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A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery?
- A. Place the right thumb directly on ice.
- B. Put the right thumb in a glass of warm water.
- C. Wrap the thumb in a clean piece of material.
- D. Secure the thumb in a plastic bag and place on ice.
Correct Answer: D
Rationale: Wrapping the thumb and placing it in a bag on ice preserves viability for reattachment without freezing tissue. Direct ice causes frostbite, warm water promotes decay, and wrapping alone is insufficient.
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The client is a 64-year-old male admitted to the hospital with severe pain in his right big toe, which is red and swollen. Which nursing care measure is most essential for the nurse to perform at this time?
- A. Use a bed cradle on the bed
- B. Put a bed board on the bed
- C. Obtain a heat lamp
- D. Prepare to catheterize the client
Correct Answer: A
Rationale: A bed cradle keeps bedding off the painful, swollen toe in gout, reducing discomfort.
The nurse is teaching a class to pregnant teenagers. Which information is most important when discussing ways to prevent osteoporosis?
- A. Take at least 1,200 mg of calcium supplements a day.
- B. Eat foods low in calcium and high in phosphorus.
- C. Osteoporosis does not occur until around age 50 years.
- D. Remain as active as possible until the baby is born.
Correct Answer: D
Rationale: Staying active (weight-bearing exercise) during pregnancy builds bone density, preventing future osteoporosis. Calcium supplements are secondary, low-calcium diets are harmful, and age misconception ignores prevention.
The client just underwent a left THR. After a family member assists the client with repositioning in bed, the client states hearing a 'pop' and has increased pain at the surgical site. Which is the most appropriate initial action by the nurse?
- A. Check the position of the left lower extremity.
- B. Elevate the head of the client's bed.
- C. Adjust the pillow used for abduction.
- D. Administer the prescribed pain medication.
Correct Answer: A
Rationale: A. The nurse's initial action should be to check the extremity's position. Improper movement and repositioning can cause prosthesis dislocation; an audible pop and increased pain are signs of possible dislocation.
The nurse is caring for clients on an orthopedic floor. Which client should be assessed first?
- A. The client diagnosed with back pain who is complaining of a '4' on a 1-to-10 scale.
- B. The client who has undergone a myelogram who is complaining of a slight headache.
- C. The client two (2) days post-disk fusion who has T 100.4, P 96, R 24, and BP 138/78.
- D. The client diagnosed with back pain who is being discharged and whose ride is here.
Correct Answer: C
Rationale: Fever, tachycardia, and tachypnea post-disk fusion suggest infection or complications, requiring urgent assessment. Mild pain, headache, and discharge are lower priority.
Which intervention(s) should the nurse include in the child's plan of care immediately following insertion of a ventriculoperitoneal (VP) shunt for treatment of hydrocephalus?
- A. Maintain the head of the bed in an elevated position.
- B. Ensure that the child minimizes movement of the extremities.
- C. Provide a pressure dressing over the cephalic insertion site.
- D. Maintain a flat position and reposition the child every 2 hours.
Correct Answer: D
Rationale: Maintaining a flat position and repositioning every 2 hours helps prevent complications and ensures shunt function post-VP shunt insertion.