Nokea
A client has had a knee replacement and will be discharged in the morning. What does the nurse understand is the goal for bending the knee by discharge?
- A. 15?°
- B. 30?°
- C. 60?°
- D. 90?°
Correct Answer: D
Rationale: The goal for the client to have the ability to bend the knee 90?° by discharge. The other answers are incorrect.
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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.
The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to the cast being removed?
- A. The leg will look as it did prior to the cast being applied.
- B. The leg will look moist and will have small bumps that will go away in a few days.
- C. The skin may be covered with a yellowish crust that will shed in a few days.
- D. The leg strength is enforced by the wearing of the cast.
Correct Answer: C
Rationale: Once the cast is off, the skin appears mottled and may be covered with a yellowish crust composed of accumulated body oil and dead skin. The client usually sheds this residue in a few days. The leg will not look as it did prior to the cast but will regain the same shape and status as the other leg. There should be no bumps underneath the cast. The leg may be weak and stiff for some time after the cast is removed, not stronger.
The nurse is caring for a client who has had a fracture reduction using a cast. What would be most important for the nurse to assess?
- A. Cardiac and respiratory status
- B. Renal and hepatic function
- C. Sleep status
- D. Sensation and mobility status
Correct Answer: D
Rationale: After cast application, the nurse should assess circulation, sensation, and mobility in exposed fingers and toes every 1 to 2 hours. Assessment of cardiac, respiratory, hepatic, and renal status would be priorities if the client experienced multiple fractures or had an open reduction. The client's sleep status would be a low priority.
A client is scheduled for a joint replacement surgery. Which action would be most important for the nurse to take?
- A. Ensure adequate fluid intake before the surgery.
- B. Withhold intake of solid food before the surgery.
- C. Withhold administration of aspirin before the surgery.
- D. Ensure adequate sleep before the surgery.
Correct Answer: C
Rationale: If a client is scheduled for a joint replacement or other surgery, it is crucial for the nurse to withhold aspirin before surgery to reduce the risk of excessive bleeding. It is also essential to monitor the complete blood count, prothrombin time, bleeding, and clotting time to ensure that the client is able to control bleeding. The impact of fluid or solid food intake does not have as strong implications as the impact of aspirin intake before surgery. Having adequate sleep before surgery is helpful but is not the most important action.
A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client?
- A. Cutting of a bivalve cast
- B. Cutting a cast window
- C. Removal of the cast
- D. Insertion of an external fixator
Correct Answer: B
Rationale: After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client's condition does not indicate an external fixator is required.