A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

Obtain a throat culture specimen.

Perform a complete blood count.

Check the client's temperature.

Administer an oral analgesic.

Answer and Explanation

The Correct Answer is C

A. Obtaining a throat culture specimen might be necessary if a throat infection is suspected, but it is not the immediate priority without first assessing the presence of fever or other systemic signs.
B. Performing a complete blood count could be useful in diagnosing underlying conditions or infections but is not the initial action; the temperature check provides immediate information about potential systemic infection.

C. Check the client's temperature.Headache and stiff neck are symptoms that could be associated with various conditions, including infections such as meningitis. A fever often accompanies infections, and checking the client's temperature helps in identifying if there is a fever, which could be indicative of an infection requiring further evaluation and treatment.

D. Administering an oral analgesic could provide symptom relief but does not address the underlying cause of the symptoms. It is essential first to assess the client’s condition fully before initiating symptomatic treatment.

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Correct Answer is A

Explanation

The nurse should tell the newly licensed nurse that Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that is used to immobilize and align a fractured femur. It involves placing a sling under the knee and applying weights to the aﬀected leg to provide continuous traction.

Russell's traction does not use a cervical halter, skeletal pins, or a pelvic girdle belt. A cervical halter is used to treat neck injuries. Skeletal pins are used in skeletal traction to stabilize fractures. A pelvic girdle belt is used to treat lower back pain.

A. Maintain the client on bed rest for 72 hr after surgery. B. Check capillary refill in the aﬀected extremity every 4 hr. C. Restrict oral ﬂuid intake to 1,000 ml per day. D. Remove antiembolic stockings once each day to examine skin integrity.

Correct Answer is B

Explanation

Checking capillary refill in the aﬀected extremity every 4 hr is an important intervention for a nurse to include in the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. This helps to monitor the blood ﬂow to the aﬀected extremity and ensure that it is adequate.

a. Maintaining the client on bed rest for 72 hr after surgery is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's mobility should be determined by their individual needs and the surgeon's instructions.
c. Restricting oral ﬂuid intake to 1,000 ml per day is not necessary for a patient who has undergone an open reduction and internal fixation of a fractured femur. The patient's ﬂuid intake should be determined by their individual needs and any medical conditions they may have.
d. Removing antiembolic stockings once each day to examine skin integrity is not necessarily required for a patient who has undergone an open reduction and internal fixation of a fractured femur. The use of antiembolic stockings and their removal should be determined by the patient's individual needs and the surgeon's instructions.

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A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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