Nokea
A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply.
- A. The client requests pain medication to sleep.
- B. The client has eupnea and normal sinus rhythm.
- C. The client has petechiae over the neck and chest.
- D. The client has a high arterial oxygen level.
- E. The client has yellow globules floating in the urine.
Correct Answer: C,E
Rationale: Petechiae and yellow globules suggest fat embolism syndrome, requiring immediate intervention. Pain medication, normal breathing, and high oxygen are not urgent.
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The client has returned to the nursing unit following a right below-the-knee amputation. How should the nurse position the client?
- A. Supine with head turned to the side
- B. With shock blocks placed under the foot of the bed
- C. Semi-sitting position with knees bent
- D. Left lateral with pillows between the knees
Correct Answer: C
Rationale: A semi-sitting position promotes comfort, reduces edema, and facilitates breathing post-amputation.
The nurse is analyzing the serum laboratory report for the client diagnosed with lung cancer that has metastasized to the pelvic bone. Which specific finding should the nurse anticipate?
- A. Elevated calcium
- B. Decreased hemoglobin
- C. Elevated creatinine (SCr)
- D. Elevated creatine kinase (CK)
Correct Answer: A
Rationale: A. Malignant tumors cause hypercalcemia through a variety of mechanisms, one being an increased release of calcium from the bones.
The HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication?
- A. It will help decrease the inflammation in the joints.
- B. It improves tissue function and retards breakdown of cartilage.
- C. It is a potent medication which decreases the client's joint pain.
- D. It increases the production of synovial fluid in the joint.
Correct Answer: B
Rationale: Glucosamine and chondroitin support cartilage health, slowing OA progression. They have limited anti-inflammatory effects, are not potent analgesics, and do not increase synovial fluid.
Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is common post-amputation, arising from nerve endings.
The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, 'Why do I need to lie on my stomach?' Which statement is the most appropriate statement by the nurse?
- A. This position will help your lungs expand better.'
- B. Lying on your stomach will help prevent contractures.'
- C. Many times this will help decrease pain in the limb.'
- D. The position will take pressure off your backside.'
Correct Answer: B
Rationale: Prone positioning prevents hip flexor contractures post-BKA, promoting mobility. Lung expansion, pain relief, and pressure relief are secondary or unrelated.