nutrient-packed foods. However, the diet of the older adult without other chronic health issues should include an increase of fiber and whole grains. The DASH diet is recommended to reduce blood pressure, but there is nothing to indicate this client is hypertensive. Older adults should eat lean proteins but don't necessarily need protein supplements. They should also look for foods fortified with vitamins B12 and D, as well as calcium. A newborn born prematurely is to be fed breast milk through a nasogastric tube. Why is breast milk preferred over formula for premature infants? A. Is higher in calories/ounce B. Contains less lactose C. Provides antibodies D. Has less fatty acids - correct answer -C Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is left in the infant's stomach. A client was recently released from a locked psychiatric facility. During a scheduled outpatient follow up appointment, the client states to the nurse, "I'm afraid I am going to get sick again." Which of the following responses by the nurse is a priority in preventing relapse? A. "I will provide you with a bus pass and referral to a support group that will help you learn about managing your illness and medications." B. "If you take your medications exactly as your health care provider instructed, you won't get sick again."C. "I think you are doing well but you can call for an appointment with your health care provider if you think you need help." D. "You shouldn't fear a relapse because it can happen to anyone and we will be here to help you." - correct answer -A Relapse prevention is a priority focus for clients recovering from an acute mental illness episode. Since education plus peer and community support rank high in helping prevent relapse, the priority is to refer the client to after-care and support groups. Additionally, since continuity of care involves access to care, the nurse should address the client's transportation needs by offering him a bus pass so he can attend these meetings. Continuing to take medications is important, but advice and reassurance without tangible follow up is not helpful to clients in early recovery from an acute event. Reassurance and referral to a health care provider may also be inadequate and does not demonstrate the nurse's concrete role in relapse prevention. Telling the client not to fear relapse and providing false reassurance is non-therapeutic. A client being treated for hypertension returns to the community clinic for a follow-up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which nursing diagnosis should the nurse select for this client? A. Defensive coping related to chronic illness B. Knowledge deficit related to misunderstanding of disease state C. Altered health maintenance related to occupation D. Noncompliance related to medication side effects - correct answer -D The client kept the appointment and stated knowledge that the pills were important. The client is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process. A nurse is caring for a client suspected to have a diagnosis of active tuberculosis (TB). Which diagnostic tests is essential for the nurse to obtain for the determination of the presence of active TB? A. Sputum culture for cytology B. Tuberculin skin testing C. White blood cell count D. Chest x-ray anterior/posterior and lateral - correct answer -A The sputum culture is the method for the determination if active TB is present. This test takes one to two weeks to get the results. Thus, these clients would need to be in isolation or on medication and not coughing during the wait.The client is taking bupropion to treat depression and is worried about taking the medication. The client tells the nurse a friend said the medication was removed from the market because it caused seizures. What is an appropriate response by the nurse? A. "Omit the next doses until you talk with the health care provider." B. "Your health care provider knows the best drug for your condition." C. "Ask your friend about the source of this information." D. "There were problems, but the recommended dose is changed." - correct answer -D Bupropion (Budeprion, Buproban, Wellbutrin, Zyban) was introduced in the United States in 1985 and then withdrawn because of the occurrence of seizures in some clients who took the drug. The drug was reintroduced in 1989 with specific recommendations about dose ranges to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with higher dosages. The nurse is caring for a 17 month-old child diagnosed with acetaminophen poisoning. Which of these lab reports should the nurse review first? A. Aspartate aminotransferase (AST) and Alanine transaminase (ALT) B. Prothrombin Time (PT) and partial thromboplastin time (PTT) C. Red blood cell and white blood cell counts D. Blood urea nitrogen (BUN) and creatinine clearance - correct answer -A Acetaminophen is toxic to the liver and causes hepatic cellular necrosis. This causes the liver enzymes AST and ALT to be released into the blood stream, which elevates serum levels. The next lab values to review are those associated with coagulation, then the blood counts and lastly the renal-associated labs, including BUN and creatinine. The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.) A. No showering for 48 hours after surgery B. Maintain bedrest for 24 hours before gradually resuming regular activities C. Some shoulder discomfort can be expected D. Use 2 tablespoons of Milk of E. Magnesia if no bowel movement 3 days after surgery E. Restrict diet to bland, easily digestible food for a few daysF. Gently scrub off the "skin glue" when you feel able - correct answer -A,C,D,E Laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days. The home health nurse observes the client change an ileostomy pouch. Which action is best to help prevent skin breakdown? A. Use deodorant soaps the contain lotion to clean the stoma B. Change the stoma pouch daily C. Apply antiseptic cream to reddened stoma D. Make sure the skin around the stoma is wrinkle-free - correct answer -D The ileostomy pouch should be changed approximately every 5 to 7 days; the bag should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma. The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer