NR-324 Adult Health I - Set 5 - Part 1

Correct Answer: Hold the cane in the right hand

The cane is held on the strong side, opposite the painful leg, so it advances with that leg and shares the load. It widens the base of support and copies the normal arm swing. Option a is incorrect because a cane on the painful side narrows the base of support and loads the very leg that hurts. The client leans over the injury instead of away from it. Option b is incorrect because the side is not optional. Switching hands changes the gait pattern and removes the support just when the weak leg takes weight, which raises the risk of a fall. Option d is incorrect because a cane placed directly ahead of both feet offers no lateral stability and blocks the step. It is advanced ahead and slightly to the side of the strong foot.

Correct Answer: Notify the provider to split the cast immediately

These findings describe compartment syndrome, a surgical emergency. The external source of pressure must come off, so the provider is notified at once to split or bivalve the cast and cut the padding beneath it. Option b is incorrect because raising the limb above the heart drops arterial inflow without lowering the pressure inside the compartment. The leg is held at heart level while help is coming. Option c is incorrect because analgesia masks the one finding that tracks the emergency and wastes the narrow window before muscle dies. Fasciotomy gives the best outcome within about six hours. Option d is incorrect because cold causes vasoconstriction and further reduces flow through a compartment that is already ischemic. Ice belongs to the first day of an uncomplicated cast, not to this.

Correct Answer: "You could already be spreading the virus without any symptoms."

During the incubation period the organism multiplies while the client still feels well, and transmission can already occur. Communicability is often highest in the prodromal stage, before any diagnosis is made, so postponing the visit protects the older relative. Option a is incorrect because the absence of symptoms proves nothing so soon after an exposure. Incubation may last hours or days, during which the organism replicates silently and the client remains entirely unaware of carrying it. Option b is incorrect because infectiousness frequently precedes the first symptom rather than following it. Waiting for a sign to appear would place the relative at risk during the very window when spread is most likely. Option d is incorrect because testing too early in the incubation period can return a falsely reassuring result. A negative report obtained before viral replication reaches a detectable level would not establish that the client is noninfectious.

Correct Answer: Remove the pillow and keep the leg flat

A pillow under a new knee replacement holds the joint in flexion and produces a flexion contracture within days. The leg is kept flat, with support under the heel if extension needs encouragement. Option b is incorrect because comfort for an hour costs the client extension later. Full straightening is the main rehabilitation goal after knee replacement, and a knee that will not extend leaves a permanent limp. Option c is incorrect because stacking pillows deepens the same flexed position and speeds the contracture. Elevation for swelling, when ordered, is achieved by raising the whole leg rather than propping the knee. Option d is incorrect because the position must be corrected now, not at some later round. Raising the side rails addresses falls and does nothing about the flexed knee that is the actual problem.

Correct Answer: Antibodies may not appear this early, so retesting is needed

A rapid antibody test can take three weeks or longer to turn positive, so a negative result this soon cannot exclude recent infection. A nucleic acid test detects the virus earliest. Option a is incorrect because the window period makes an early negative result uninterpretable. Telling the client the exposure is behind them could send an infected person away during the most contagious stage. Option b is incorrect because the Western blot has been dropped from the testing algorithm. Reactive screens are now followed by an antibody differentiation assay and, if needed, a nucleic acid test. Option d is incorrect because antibody assays are the slowest to become positive, not the fastest. Viral genetic material can be found from about ten days after exposure, well before antibodies appear.

Correct Answer: Bouchard nodes sit at the proximal interphalangeal joints

Bouchard nodes occupy the proximal interphalangeal joints in the middle of the finger, while Heberden nodes occupy the distal joints at the fingertip. The student named the right lumps in the wrong place. Option a is incorrect because Heberden nodes belong at the distal interphalangeal joints nearest the fingertip. Placing them in the middle of the finger is the exact reversal that students make most often. Option b is incorrect because rheumatoid nodules are firm subcutaneous swellings of rheumatoid arthritis that appear over bony pressure areas such as the forearm and elbow, not hard osteophytes within the finger joints. Option c is incorrect because the metacarpophalangeal joints at the base of the fingers are classic rheumatoid arthritis targets, and no node in osteoarthritis carries the Bouchard name at that location.

Correct Answer: Notify the provider about the impaired perfusion

Sluggish refill distal to a femur fracture signals impaired perfusion to the foot and calls for immediate notification of the provider. Comparison with the uninjured limb confirms that the change is real. Option a is incorrect because delaying reassessment lets ischemia progress while the leg is unobserved. A perfusion change distal to a fracture is acted on when it is found, not hours later. Option b is incorrect because external warmth does nothing for blood that cannot reach the tissue. Covering the foot also hides the color and temperature the nurse needs to keep watching. Option d is incorrect because slowed refill after a long bone fracture is never a normal finding. Recording it without reporting it leaves an early sign of vascular compromise unaddressed.

Correct Answer: Lifting stays restricted for several more weeks.

A closed incision has only a fraction of its eventual strength. Collagen is remodeled and cross linked over months, with maximal tensile strength reached near three months and a permanent plateau below normal skin. Option b is incorrect because staple removal reflects surface epithelialization, not deep strength. The mechanical support the staples provided is withdrawn at exactly the point when collagen has not yet replaced it. Option c is incorrect because appearance and strength are different things. A wound that looks sealed is still in the proliferative phase, which is the window in which surgical wounds separate. Option d is incorrect because a scar becomes pale and avascular over many months, long after activity is safely resumed. Color change is a poor marker for judging when lifting may restart.

Correct Answer: Record it unstageable until the base is visible.

Staging names the deepest tissue that can be seen. When slough covers the base the extent cannot be confirmed, so the injury is recorded as unstageable. It will prove to be Stage three or four. Option a is incorrect because Stage two is partial thickness by definition and never contains slough. A wound with slough has lost skin through its full thickness, so it cannot be a Stage two. Option b is incorrect because rolled edges occur in Stage three and Stage four alike and say nothing about depth. Only exposed or palpable bone, muscle or tendon justifies the highest number. Option d is incorrect because deep tissue injury describes maroon or purple discoloration under intact or newly opened skin, or a blood filled blister. An open wound packed with slough does not fit that picture.

Correct Answer: Wash the puncture site with soap and water

Washing the site with soap and water is the immediate step, followed at once by reporting to occupational health so source testing and prophylaxis can begin. Mucous membranes are flushed with water instead. Option b is incorrect because milking a wound damages tissue and has never been shown to lower transmission. The recommendation is to wash the area, not to force bleeding from it. Option c is incorrect because paperwork follows first aid and direct notification of occupational health. Reporting must happen quickly, yet the form itself does nothing for the wound sitting in front of the nurse. Option d is incorrect because caustic antiseptics and bleach injure tissue without reducing risk. Plain soap and running water are what the protocol calls for at a percutaneous exposure site.

Correct Answer: Advocate for removal of the urinary catheter

An indwelling catheter bypasses intact skin and mucosa, making it the portal of entry. Removing a device the client no longer needs closes that opening and is the core prevention for catheter associated urinary tract infection. Option a is incorrect because isolation placement interrupts the mode of transmission rather than the portal of entry. Nothing in the scenario indicates a transmissible organism, and a private room leaves the catheter and its risk untouched. Option b is incorrect because prophylactic antibiotics in a client without infection drive resistance and invite Clostridioides difficile. Stewardship principles reserve antimicrobials for a documented indication, and they act on the infectious agent link, not the entry site. Option c is incorrect because cough etiquette blocks the portal of exit, controlling how an organism leaves a reservoir. It is valuable for respiratory spread but has no bearing on a urinary device already breaching the bladder.

Correct Answer: Draw the cultures, then start the antibiotic

Cultures are obtained before the first antibiotic dose so the organism can still be recovered and therapy narrowed later. Antibiotics follow immediately, with the target being administration within one hour of the neutropenic fever being identified. Option a is incorrect because a culture drawn after the drug is in the blood may fail to grow the organism. Losing that identification removes the chance to narrow therapy and leaves the client on broad coverage unnecessarily. Option b is incorrect because transfusing red cells does nothing for an absent neutrophil defense. The deficit here is in white cells, and erythrocytes neither fight the organism nor alter the urgency of starting antimicrobial therapy. Option d is incorrect because culture results take one to several days, and this client can progress to septic shock within hours. Broad spectrum coverage is begun empirically and adjusted once the laboratory identifies the organism.

Correct Answer: Place an ice pack over the cast

Applying ice over the outside of a cast is a standard comfort measure within assistive personnel scope. Assessment, evaluation and teaching remain nursing responsibilities that require judgment and cannot be handed off. Option b is incorrect because neurovascular assessment requires interpreting refill, color, sensation and movement together. That judgment sits with the nurse, who repeats and documents the check on a schedule. Option c is incorrect because client teaching demands assessing what the client already knows and correcting what is wrong. Instruction about cast care belongs to the registered nurse alone. Option d is incorrect because burning under a cast is an early neurovascular warning that must be evaluated, not delegated. The nurse investigates it immediately and reports the finding to the provider.

Correct Answer: This is a deep tissue pressure injury.

Any blood in blister fluid moves the injury out of Stage two and into deep tissue pressure injury. Pain preceding visible change fits damage that starts at the bone muscle interface and works outward toward the skin. Option a is incorrect because the Stage two definition names only a serum filled blister. Blood tinged or frankly bloody contents indicate that vessels deeper than the dermis have already been destroyed. Option b is incorrect because unstageable applies when slough or eschar hides the wound base. This blister is intact, there is no necrotic covering, and the discoloration itself identifies the category. Option c is incorrect because friction abrades the epidermis and produces a superficial raw area, not a deep bloody blister. Sitting loads the ischial tuberosity with sustained pressure and shear instead.

