1)  What is the priority nursing intervention(s) in the care of a client in skeletal traction? A) Keep an abduction device between his legs to prevent external rotation of the affected leg

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1)  What is the priority nursing intervention(s) in the care of a client in skeletal traction?

A) Keep an abduction device between his legs to prevent external rotation of the affected leg.

B) Encourage a diet high in calcium to promote an increase in bone strength and repair.

C) Increase fluid intake to prevent the development of renal stone due to the stasis of urine in the bladder.

D) Frequent pulse checks distal to the affected extremity, cleanse the pin site and apply antibiotic ointment to area.

2)A client with borderline personality disorder says to the nurse, "You're the only one i trust around here. The others don't know what they are doing, and they don't care about anyone except themselves. I only want to talk with you. "What priority action should the nurse advocate to be included in the client's nursing care plan?

A) Frequently reassure the client that all staff members are competent in their jobs

B) Assign different staff members to take care for the client each day

C) Continue assigning the client's stated preferred nurse to care for the client

D) Reinforce unit roles and consequences of inappropriate behaviors

3) When reinforcing teaching for a client with polycythemia vera, which instructions should the nurse include? Select all that apply.

A) Increase dietary intake of foods rich in iron.

B) Report swelling or tenderness in the legs.

C) Elevate the legs and feet when sitting.

D) Increase fluid intake during exercise and hot weather

E) Increase water temperature to reduce post-bath itching

4) A client is scheduled for a lumbar laminectomy with bone graft. In preparation for surgery, what should the nurse include in the teaching plan?

A) Logrolling when turning from side to side. Cool

B) Stretching from the waist when reaching for things

C) Completing straight leg raises while on bed rest

D) How to get on and off a bedpan by lifting his hips.

5)The nurse is assessing a child who has asthma. What data collection would confirm early problems of hypoxia?

A) Cyanosis

B) Frequency of cough

C) Tachypnea

D) Confusion

6)A diabetic client at 35 weeks' gestation has come to the antepartal testing unit for a non- stress test. Which statement is accurate about this test?

A) It is a test that determines fetal- maternal-placental function

B) It locates and identifies placental placement

C) It requires attachment of an electrode to fetal scalp

D) It is a non-invasive test that observes the response of fetal heart rate to the stress of activity

7) A chronic obstructive lung disease (COPD) client complains of dyspnea after his daily exercises. What is the best nursing response?

A) Assist him to bed and put his oxygen on at 3 liter per minute

B) Discourage him from further exercising since it is increasing his dyspnea

C) Have him lay down immediately and administer an aerosol treatment

D) Explain that the dyspnea is an anticipated response to the increased level of activity

8)The nurse is assessing a client who sustained multiple injuries. Significant bleeding is noted from the transverse fracture site at the left femur. What action should the nurse take after applying pressure over the area?

A) Wrap the leg in an Ace bandage

B) Place the client in the Trendelenburg position

C) Put the extremity in ice

D) Apply direct digital pressure over the femoral artery

9) The nurse is completing her data collection of a client who is 12 hours post delivery. Where would the nurse anticipate the level of the fundus?

A) At the level of the umbilicus diverted to the right

B) Two fingerbreadths above the umbilicus.

C) Behind the symphysis pubis.

D) One to two fingerbreadths below the umbilicus

10)A client returns to his room from a laminectomy surgery. What is important to include in the nursing care for this client?

A) Assist client to perform straight leg exercises

B) Evaluate client's ability to control bowel and bladder.

C) Encourage the client to ambulate around the unit

D) Keep the client flat in bed for four days