Exam A Flashcards
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A hospice nurse is caring for a preschooler who has a terminal illness. One of the child’s parents tells the nurse that it is too difficult to cope any longer and has decided to move out of the house. Which of the following responses should the nurse make?
A: “Let’s talk about a few ways you have dealt with stress in the past.”
B: “I believe that you will regret that decision. Your family needs your support.”
C: “I agree that you have to do what is best for your well-being at this time.”
D: “I think you should try to put your feelings aside and focus solely on your child.”
A: “Let’s talk about a few ways you have dealt with stress in the past.”
Rational:This statement by the nurse combines two therapeutic responses, active listening and focusing. Used together, these techniques facilitate communication by letting the parent know one’s feelings are heard and taken seriously, which conveys acceptance and respect. Therefore, the parent feels the nurse validates the concerns and becomes comfortable asking the nurse sensitive questions about the child.
A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis. Which of the following information should the nurse include in the teaching?
A: “Maintain bone health by eating fruits, vegetables, and protein.”
B: “Tamsulosin can slow the progression of bone deterioration.”
C: “Walk 20 minutes two times a week to manage osteoporosis.”
D: “Start to increase vitamin C and magnesium in your diet.”
A: “Maintain bone health by eating fruits, vegetables, and protein.”
Rational: The nurse should instruct the client that the best way to maintain bone health and bone remodeling is by eating fruits, vegetables, and protein.
- A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of the following statements should the nurse make?
A: “You’ll need to take this medication once a day at bedtime.”
B: “This medication causes adverse effects if the dosage is too high or too low.”
C: “Continuing this medication therapy long-term will eventually cure your hypothyroidism.”
D: “Potassium supplements can reduce the effectiveness of this medication.”
B: “This medication causes adverse effects if the dosage is too high or too low.”
Rational: The nurse should instruct the client that levothyroxine, in the right dosage, does not typically cause adverse effects. If the dosage is too low, the manifestations of hypothyroidism will recur. If the dosage is too high, the manifestations of hyperthyroidism will occur.
4. A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? A: Urine output 0.5 mL/kg/hr B: Capillary refill 3 seconds C: Heart rate 148/min D: Brisk skin turgor
D: Brisk skin turgor
Rational: The nurse should expect the child to have brisk skin turgor if fluid replacement therapy is effective.
- A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take?
A: Use a gait belt and stand on the client’s right side to assist with ambulation.
B: Encourage the client to use wide-grip utensils when eating with the right hand.
C: Place personal items on the bedside table close to the bed on the client’s left side.
D: Remove rolled toilet paper from the holder for easier access for the client
B: Encourage the client to use wide-grip utensils when eating with the right hand.
Rational: The nurse should encourage the client who has hemiparesis to use wide-grip utensils when eating with the right hand, which can accommodate a weak grasp and encourage independence in eating.
6. A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which of the following herbal supplements should the nurse include in the teaching for treating hyperlipidemia? A: Feverfew B: Gingko C: Valerian D: Garlic
D: Garlic
Rational: The nurse should include that garlic can help improve cholesterol levels, which then helps to reduce the buildup of plaque in the arteries. For some clients, it can also help lower blood pressure.
- A nurse is admitting a client who has an acute bacterial wound infection and a temperature of 39.8° C (103.6° F). Which of the following actions should the nurse take?
A: Obtain a wound culture 30 min after initiating IV antibiotics.
B: Place a fan on the lowest setting in the client’s room.
C: Apply a cooling blanket directly on the client’s skin.
D: Set the temperature of the client’s room to 22.2° C (72° F).
D: Set the temperature of the client’s room to 22.2° C (72° F).
Rational: The nurse should set the temperature of the client’s room at 21° C to 27° C (70° F to 80° F). This promotes a reduction in the client’s fever without causing shivering. By combining nonpharmacological interventions with antipyretics, the nurse can reduce the client’s fever.
- A nurse is assessing a client who is 1 hour postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider?
A: Urine color is light pink.
B: The suprapubic area is soft to palpation.
C: The catheter tubing has multiple red clots.
D: The bowel sounds are hypoactive
C: The catheter tubing has multiple red clots.
Rational: The nurse should identify that the presence of multiple red clots in the catheter tubing or drainage that is ketchup-like are manifestations of postoperative bleeding. The nurse should notify the provider and provide hand irrigation of the bladder per provider prescription.
- A nurse is planning care for a client who had surgery for osteomyelitis from a past musculoskeletal trauma to the lower leg. Which of the following interventions should the nurse include in the plan of care?
