Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect?
A. Uneven cast drying
Choice A reason: This is incorrect. Uneven cast drying is not a complication that can cause a warm area on the cast. Cast drying is a normal process that occurs after the application of a plaster or synthetic cast. It can take several hours to days, depending on the type and thickness of the cast material. Uneven cast drying can cause some areas to be weter or harder than others, but it does not affect the temperature of the cast.
B. Poor circulation
Choice B reason: This is incorrect. Poor circulation is not a complication that can cause a warm area on the cast. Poor circulation is a condition that occurs when the blood flow to the affected limb is reduced or impaired due to injury, swelling, or compression. Poor circulation can cause symptoms such as coldness, numbness, tingling, or pain in the limb. Poor circulation can also increase the risk of tissue damage or necrosis.
C. Pressure from the cast
Choice C reason: This is incorrect. Pressure from the cast is not a complication that can cause a warm area on the cast. Pressure from the cast is a condition that occurs when the cast is too tight or too loose, or when it rubs against the skin or underlying tissues. Pressure from the cast can cause symptoms such as skin irritation, blisters, ulcers, or pressure sores. Pressure from the cast can also increase the risk of infection or nerve damage.
D. Infection
Choice D reason: This is the correct answer. Infection is a complication that can cause a warm area on the cast. Infection is a condition that occurs when bacteria enter and multiply in the wound, bone, or soft tissues under the cast. Infection can cause symptoms such as fever, chills, redness, swelling, drainage, or odor from the wound site. Infection can also cause increased warmth or heat in the affected area, which can be detected through the cast. Infection can lead to serious complications such as osteomyelitis, septicemia, or amputation if not treated promptly.
This question is an excerpt from Nurse Dive's nursing test bank - NY BSN Proctored Exam. Take the full exam now
Similar Questions
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the
nurse expect to find in this client?
A. Scoliosis
Choice A reason: This is incorrect. Scoliosis is a spinal deformity that causes a lateral curvature of the spine. It can affect people of any age, but it usually develops during childhood or adolescence. Scoliosis can be caused by congenital defects, neuromuscular disorders, injuries, or idiopathic factors. Scoliosis can cause symptoms such as uneven shoulders, hips, or waist, back pain, or breathing problems.
B. Lordosis
Choice B reason: This is incorrect. Lordosis is a spinal deformity that causes an excessive inward curvature of the lower spine. It can affect people of any age, but it is more common in young children and pregnant women. Lordosis can be caused by poor posture, obesity, spinal injuries, or congenital defects. Lordosis can cause symptoms such as a protruding abdomen, back pain, or difficulty moving.
C. Kyphosis
Choice C reason: This is the correct answer. Kyphosis is a spinal deformity that causes an excessive outward curvature of the upper spine. It can affect people of any age, but it is more common in older adults who have osteoporosis. Osteoporosis is a condition that causes the bones to become weak and brittle and prone to fractures. Kyphosis can be caused by compression fractures of the vertebrae due to osteoporosis, poor posture, spinal injuries, or congenital defects. Kyphosis can cause symptoms such as a hunched back, neck pain, or breathing problems.
D. Ankylosis
Choice D reason: This is incorrect. Ankylosis is a condition that causes stiffness and immobility of a joint due to fusion of the bones. It can affect any joint in the body, but it is more common in the spine, especially in people who have an inflammatory disease such as rheumatoid arthritis or ankylosing spondylitis. Ankylosis can cause symptoms such as pain, swelling, reduced range of motion, or deformity of the joint.
E. Ankylosis
A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
A. "I know you're anxious, but this procedure is recommended for people your age.”
Choice A reason: This is incorrect. This response is dismissive and does not address the client's concern about pain. The nurse should acknowledge the client's anxiety and provide factual information about the procedure and pain management. The nurse should also avoid using age as a reason for recommending the procedure, as this may imply that the client is old or at risk for colon cancer.
B. "Don't worry; most clients dislike the prep more than the procedure itself.”
Choice B reason: This is incorrect. This response is trivializing and does not address the client's concern about pain. The nurse should acknowledge the client's anxiety and provide factual information about the procedure and pain management. The nurse should also avoid comparing the client's experience with others, as this may imply that the client is overreacting or being unreasonable.
C. "After you have signed the consent form, we can talk more about this.”
Choice C reason: This is incorrect. This response is delaying and does not address the client's concern about pain. The nurse should acknowledge the client's anxiety and provide factual information about the procedure and pain management before asking the client to sign the consent form. The nurse should also ensure that the client understands the risks, benefits, and alternatives of the procedure and has an opportunity to ask questions.
D. "Before the examination, your provider will give you a sedative that will make you sleepy.”
Choice D reason: This is the correct answer. This response is informative and addresses the client's concern about pain. The nurse acknowledges the client's anxiety and provides factual information about the procedure and pain management. The nurse explains that the provider will give the client a sedative that will make him sleepy and reduce his awareness of pain during the examination. The nurse also implies that the procedure will be done under moderate sedation, which means that the client will be able to breathe on his own and respond to verbal commands.
A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?
A. Warm the feeding to room temperature.
Choice A reason: This is incorrect. Warming the feeding to room temperature is an important action to prevent abdominal cramps and discomfort, but it is not the first action to take. The nurse should warm the feeding to room temperature before administering it, but only after verifying that the client can tolerate the feeding.
B. Hang the feeding bag 30 cm (12 in) above the client.
Choice B reason: This is incorrect. Hanging the feeding bag 30 cm (12 in) above the client is an important action to ensure proper flow and prevent air embolism, but it is not the first action to take. The nurse should hang the feeding bag 30 cm (12 in) above the client before administering the feeding, but only after verifying that the client can tolerate the feeding.
C. Aspirate the client's stomach contents.
Choice C reason: This is the correct answer. Aspirating the client's stomach contents is the first action to take before administering an enteral feeding through an NG tube. The nurse should aspirate the client's stomach contents to check for gastric residual volume (GRV), which is the amount of fluid left in the stomach before feeding. The nurse should compare the GRV with the facility's protocol and determine if it is safe to proceed with the feeding or if it needs to be delayed or adjusted. The nurse should also assess the color, consistency, and pH of the aspirate to confirm tube placement and prevent aspiration.
D. Label the feeding bag with the date and time of the start of the feeding.
Choice D reason: This is incorrect. Labeling the feeding bag with the date and time of the start of the feeding is an important action to prevent bacterial contamination and ensure quality control, but it is not the first action to take. The nurse should label the feeding bag with the date and time of the start of the feeding before administering it, but only after verifying that the client can tolerate the feeding.