Nokea
A patient has a quarter-size amount of drainage on her cast. The next day the amount of drainage has increased to 2 inches (5 cm) in diameter. The nurse would be most concerned about
- A. Swelling beneath the cast.
- B. Neurovascular impairment.
- C. Infection under the cast.
- D. Placing tape petals over the edges of the cast.
Correct Answer: C
Rationale: Increasing drainage on a cast suggests possible infection, requiring immediate attention. Swelling or neurovascular issues are less directly tied to drainage.
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You are working in a home health setting. Which of the following assessments would cause you to consider asking your supervisor to arrange for a physical therapy referral for your patient?
- A. The patient is ambulating in the home with a walker.
- B. The patient had surgery recently and is holding on to furniture to ambulate.
- C. The patient uses a wheelchair in the home, which has been remodeled to accommodate it.
- D. The patient is able to transfer with the assistance of one person and has a 24-hour caregiver in the home.
Correct Answer: B
Rationale: Holding onto furniture to ambulate post-surgery indicates unsafe mobility, warranting a physical therapy referral to improve strength and safety. Other options suggest stable mobility or adequate support.
When you care for a patient prior to surgery, one of your primary concerns is
- A. Researching the exact surgery that will take place.
- B. Ensuring that all preoperative orders are carried out correctly.
- C. Showing the family where to wait during the surgery.
- D. Explaining the surgical techniques that will be used with the patient.
Correct Answer: B
Rationale: Ensuring preoperative orders are followed is critical to prepare the patient safely for surgery. Researching surgery details, showing family waiting areas, or explaining techniques are not primary nursing responsibilities.
A patient states he has fallen twice since using crutches for a foot injury. Which of the following questions might you want to ask him?
- A. Have you had any physical therapy for balancing exercises?
- B. Are you sure your crutch tips are not too slick?
- C. Would you show me how you hold your foot when you walk with the crutches?
- D. Haven't you ever used crutches before?
Correct Answer: A,B,C
Rationale: Asking about balance therapy, crutch tip condition, and walking technique helps identify fall causes. Option D is judgmental and unhelpful.
A patient has skeletal traction applied to his left lower leg. Why is pin site care critical for this patient?
- A. To prevent infection at the pin insertion sites.
- B. To promote faster bone healing.
- C. To reduce pain during traction.
- D. To maintain traction alignment.
Correct Answer: A
Rationale: Pin site care is critical to prevent infection, as pins penetrate skin and bone, creating an infection risk. Other options are not directly related to pin site care.
The reason(s) that a limb might have to be amputated include
- A. Severe tissue damage from trauma.
- B. Severely decreased blood flow to the limb.
- C. Failure of skeletal traction to successfully treat a fracture.
- D. Gangrene (death of tissue) in the limb.
- E. Cancerous tumor of the bone.
Correct Answer: A,B,D,E
Rationale: Amputation may be necessary due to severe trauma, poor blood flow (e.g., peripheral vascular disease), gangrene, or bone cancer. Failure of skeletal traction is not a typical reason for amputation.