Nokea
A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action?
- A. Pain of 4 on a scale of 0 to 10.
- B. Numbness in the extremity.
- C. Swollen extremity at the injury site.
- D. Feeling cold while lying in bed.
Correct Answer: B
Rationale: The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling are expected after a fracture and can be treated with comfort measures. Feeling cold can be addressed with additional blankets or increasing the room temperature.
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A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery. Which actions should the nurse include in this client's plan of care? (Select all that apply.)
- A. Elevate heels off the bed with a pillow.
- B. Ambulate the client on the first postoperative day.
- C. Use an abduction pillow to prevent hip subluxation.
- D. Re-position the client every 2 hours.
- E. Push the client's patient-controlled analgesia button.
Correct Answer: A,B,C,D
Rationale: Postoperative care for a client who has ORIF of the hip includes elevating the client's heels off the bed and repositioning every 2 hours to prevent pressure and skin breakdown, ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should never push the patient-controlled analgesia button for the client.
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.
A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities should the nurse include in this client's teaching? (Select all that apply.)
- A. Frequently assess the ergonomics of the equipment being used.
- B. Take breaks to stretch fingers and wrists during working hours.
- C. Perform wrist exercises to strengthen muscles.
- D. Adjust activities to increase pain and swelling in wrists.
- E. Use wrist splints during repetitive tasks.
Correct Answer: A,B,C,E
Rationale: To prevent carpal tunnel syndrome, the nurse should teach the client to assess the ergonomics of their workspace, take breaks to stretch fingers and wrists, perform wrist exercises to strengthen muscles, and use wrist splints during repetitive tasks. Adjusting activities to increase pain and swelling would worsen the condition and should not be recommended.
Which intervention should the nurse include in this client's plan of care for a client recovering from a below-the-knee amputation?
- A. Place pillows between the client's knees.
- B. Encourage range-of-motion exercises.
- C. Administer prophylactic antibiotics.
- D. Implement strict bedrest in a supine position.
Correct Answer: B
Rationale: Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractures and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to reposition, move, and exercise frequently, and therefore should not implement strict bedrest.
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.