A: Position the affected leg flat when sitting up in bed.
B: Instruct the client to perform weight-bearing activities on the affected leg.
C: Check for paresthesia of the affected leg.
D: Apply heat to the surgical incision area of the affected leg.
C: Check for paresthesia of the affected leg.
Rational: The nurse should include in the interventions to check for paresthesia, such as a tingling sensation of the leg and foot, which can indicate manifestations of neurovascular compromise or compartment syndrome.
- A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider?
A: Presence of a transparent cornea
B: Presence of strabismus
C: Pinna moderately extends outward from the skull
D: Walls of peripheral aspect of auditory canal are pink
B: Presence of strabismus
Rational: The nurse should recognize that the presence of strabismus, or crossing of the eyes, should disappear by 4 months of age. If this is not corrected by 4 to 6 years of age, it can lead to amblyopia; therefore, the nurse should report this finding to the provider.
- A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching?
A: Consume five to seven servings of red meat per week.
B: Limit daily calorie intake from saturated fat to 18%.
C: Increase fiber intake to at least 30 g per day.
D: Exercise 2 days a week for at least 60 min
C: Increase fiber intake to at least 30 g per day.
Rational: The nurse should instruct the client to increase daily fiber intake to at least 30 g. Fiber assists in the elimination of lipids and minimizes the development of atherosclerosis.
- A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer?
A: Diminished peripheral pulsations in the right lower leg
B: Discoloration and edema of the right ankle
C: Atrophy of the skin and hair loss on the right leg
D: Dependent rubor in the right leg
B: Discoloration and edema of the right ankle
Rational: The nurse should identify that manifestations of peripheral venous disease include discoloration and edema of the ankle, resulting from venous hypertension.
- A nurse is providing discharge teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching?
A: “Notify your provider if you notice small pieces of tissue in your urine.”
B: “Any urinary incontinence will be permanent.”
C: “Expect to see an increase in the amount of semen produced.”
D: “Perform Kegel exercises several times throughout the day.”
D: “Perform Kegel exercises several times throughout the day.”
Rational: The nurse should instruct the client on the performance of Kegel exercises, or tightening and then relaxing the urinary sphincter, to assist the client in regaining urinary control and eliminate dribbling or the leakage of urine. The nurse should encourage the client to perform these exercises several times each day.
14. A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all the apply.) A: Nocturia B: Dependent edema C: Dyspnea D: Hacking cough E: Anorexia
A: Nocturia
Rational: Left-sided heart failure causes oliguria during the day and nocturia during sleeping hours.
C: Dyspnea
Rational: Left-sided heart failure causes pulmonary manifestations, such as dyspnea, orthopnea, crackles, and wheezes.
D: Hacking cough
Rational: Left-sided heart failure causes a hacking cough that worsens at night and eventually produces frothy sputum.
- A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching?
A: Drink tomato juice with the breakfast meal.
B: Suck on peppermint when having indigestion.
C: Elevate the head of the bed 10 cm (4 in) using wooden blocks.
D: Plan to finish eating at least 3 hr before bedtime.
D: Plan to finish eating at least 3 hr before bedtime.
Rational: The nurse should encourage the client not to eat anything at least 3 hr before bedtime to prevent reflux.
- A nurse is providing teaching for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). Which of the following instructions should the nurse include to promote elimination?
A: “Drink at least 24 ounces of water each hour.”
B: “Void as soon as you feel the urge.”
C: “Expect a prescription for a diuretic.”
D: “Take an antihistamine each night at bedtime.”
B: “Void as soon as you feel the urge.”
Rational: The nurse should instruct a client who has BPH on measures to prevent distension of the bladder and urinary retention. Encouraging the client to void as soon as the urge develops decreases the risk of bladder distension.
17. A nurse is assessing for manifestations of hyponatremia in a client who has been taking twice the prescribed dose of a diuretic. Which of the following findings should the nurse expect? A: Increased deep tendon reflexes B: Hypoactive bowel sounds C: Decreased level of consciousness D: Bradycardia
C: Decreased level of consciousness
Rational: The nurse should expect a client who has hyponatremia to have cerebral edema and increased intracranial pressure as fluid moves into the cells in the brain. This can manifest as confusion, changes in level of consciousness, and seizures.
- A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the following statements should the nurse identify as an indication the client understands the teaching?
A: “I will blow out as hard as I can before I use the peak flow meter.”
B: “I will not take my controller medication if my peak flow meter scores in the yellow zone.”