Correct Answer: Treat the pain as any other pain

Phantom limb pain is genuine pain from nerve and cortical reorganization, and most amputees experience it. It is managed like other pain, with analgesics, a gabapentinoid or a tricyclic, mirror therapy and support. Option a is incorrect because telling a client the pain is imaginary denies a well documented condition and destroys trust. The limb is gone, but the pain pathways that report it are intact. Option b is incorrect because phantom pain is a neurologic phenomenon rather than a psychiatric illness. Counseling helps with grief over the lost limb and altered body image, but it does not substitute for analgesia. Option d is incorrect because this pain may persist for years and can be disabling while it lasts. Waiting leaves the client suffering when several effective treatments could be started now.

Correct Answer: Flex the knees and keep the client NPO

Flexing the hips and knees in low Fowler position relaxes the abdominal wall and lowers intra abdominal pressure, so less viscera is pushed out. NPO status is required because emergency surgery is coming. Option a is incorrect because anything taken by mouth becomes an aspiration hazard under anesthesia. Leg elevation addresses venous return and does nothing for the abdominal wall tension that is pushing the bowel outward. Option b is incorrect because sitting upright and coughing both spike pressure inside the abdomen, forcing more bowel through the opening. The client should lie still and avoid coughing or straining. Option c is incorrect because a binder over protruding organs compresses and injures them, and walking is unthinkable with an open peritoneum. Binders belong to superficial dehiscence managed conservatively, never to evisceration.

Correct Answer: Immunoglobulin G transferred across the placenta

IgG is the only immunoglobulin that crosses the placenta. It is actively transported to the fetus late in pregnancy, so the newborn begins life carrying the mother's IgG repertoire until that borrowed antibody wanes. Option b is incorrect because IgM is the largest immunoglobulin and cannot cross the placenta. It marks the primary response, so IgM found in an infant signals infection the infant acquired rather than maternal transfer. Option c is incorrect because IgE fixes to mast cells and basophils, mediating allergic reactions and defense against parasites. It plays no part in protecting a newborn against a viral illness such as measles. Option d is incorrect because IgD sits on the surface of B lymphocytes and assists their differentiation. It functions as a receptor rather than a circulating weapon and confers no transferable protection on an infant.

Correct Answer: The immediate reaction is IgE mediated and dangerous

Immediate urticaria, bronchospasm or anaphylaxis on latex exposure is a type I IgE mediated allergy and is the life threatening form. The delayed itchy scaling hand rash is type IV contact dermatitis, uncomfortable but not dangerous. Option a is incorrect because contact dermatitis stays localized to the skin it touched and does not progress to systemic collapse. The airway and lip findings after balloon exposure are the ones that signal anaphylactic potential. Option b is incorrect because the two presentations run through different pathways. Antibody bound to mast cells drives the balloon reaction in minutes, while sensitized T lymphocytes produce the glove rash only after a day or more. Option d is incorrect because nonlatex powder free gloves are mandatory for this client. Airborne latex protein carried on glove powder can trigger a systemic reaction, so the product itself must be removed from the care environment.

Correct Answer: Leave the blood pressure cuff in the room

Contact precautions require dedicated or disposable equipment, so the cuff, thermometer and stethoscope stay in the room. Shared items carry spores from one client to the next, and the environment is a major reservoir in this infection. Option b is incorrect because a thermometer moved between clients carries spores directly to the next person. Sharing any patient care item defeats the purpose of contact precautions and is a recognized route for spreading this organism. Option c is incorrect because alcohol has no effect on the spore coat this organism produces. Hands must be washed with soap and running water after glove removal so the spores are physically lifted away. Option d is incorrect because ordinary hospital disinfectants leave spores viable on surfaces. Environmental cleaning during treatment and at discharge calls for a bleach based sporicidal product, applied after the surface has first been cleaned.

Correct Answer: Oral colchicine started as soon as possible

Colchicine, an NSAID or a corticosteroid shuts down the inflammation set off by urate crystals already in the joint, and colchicine works best when it is started within a day of onset. Option a is incorrect because allopurinol lowers urate over weeks to prevent later attacks and does nothing for inflammation in progress. Starting it now can shift urate levels and worsen the flare. Option b is incorrect because probenecid is a uricosuric agent used between attacks to increase renal excretion of uric acid. It has no anti-inflammatory action and will not relieve the toe tonight. Option c is incorrect because calcium supplements treat bone loss, not crystal induced arthritis, and they play no part in a gout flare. The crystals in gout are made of sodium urate.