A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?

Answer and Explanation

The Correct Answer is A

A: Image A shows hands with fingers that appear elongated and have widened nail beds. The fingertips look rounded and bulbous, which is characteristic of clubbing. Clubbing often results from chronic hypoxia and is seen in conditions like congenital heart disease, cystic fibrosis, and chronic lung disease.

B: Image B shows normal-appearing fingers with straight nail beds and no signs of bulbous enlargement at the fingertips. This appearance is not consistent with clubbing and represents normal finger structure without signs of chronic hypoxia or circulatory issues.

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Correct Answer is A

Explanation

A. Administer the tablet to the client with applesauce: Administering the tablet with a small amount of soft food like applesauce can help facilitate swallowing without altering the integrity of the enteric coating. This method eases the swallowing process while ensuring the medication is delivered properly.

B. Position the client at a 45-degree angle: Clients who have difficulty swallowing should be positioned in an upright 90-degree sitting position, not at 45 degrees, to reduce the risk of aspiration and promote safer swallowing mechanics.

C. Crush the tablet and mix it in pudding for the client: Enteric-coated tablets should never be crushed, as crushing destroys the protective coating designed to prevent the medication from being released in the stomach, potentially causing irritation or reducing drug effectiveness.

D. Instruct the client to tilt their head back when swallowing: Tilting the head back increases the risk of choking and aspiration, especially in clients with swallowing difficulties. It is safer to encourage tucking the chin slightly down when swallowing to help protect the airway.

A. Apply a 9 kg 120 lb weight to the traction B. Clean the pin insertion sites on a daily basis. C. Remove the weights while the client is eating D. Ensure that the weights are hanging freely.

Correct Answer is D

Explanation

A. Apply a 9 kg (20 lb) weight to the traction: Buck’s traction is designed for short-term immobilization and uses lighter weights, typically between 2 to 5 kg (4.5 to 10 lb). Applying 9 kg (20 lb) would be excessive and could lead to nerve damage, impaired circulation, or additional injury.

B. Clean the pin insertion sites on a daily basis: Buck’s traction is a type of skin traction, not skeletal traction, and does not involve pins inserted into the bone. Therefore, there are no pin sites to clean in Buck’s traction, making this action irrelevant for the client’s care.

C. Remove the weights while the client is eating: Weights should never be removed or lifted unless there is a provider’s specific order to do so. Interrupting the continuous pull of the traction can cause misalignment of the fracture and delay healing.

D. Ensure that the weights are hanging freely: It is essential that the weights in Buck’s traction hang freely without resting on the floor or bed. This ensures a constant, steady pull on the extremity, which helps maintain proper alignment and promotes effective immobilization.

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A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

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A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering an enteric-coated medication to an adult client who has right-sided weakness and is having difficulty swallowing tablet. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client who has a fractured femur and is in Buck's traction. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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