C: “I will base my peak flow meter score on the best of three attempts.”
D: “I will go to the emergency room if my peak flow meter is in the green zone.”
C: “I will base my peak flow meter score on the best of three attempts.”
Rational: The client’s peak flow rate should be based on the best of three trials of the peak flow meter. The client should record this finding and share it with the provider on the next visit.
19. A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect? A: Hyperreflexia B: Fruity breath odor C: Sweating D: Shallow respirations
B: Fruity breath odor
Rational: The nurse should expect a child who has a blood glucose level of 250 mg/dL to have a fruity or acetone breath odor. Other manifestations include lethargy, thirst, and confusion.
20. A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of 36.1° C (97° F). Which of the following manifestations should the nurse expect? A: Hypoglycemia B: Flushed skin C: Tachycardia D: Hypertonicity
A: Hypoglycemia
Rational: The nurse should expect an infant who has hypothermia to have hypoglycemia. Other manifestations of hypothermia include apnea, central cyanosis, hypotonia, irritability, lethargy, weak cry or suck, poor weight gain, and hypoxia.
- A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when having manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL. Which of the following instructions should the nurse include?
A: Self-administer 1 mg of glucagon subcutaneously.
B: Self-administer 20 units of regular insulin.
C: Drink 120 mL (4 oz) of skim milk.
D: Drink 120 mL (4 oz) of fruit juice.
D: Drink 120 mL (4 oz) of fruit juice.
Rational: The nurse should instruct the client to drink 120 mL (4 oz) of fruit juice, which will provide 10 to 15 g of carbohydrates to treat the hypoglycemia.
- A nurse is leading a small group discussion in an acute care mental health facility when one client suddenly begins to experience a panic attack. Which of the following actions should the nurse take?
A: Teach the client how to use breathing techniques while continuing the discussion.
B: Remain with the client until manifestations subside.
C: Speak in a high-pitched louder voice to gain the client’s attention.
D: Instruct the client to join another group who is practicing yoga
B: Remain with the client until manifestations subside.
Rational: The nurse should remain with the client in a quiet place throughout the panic attack to ensure the client’s safety and assist with anxiety reduction techniques.
- A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia?
A: Apply ice packs to the client’s axillae, neck, groin, and chest.
B: Administer aspirin to the client
C: Initially offer the client cool, oral fluids.
D: Continue cooling measures until the client’s rectal temperature is 37.2º C (99º F).
Answer: A
A: Apply ice packs to the client’s axillae, neck, groin, and chest.
Rational: The nurse should recognize that treatment for heat stroke involves cooling the client’s core body temperature quickly. The nurse should apply ice to the client’s axillae, neck, groin, and chest while also spraying the client’s body with tepid water.
- A nurse in a provider’s office is completing a preoperative screening for a client who is scheduled for a knee arthroplasty later that week. Which of the following findings requires the nurse’s intervention? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.)
Exhibit 1: Graphic record Oral temperature 36.9° C (98.4° F) Pulse rate 78/min Respiratory rate 17/min BP 134/86 mm Hg Oxygen saturation 95%
Exhibit 2: Diagnostic results Hgb 15.1 g/dL Hct 42.4% Fasting glucose 106 mg/dL Potassium 4.5 mEq/L International normalized ratio (INR) 4.2
Exhibit 3: Medication administration record
Enalapril 2.5 mg PO daily
Atorvastatin 10 mg PO daily
Hydrocodone 5 mg/acetaminophen 325 mg PO q 6 hr PRN for joint pain
A: Oxygen saturation
B: Potassium level
C: ACE inhibitor therapy
D: Coagulation time
D: Coagulation time
Rational: The nurse should report the client’s coagulation time, or INR, to the provider immediately because it is above the expected reference range, which predisposes the client to intraoperative and/or postoperative hemorrhage. The nurse should expect the provider to postpone the joint arthroplasty until the client’s clotting time is within the expected reference range.
- A nurse is planning care for a client who has pneumonia. WHich of the following interventions should the nurse include in the plan?
A: Direct the client to perform incentive spirometry every 2 hr.
B: Titrate oxygen to maintain the client’s oxygen saturation level at 90%.
C: Teach the client how to cough up secretions.
D: Maintain the client in a low-Fowler’s position
C: Teach the client how to cough up secretions.
Rational: The nurse should instruct the client how to cough and breathe deeply to expel productive secretions and clear the airway for optimal breathing.
26. A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. WHich of the following values should indicate to the nurse that the client has a continuing infection? A: Negative nitrites B: RBCs < 2 C: Positive leukocyte esterase D: Amber-colored urine
C: Positive leukocyte esterase
Rational: The nurse should identify that a positive leukocyte esterase test is an indication of the presence of WBCs in the urine and the presence of continued infection.
- A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider?
A: Melena stools
B: Hemoglobin 7.6 mg/dL
C: Weight gain of 1.4 kg (3 lb) in 2 weeks
D: Dyspepsia during the day
B: Hemoglobin 7.6 mg/dL
Rational: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the hemoglobin below the expected reference range, which in an indication of a peptic ulcer that is chronically bleeding.
28. A nurse is caring for a client who has a fear of open spaces. WHich of the following clinical names for this fear should the nurse document in the client's medical record? A: Pyrophobia B; Agoraphobia C: Monophobia D: Astraphobia
B; Agoraphobia
Rational: The nurse should document that the client is experiencing agoraphobia in the client’s medical record. Agoraphobia is the fear of being outside and can be debilitating and limit a client’s ability to function.
- A nurse on a pediatric unit is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?
A: Place the child in a room equipped with a positive-pressure airflow system.
B: Place the child in a room equipped with a negative-pressure airflow system.
C: Initiate droplet precautions for the child.
D: Initiate contact precautions for the child.
C: Initiate droplet precautions for the child.
Rational: The nurse should initiate droplet precautions for a child who has pertussis, which is spread by large droplets in the air; therefore, the nurse should wear a surgical mask within 1 m (3.3 feet) of the child.
- A nurse is teaching a client who has tuberculosis about taking rifampin. Which of the following instructions should the nurse include?
A: “Expect this medication to give your urine a greenish tinge.”
B: “Do not drink alcohol while taking this medication.”
C: “Take this medication with food.”
D: “Take a stool softener for the duration of therapy with this medication.”
B: “Do not drink alcohol while taking this medication.”
Rational: The nurse should instruct the client that rifampin could cause liver damage. Alcohol intensifies this risk. Rifampin is contraindicated for clients who have liver disease or consume alcohol in excess.
31. A nurse is caring for a client who has Cushing's disease. The nurse should identify that the client is at risk for which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis
B: Metabolic alkalosis
Rational: The nurse should identify that with Cushing’s disease, also known as hypercortisolism, adrenocorticotropic hormone levels are low due to hypersecretion of the adrenal cortex. This leads to an increase is renal excretion of potassium and, therefore, hypokalemia. This electrolyte imbalance puts the client at risk for metabolic alkalosis as the kidneys try to retain potassium by increasing hydrogen ion excretion, and as potassium moves out of the cells and into the extracellular fluid and hydrogen ions move into the cells.
- A nurse is planning care for a client who has chemotherapy-induced anemia and is starting epoetin. Which of the following interventions should the nurse include in the plan?
A: Shake the medication vial prior to drawing up the medication.
B: Withhold epoetin if hemoglobin is less than 9 g/dL.
C: Initiate contact isolation.
D: Monitor for hypertension.
D: Monitor for hypertension.
Rational: The nurse should monitor the client’s blood pressure while receiving epoetin to identify and treat hypertension. Hypertension and cardiovascular events, such as myocardial infarction and stroke, are adverse effects of epoetin.
- A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss?
A: Becomes angry when it is time to perform colostomy care
B: Touches the colostomy stoma when the bag is changed
C: Looks away as the nurse empties the colostomy bag
D: Tells others that it will be nice to have a normal bowel movement again
B: Touches the colostomy stoma when the bag is changed
Rational: The client touching the colostomy stoma when the bag is changed should indicate to the nurse that the client is accepting and coping with the alteration of body image and has gone through the stages of grief.
1. A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client's ABG results are ph 7.28, PaCO2 49 mm Hg, and HCO3 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis
C: Respiratory acidosis
Rational: With this acid-base imbalance, the client’s pH is below the expected reference range, the PaCO2 is above the expected reference range, and the HCO3- is within or possibly above the expected reference range. Common causes of respiratory acidosis are respiratory depression due to anesthesia or opioid administration, airway obstruction, and inadequate chest expansion.
- A nurse is teaching a female adult client who is obese about disease management. Which of the following information should the nurse include in the teaching?
A: Average body fat for women is 15%.
B: Obesity can cause osteoporosis.
C: Morbid obesity is measured as a BMI over 40.
D: Coronary artery disease increases with a waist size of 81.28 cm (32 in).
C: Morbid obesity is measured as a BMI over 40.
Rational: The nurse should instruct the client that the expected reference range for a healthy weight is a BMI of 25 or less. A client who has a BMI of 40 or greater is considered morbidly obese.
- A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider?
A: The stool is a dark green liquid with a small amount of blood.
B: The ileostomy output is 1,000 mL for the past 24 hr.
C: The stoma is purple in color.
D: The output from the NG tube has decreased over the past 24 hr
C: The stoma is purple in color.
Rational: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is the color of the stoma. Stomas should be pink to bright red in color and shiny. A stoma that is pale bluish, dark red-purplish, or black in color is not receiving adequate blood supply.
- A community health nurse is teaching a group of older adult clients about interventions to prevent pneumonia. Which of the following instructions should the nurse include in the teaching?
A: “Obtain a pneumococcal vaccination every 2 years.”
B: “Contact your provider if you have a fever that lasts 18 hours.”
C: “Wash your hands when you return home from running errands.”
D: “Avoid exposure to cold air by shopping inside enclosed malls.”
C: “Wash your hands when you return home from running errands.”
Rational: The nurse should instruct clients that handwashing is one way to avoid organisms that can cause pneumonia. Handwashing after using the restroom or being in public areas can minimize the risk of developing pneumonia.
- A nurse is providing discharge teaching for a client who has a hearing impairment. Which of the following actions should the nurse take?
A: Encourage the client to repeat what the nurse has said.
B: Stand to the side of the client and speak directly into the client’s ear.
C: Talk to the client by speaking in a loud tone of voice.
D: Avoid the use of hand gestures and motions when speaking with the client.
A: Encourage the client to repeat what the nurse has said.
Rational: The nurse should have the client repeat back what is discussed. The nurse should not rely on the client’s nonverbal communications, such as a nod of the head, to ensure the client understands the information.
- A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching?
A: “The adhesive bandages on my incision will fall off as the incision heals.”
B: “I will be able to take a shower in 1 week.”
C: “I will need to follow a liquid diet for the first 3 days after surgery.”
D: “I can begin to resume my normal activity level in 2 weeks.”
A: “The adhesive bandages on my incision will fall off as the incision heals.”
Rational: The nurse should instruct the client that the small adhesive bandages will lose their adhesiveness in 7 to 10 days. The client can then remove the bandages or allow the bandages to fall off over time as the incision heals.
40. A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect? A: Otitis media B: Parotitis C: Facial eruption D: Lymphadenopathy
C: Facial eruption
Rational: The nurse should identify that facial eruption, predominantly located on the cheeks, is a manifestation of erythema infectiosum. The child has a “slapped face” appearance. The eruption generally disappears after 4 days, but can reappear if the skin is traumatized or irritated by sun, heat, cold, or friction.
- A nurse is planning care for a client who has renal calculi. WHich of the following interventions should the nurse include to promote elimination of the calculi?
A: Maintain bedrest until calculi are expelled.
B: Withhold thiazide diuretics.
C: Encourage intake of at least 3 L of fluid each day.
D: Collect all urine for 24 hr in a collection container
C: Encourage intake of at least 3 L of fluid each day.
Rational: The nurse should encourage the client to consume at least 3 L of fluid each day. Increased fluid intake increases urine production, promotes eliminiation of calculi, and helps prevent recurrence.
42. A nurse is caring for a client who has generalized anxiety disorder and is experiencing a mild level of anxiety. Which of the following manifestations should the nurse expect? A: Chest pain B: Hallucinations C: Feels unreal D: Follows directions
D: Follows directions
Rational: The nurse should expect a client who is experiencing a mild level of anxiety to be able to follow directions and focus on the nurse’s instructions. Other manifestations the nurse should expect include restlessness, heightened perception, and ability to problem solve.
43. A nurse on a mental health unit is developing a plan of care for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse identify as a priority? A: Reduce environmental stimulation. B: Protect the client from harm. C: Administer an anxiolytic. D: Encourage physical exercise.
B: Protect the client from harm.
Rational: The greatest risk to this client is injury from uncontrollable thoughts and activity; therefore, the priority intervention is to protect the client from harming himself or others by moving to a quiet environment with decreased stimulation and staying with the client.
- A nurse is providing home care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include?
A: Apply heat for the first 48 hr.
B: Wear a sling when resting in bed.
C: Elevate the wrist above heart level.
D: Use a soft-bristle toothbrush to relieve itching under the cast.
C: Elevate the wrist above heart level.
Rational: The nurse should instruct the client to elevate the wrist above heart level to reduce swelling and minimize pain.