to ensure a tight, leakfree seal. A nurse is caring for a client who is receiving a blood transfusion and develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A. Slow the rate of infusion B. Stop the infusion C. Take vital signs and observe for further deterioration D. Administer Benadryl and continue the infusion - correct answer -B This is an indication of an allergy to the plasma protein. The priority action of the nurse is to stop the transfusion by disconnecting at the IV insertion site. The nurse should then start a saline line at the IV insertion site and notify the health care provider. A client has end-stage renal disease. Which of these statements made by the client indicates a correct understanding of the issues related to this disease?A. "I can expect to have periods of little urine and then sometimes a lot of urine." B. "I have to go for epoetin (Procrit) injections at the health department." C. "I know I have a high risk of clot formation since my blood is thick from too many red cells." D. "My bones will be stronger with this disease since I will have higher calcium than normal." - correct answer -B Anemia in end-stage renal failure is caused by reduced endogenous erythropoietin production in the kidney. Anemia in primary end-stage renal disease is treated with subcutaneous injections of Procrit or Epogen to stimulate the bone marrow to produce red blood cells. With kidney failure, too much phosphorus can build up in the blood and calcium is pulled from the bones, resulting in weakened bones. The statement about producing variable amounts of urine is incorrect, as the client will produce little to no urine at this stage of the disease. The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU? A. An ICU nurse and intensivist remotely monitor ICU clients around the clock B. An ICU nurse is on-call to answer questions when needed C. Clients can ask the intensivist for a second opinion D. Less staff is needed on site when a remote eICU is available - correct answer -A Using cameras, microphones, and high-speed computer data lines, the eICU involves having an experienced ICU nurse and practicing intensivist monitoring ICU clients in remote locations around the clock. The eICU does not change the ratio of nurses to clients at the bedside, but it does make the nurse's bedside time more productive and assistance from their remote colleagues is only a push button away. The client is diagnosed with tuberculosis (TB). The nurse understands that the treatment plan for this client will involve what type of drug therapy? A. Administering two antituberculosis drugs B. Aminoglycoside antibiotics C. An anti-inflammatory agent D. High doses of B complex vitamins - correct answer -A In order to prevent drug-resistant strains of TB, clients are always prescribed at least two different antitubercule medications. Rifampin and isoniazid are the most effective drugs used to treat TB and are always used together, for at least six months. Additional medications, such as pyrazinamide and either streptomycin or ethambutol, may also be prescribed. Vitamin B6 is usually prescribed to help prevent expected side effect of isoniazid. While working a 12-hour night shift, the nurse has a "near miss" and catches an error before administering a new medication to the client. Which factors could have contributed to the near miss? (Select all that apply.) A. The nurse works in the intensive care unit (ICU) B. The nurse has worked on the same unit for five years C. The nurse is assigned more clients than usual due to staffing issues D. The nurse was interrupted when preparing the medication E. The nurse has worked four 12-hour night shifts in a row - correct answer -A,C,D,E There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients such as the ICU. A 4 month-old infant is being given digoxin. The client's blood pressure is 92/78 mm Hg; resting pulse is 78 BPM; respirations are 28 BPM; and the serum potassium level is 4.8 mEq/L (4.8 mmol/L). The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? A. Irritability B. Vomiting C. Bradycardia D. Dyspnea - correct answer -C The most common sign of digoxin toxicity in children is bradycardia which is a heart rate below 100 BPM in an infant. Normal resting heart rate for infants 1-11 months-old is 100-160 BPM. A client is receiving total parenteral nutrition (TPN) via a tunneled catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? A. Monitor respiratory status B. Apply a pressure dressing to the site C. Assess for mental status changesD. Check that the catheter tip is intact - correct answer -B The client is at risk of bleeding or developing an air embolus if the catheter exit site is not covered with a pressure and occlusive dressing. An occlusive dressing is one that is totally covered by adhesive tape around the edges, as well as over the entire dressing. The oncology client reports pain, and the provider orders hydromorphone IM 0.015 mg/kg right away. How many milligrams does the nurse administer? The nurse checks the chart and determines the client weighs 119 pounds. How many milligrams of hydromorphone (Dilaudid, Exalgo) will the nurse administer? (Report your answer to one decimal point and write only the number.) - correct answer -0.8 Using dimensional analysis, the final units will be milligrams, so begin the equation with milligrams on top, then multiply to cancel unwanted units until only the milligrams remain.(0.015 mg/kg) X (1 kg/2.2 lbs) X (119 lb/1) = 1.79/2.2 = 0.82 = 0.8 The nurse is caring for a client admitted with a diagnosis of Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in which substance? A. Fiber B. Carbohydrates C. Calcium D. Sodium - correct answer -D The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low-sodium diet will aid in reduction of the fluid. Sodium restriction is commonly ordered as adjunct to diuretic therapy in the acute and chronic treatment. The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? A. Notify the health care provider B. Administer the ordered PRN medication C. Reassess the extremity in 15 minutes D. Readjust the traction for comfort - correct answer -A Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome i