Halo traction will be ordered for the client with a cervical fracture. Options A and B: Russell’s traction is used for bones of the lower extremities, as is Buck’s traction. Option D: Crutchfield tongs are used while in the hospital and the client is immobile.
The controller for the continuous-passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg. Option A: The client is in the bed during CPM therapy. Option C: The client will experience pain with the treatment. Option D: Use of the CPM does not alleviate the need for physical therapy.
The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. Option A: The client is too old and is female. Option C: The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed Option D: The 6-year-old with osteomyelitis is infectious.
The client’s family member should be taught to flush the tube after each feeding and clamp the tube. Options B and C: The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client. Option D: Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing.
The active phase of labor occurs when the client is dilated 4–7cm. Options B and D: The latent or early phase of labor is from 1cm to 3cm in dilation. Options C: The transition phase of labor is 8–10cm in dilation.
The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. Option B: The recliner is good because it prevents 90° flexion but not daily activities. Option C: A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management. Option D: An abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis.
Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Option A: Traveling out of the country does not increase the risk of plumbism. Option C: The house was built after the lead was removed with the paint. Option D: Having several siblings is unrelated to the stem.
A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. Option A: The cast should be handled with the palms, not the fingertips. Option B: Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast. Option C: The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying.
When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. Options A, C, and D: After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort.
he major complication of SLE is lupus nephritis, which results in end-stage renal disease. SLE affects the musculoskeletal, integumentary, renal, nervous, and cardiovascular systems, but the major complication is renal involvement; therefore, answers B and D are incorrect. Answer C is incorrect because the SLE produces a “butterfly” rash, not desquamation.
The nurse should avoid giving the infant a pacifier or bottle because sucking is not permitted. Holding the infant cradled in the arms, providing a mobile, and offering sterile water using a Breck feeder are permitted; therefore, answers A, C, and D are incorrect.
The client with esophageal varices can develop spontaneous bleeding from the mechanical irritation caused by taking capsules; therefore, the nurse should request the medication in a suspension. Answer A is incorrect because it does not best meet the client’s needs. Answer B is incorrect because it is not the best means of preventing bleeding. Answer C is incorrect because the medications should not be given with milk or antacids.
Tomatoes are a poor source of iron, although they are an excellent source of vitamin C, which increases iron absorption. Answers B, C, and D are good sources of iron; therefore, they are incorrect.
Periodically lying in a prone position without a pillow will help prevent the flexion of the spine that occurs with Parkinson’s disease. Answers B and C flex the spine; therefore, they are incorrect. Answer D is not realistic because of position changes during sleep; therefore, it is incorrect.
The client recovering from pancreatitis needs a diet that is high in calories and low in fat. Answers A, C, and D are incorrect because they can increase the client’s discomfort.
Dressing in layers and using extra covering will help decrease the feeling of being cold that is experienced by the client with hypothyroidism. Decreased sensation and decreased alertness are common in the client with hypothyroidism; therefore, the use of electric blankets and heating pads can result in burns, making answers A and C incorrect. Answer D is incorrect because the client with hypothyroidism has dry skin, and a hot bath morning and evening would make her condition worse.
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NCLEX-RN Test #10
