Nokea
Before turning the client postoperatively, which nursing instruction is especially important to prevent postoperative complications?
- A. Hold your breath as you are turning.
- B. Move your lower body first, then your chest.
- C. As you hold onto the trapeze, lift your hips off the bed.
- D. Let me roll you as if you were a log.
Correct Answer: D
Rationale: Log-rolling maintains spinal alignment during turning post-laminectomy, preventing strain on the surgical site and reducing complications like nerve damage or incision dehiscence.
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When the nurse is documenting the client's progress while using a continuous passive motion (CPM) machine, which assessment data are essential to include?
- A. Degree of flexion, number of cycles, and condition of the skin
- B. Degree of flexion, number of cycles, and amount of time the client used the machine
- C. Degree of flexion, number of cycles, and characteristics of drainage from the wound
- D. Degree of flexion, number of cycles, and presence and quality of arterial pulses
Correct Answer: B
Rationale: Flexion degree, cycles, and usage time measure CPM effectiveness.
The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse?
- A. Capillary refill time is less than three (3) seconds.
- B. Pain is not relieved by the patient-controlled analgesia.
- C. Left fingers are edematous and the left hand is purple.
- D. Warm and dry skin on left fingers distal to the elastic bandage.
Correct Answer: C
Rationale: Edema and purple discoloration indicate neurovascular compromise, requiring immediate intervention. Normal refill, unrelieved pain, and warm skin are less urgent.
When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying prone
- D. Standing to shower
Correct Answer: C
Rationale: Prone positioning stresses the stump and impairs healing.
The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA?
- A. I take medication every two (2) hours for my pain.'
- B. I use a heating pad when I go to bed at night.'
- C. I wear a copper bracelet to help with my OA.'
- D. I always wear my ankle splints when I sleep.'
Correct Answer: C
Rationale: Copper bracelets are an alternative therapy for OA, believed to reduce symptoms. Pain medication and heating pads are conventional, and splints are for support, not alternative.
Which priority intervention should the day surgery nurse implement for a client who has had right knee arthroscopy?
- A. Encourage the client to perform range-of-motion exercises.
- B. Monitor the amount and color of the urine.
- C. Check the client’s pulses distally and assess the toes.
- D. Monitor the client’s vital signs.
Correct Answer: C
Rationale: Checking distal pulses and toes assesses for neurovascular compromise, a priority post-arthroscopy. ROM, urine, and vitals are secondary.