Nokea
A phone triage nurse speaks with a client who has an arm cast. The client states, 'My arm feels really tight and puffy.' How should the nurse respond?
- A. Elevate your arm on two pillows and get ice to apply to the cast.
- B. Continue to take ibuprofen (Motrin) until the swelling subsides.
- C. This is normal. A new cast will often feel a little tight for the first few days.
- D. Please come to the clinic today to have your arm checked by the provider.
Correct Answer: D
Rationale: Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and ibuprofen are acceptable actions, but checking the cast is the priority to ensure client safety. The nurse should not reassure the client that this is normal.
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A nurse cares for a client placed in skeletal traction. The client asks, What is the primary purpose of this type of traction? How should the nurse respond?
- A. This traction will prevent fat aligning your fractured bone.
- B. This traction will prevent future complications and back pain.
- C. Traction decreases muscle spasms that occur with a fracture.
- D. This type of traction minimizes damage as a result of fracture treatment.
Correct Answer: A
Rationale: Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a secondary benefit, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage, but these are not the primary purposes of skeletal traction.
A nurse reviews prescriptions for an 82-year-old client with a fractured left hip. Which prescription should alert the nurse to contact the provider and express concerns for client safety?
- A. Meperidine (Demerol) 30 mg IV every 4 hours.
- B. Patient-controlled analgesia (PCA) with morphine sulfate.
- C. Percocet 2 tablets orally every 6 hours PRN for pain.
- D. Percocet 2 tablets every 6 hours for pain.
Correct Answer: A
Rationale: Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this client's pain management.
A nurse cares for a client with a fracture injury. Twenty minutes after an opioid pain medication is administered, the client reports pain in the site of the fracture. Which actions should the nurse take? (Select all that apply.)
- A. Administer additional opioids as prescribed.
- B. Elevate the extremity on pillows.
- C. Apply ice to the fracture site.
- D. Apply heat to the fracture site.
- E. Keep the extremity in a dependent position.
Correct Answer: A,B,C
Rationale: The client with a new fracture likely has edema; elevating the extremity and applying ice will help in decreasing pain and swelling. Administration of additional opioids within dosage guidelines may be ordered. Heat and dependent positioning will increase edema and potentially worsen pain.
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.
An emergency nurse assesses a client who is admitted with a pelvic fracture. Which assessments should the nurse monitor? (Select all that apply.)
- A. Temperature
- B. Urinary output
- C. Blood pressure
- D. Pulse rate
- E. Level of consciousness
Correct Answer: A,B,C,D,E
Rationale: A client with a pelvic fracture is at risk for complications such as internal bleeding, infection, and shock. Monitoring temperature can indicate infection, urinary output can reflect kidney function or hypovolemia, blood pressure and pulse rate can indicate hemodynamic stability, and level of consciousness can signal neurological changes or shock. These assessments are critical for client safety.