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A nurse assesses a client with a rotator cuff injury. Which finding should the nurse expect to assess?
- A. Stability to maintain abduction of the affected arm for more than 90 seconds.
- B. Shoulder pain that is relieved with overhead stretches and at night.
- C. Inability to initiate or maintain abduction of the affected arm at the shoulder.
- D. Referred pain to the shoulder and arm opposite the affected shoulder.
Correct Answer: C
Rationale: Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The client should not have difficulty with adduction of the arm, nor experience pain relief with overhead stretches. Pain is usually more intense at night and with related activities, and referred pain to the opposite shoulder is not typical.
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A nurse plans care for a client who is prescribed skeletal traction. Which intervention should the nurse include in this plan of care to decrease the client's risk for infection?
- A. Wash the traction lines and sockets once a day.
- B. Release traction tension for 30 minutes twice a day.
- C. Do not place the traction weights on the floor.
- D. Schedule for pin care to be provided every shift.
Correct Answer: D
Rationale: To decrease the risk for infection in a client with skeletal traction or external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the client's skin, so these do not need to be washed. Releasing traction tension requires a prescription, and placing weights on the floor does not directly decrease infection risk.
A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?
- A. Immobilize the client's arm.
- B. Assess the client's distal pulse.
- C. Monitor for signs of infection.
- D. Administer prescribed steroids.
Correct Answer: A
Rationale: A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client's arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.
A nurse is caring for a client who is recovering from an above-the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond?
- A. The pain you are feeling does not actually exist.
- B. This type of pain will not actually go away.
- C. Would you like to learn how to use imagery to minimize your pain?
- D. How would you describe the pain that you are feeling?
Correct Answer: D
Rationale: The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating it does not exist or will not go away. Offering imagery techniques may be appropriate after assessing the pain.
After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?
- A. Baked fish with orange juice and a vitamin D supplement.
- B. Bacon, lettuce, and tomato sandwich with a vitamin B supplement.
- C. Bacon, lettuce, and tomato sandwich with a vitamin C supplement.
- D. Roast beef with low-fat milk and a vitamin C supplement.
Correct Answer: D
Rationale: The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk provides calcium supplementation, and vitamin C aids in healing. Roast beef provides high protein, making this the best choice. Fish and sandwiches provide less protein.
Which action should the nurse take to ensure proper traction management?
- A. Inspect the client's skin when performing a bed bath.
- B. Apply oxygen by nasal cannula.
- C. Provide pin care by using alcohol wipes to clean the sites.
- D. Ensure that the weights remain freely hanging at all times.
Correct Answer: D
Rationale: Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the client's skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.