Nokea
A 68-year-old female client who had a below the knee amputation is to be discharged because her healing is almost complete. Which of the following would be most important for the nurse to discuss with this client?
- A. Advising the client to avoid red meat
- B. Urging her to keep the affected limb in an elevated position
- C. Educating the client about the effects of menopause
- D. Exploring factors related to the client's home environment
Correct Answer: D
Rationale: Exploring factors related to the older adult client's home environment and determining a plan for continued rehabilitation before discharge is most important. The client should be encouraged to eat foods rich in protein, calcium, and vitamin D. Because the healing is almost complete, the client need not always keep the affected limb elevated unless prescribed to do so. Because the client is in her late 60s, she is most likely to have already undergone menopause. Therefore, educating her about the effects of menopause is not as important.
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The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?
- A. Scrubbing the drainage from around the pin site
- B. Obtaining a culture
- C. Applying iodine-based solution
- D. Apply ointment to the pin site.
Correct Answer: B
Rationale: A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.
A client has a fractured jaw sustained in an automobile accident and has had the fracture surgically reduced and immobilized with a wire loop. What should the nurse ensure is present at the client's bedside in case of vomiting?
- A. Wire cutters
- B. A tracheostomy tray
- C. Ice water with a straw
- D. An antiemetic medication
Correct Answer: A
Rationale: Ensure that wire cutters are easily accessible at the client's bedside. The nurse should be familiar with how to cut wire loops if the client vomits or chokes. A tracheostomy tray is not necessary when an airway can be obtained by cutting the wires so the client does not aspirate. If vomiting occurs, the client should have nothing by mouth. Antiemetic medication should be administered prior to the client vomiting and should not be kept at the bedside.
A client's cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?
- A. Consult a skin specialist.
- B. Scrub the area vigorously to remove the crust.
- C. Apply lotions and take warm baths or soaks.
- D. Avoid exposure to direct sunlight.
Correct Answer: C
Rationale: The client should be advised to apply lotions and take warm baths or soaks. This will help in softening the skin and removing debris. The client usually sheds this residue in a few days so the client need not consult a skin specialist. It is not advisable to scrub the area vigorously. The client need not avoid exposure to direct sunlight because the area is not photosensitive.
The clinic nurse is caring for a client with an injured body part that does not require rigid immobilization. What method of immobilization would the nurse expect the health care provider to use on a short-term basis?
- A. Cast
- B. Brace
- C. Splint
- D. Skin traction
Correct Answer: C
Rationale: A splint immobilizes and supports an injured body part in a functional position and is used when the condition does not require rigid immobilization, causes a large degree of swelling, or requires special skin treatment. Casts and traction provide rigid immobilization. A brace provides support, controls movement, and prevents additional injury for more long-term use.
A client had a surgical amputation of an arm and is having a myoelectric arm applied. What does the nurse understand is the benefit(s) of this type of device? Select all that apply.
- A. Eliminates the need to wear a harness
- B. Terminal device looks natural
- C. Better function than cosmetic hand
- D. Stronger than other devices
- E. Lasts longer than other devices
Correct Answer: A,B,C
Rationale: The myoelectric arm has three advantages: eliminates the need to wear a harness, the terminal device looks natural, and it has somewhat better function than the cosmetic hand. Despite its advantages, the myoelectric arm is not rugged enough to do the work of the mechanical terminal device, and it does not last longer than other devices.