ANCC-MSN
Medical
ANCC (RN-BC) Medical-Surgical Nursing
Question:
60
The nurse includes the important measures for stump care in the teaching plan for
a client with an amputation. Which measure would be excluded from the teaching
plan?
A. Wash, dry, and inspect the stump daily
B. Treat superficial abrasions and blisters promptly
C. Apply a “shrinker” bandage with tighter arms around the proximal end of the
affected limb
D. Toughen the stump by pushing it against a progressively harder substance
(e.g., pillow on a foot-stool)
Answer:
C
Apply a "shrinker" bandage with tighter arms around the proximal end of the
affected limb. The “shrinker” bandage is applied to prevent swelling of the stump.
It should be applied at the distal end with the tighter arms. Applying the tighter
arms at the proximal end will impair circulation and cause swelling by reducing
venous flow.
Question:
61
Which nursing action is the first priority during a generalized tonic-clonic seizure
episode?
A. Observe and record all events that occur before, during, and after the seizure
B. Maintain a patent airway by turning the head to the side
C. Protect the client from injury
D. Monitor vital signs, with special attention directed to respiratory status
Answer:
C
The first priority is to
protect the client from injury. Do not restrain the client’s
arms or legs, but make sure he or she does not hit anything. Protect the head with
the nurse’s hand, a towel, or a jacket. During the initial tonic phase, the client
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- Fall '20
- Nursing, Seizure, Electroencephalography, Tonic–clonic seizure
