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A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?
- A. Assess the distal circulation in 30 minutes
- B. Change the settings based on a range of motion
- C. Raise the lower siderail on the affected side
- D. Remind the client to do quad-setting exercises
Correct Answer: C
Rationale: Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and knee) could be injured. Raising the siderail prevents this. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjust the CPM settings. Quad-setting exercises are not related to the CPM machine.
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A client is on the postoperative unit after a total hip replacement. The client reports a sudden onset of shortness of breath, chest pain, and coughing. What action by the nurse is best?
- A. Assess neurovascular status of both legs
- B. Elevate the affected leg and apply ice
- C. Prepare to administer pain medication
- D. Try to place the affected leg in abduction
Correct Answer: A
Rationale: This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess this client.
A nurse is caring for a client with systemic sclerosis. The client's facial skin is very tight, limiting the ability to open the mouth. Besides a consultation with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate?
- A. Dentist
- B. Massage therapist
- C. Occupational therapy
- D. Physical therapy
Correct Answer: A
Rationale: With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.
The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate?
- A. Are you compliant with following the diabetic diet?
- B. Have you been taking glucosamine supplements?
- C. How much exercise do you really get each week?
- D. You're still taking your diabetic medication, right?
Correct Answer: B
Rationale: All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them.
A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) for disease control. What information does the nurse include? (Select all that apply.)
- A. Avoid acetaminophen or over-the-counter medication
- B. It may take several weeks to become effective
- C. Pregnancy and breast-feeding are not affected by MTX
- D. You may find that folic acid, a B vitamin, reduces side effects
- E. Avoid crowds and sick people
Correct Answer: A,B,D,E
Rationale: MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take weeks to effectively treat RA. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.
A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the client's condition. What action by the nurse is best?
- A. Assess the client's culture more thoroughly
- B. Assess options for performing duties
- C. Suggest the client attend a community meeting
- D. Suggest the client give up the role of elder
Correct Answer: A
Rationale: The nurse needs a more thorough understanding of the client's culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions.