Nokea
After the client's total hip replacement surgery, which nursing actions are essential? Select all that apply.
- A. Keeping the client's knees apart at all times
- B. Avoiding flexing the client's hips more than 90 degrees
- C. Having the client use a raised toilet seat
- D. Raising the head of the client's bed 90 degrees
- E. Placing two pillows beneath the client's knees
- F. Keeping the client's legs internally rotated
Correct Answer: A,B,C
Rationale: To prevent dislocation after total hip replacement, keep knees apart (using an abductor pillow), avoid hip flexion beyond 90 degrees, and use a raised toilet seat to maintain safe hip angles. Raising the bed 90 degrees or placing pillows under knees risks dislocation, and internal rotation is contraindicated.
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The nurse knows that elderly women have a high incidence of hip fracture for which reason?
- A. Decreased progesterone secretion
- B. Decreased mobility due to arthritic conditions
- C. Increased calcium absorption
- D. Osteoporosis in the skeletal structure
Correct Answer: D
Rationale: Osteoporosis, common in elderly women, weakens bones, increasing hip fracture risk.
Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching?
- A. I need to eat a high-protein diet to ensure healing.'
- B. I need to wiggle my fingers every hour to increase circulation.'
- C. I need to take my pain medication before my pain is too bad.'
- D. I need to keep this immobilizer on when lying down only.'
Correct Answer: D
Rationale: Immobilizers must be worn continuously to stabilize a fractured ulna, not just when lying down. High-protein diet, finger movement, and proactive pain management are correct.
The nurse knows that elevated findings on which laboratory test typically validate a diagnosis of gout?
- A. Creatinine clearance
- B. Blood urea nitrogen
- C. Serum uric acid
- D. Serum calcium
Correct Answer: C
Rationale: Elevated serum uric acid confirms gout, as it causes crystal formation.
When assessing the characteristics of pain in a client with a herniated disk, the nurse would expect to document increased intensity of pain during which activity?
- A. Eating
- B. Coughing
- C. Sleeping
- D. Urinating
Correct Answer: B
Rationale: Coughing increases intraspinal pressure, exacerbating pain from a herniated disk by compressing the affected nerve root. Other activities are less likely to intensify disk-related pain.
The nurse completes teaching the client who has a plaster cast following a right wrist fracture. Which statement, if made by the client, indicates the need for additional teaching?
- A. I should keep my cast uncovered while drying so that moisture can evaporate.'
- B. My cast initially may smell musty. When dry, it should be odorless and shiny white.'
- C. My cast may feel sticky and very warm initially, but it will dry in about 30 minutes.'
- D. I should avoid sharp or hard surfaces while drying because it causes dents in the cast.'
Correct Answer: C
Rationale: C. Although the cast will feel very warm for about 15 to 20 minutes, a plaster cast requires 24 to 72 hours (not 30 minutes) to dry completely.