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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.
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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.
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.
An emergency department nurse stages a client with diabetes mellitus who has fractured her arm. Which action should the nurse take first?
- A. Remove the medical alert bracelet from the fractured arm.
- B. Immobilize the arm by splinting the fractured site.
- C. Apply a sling to support the fractured arm.
- D. Cover any open areas with a sterile dressing.
Correct Answer: A
Rationale: A client's medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed to ensure client safety.
A nurse cares for a client who had a long-leg cast applied last week. The client states, 'I cannot seem to catch my breath and I feel a bit light-headed.' Which action should the nurse take next?
- A. Auscultate the client's lung fields anteriorly and posteriorly.
- B. Administer oxygen via nasal cannula.
- C. Check the client's oxygen saturation.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Shortness of breath and light-headedness in a client with a long-leg cast may indicate a pulmonary embolism, a serious complication possibly related to fat embolism syndrome from the fracture. Notifying the healthcare provider immediately is the priority to ensure rapid evaluation and treatment. Auscultation, oxygen administration, and checking oxygen saturation are secondary actions that may follow after the provider is notified.
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.