Nokea
During the assessment of a client scheduled for orthopedic surgery, the nurse discovers that the client was previously treated for the disorder. In such a case, what additional data need to be collected?
- A. Occurrence of complications or problems during treatment
- B. Measures taken to minimize postoperative wound infection
- C. Perception of the client about the previous treatment
- D. Details of the medical team that handled the previous treatment
Correct Answer: A
Rationale: If the same disorder has been treated earlier, the nurse needs to determine and document any complications or problems that occurred during treatment. The nurse can determine whether the client understands the treatment or not based on the measures taken by the client to minimize postoperative wound infection. However, this factor can be assessed later because the nurse needs to explain the new treatment to the client. Although the client's perceptions of the previous treatment may be helpful, this data would not be as important. In addition, the nurse does not need to get details about the medical team that handled the previous treatment, unless specifically asked to do so.
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A client sustained a stable fracture of the cervical spine and is having skeletal traction applied. What type of traction does the nurse educate the client about?
- A. Kirschner wires
- B. Thomas splint
- C. Steinmann pins
- D. Crutchfield tongs
Correct Answer: D
Rationale: Crutchfield tongs are used for skeletal traction in the case of a cervical spine fracture to stabilize the spine and maintain alignment. Kirschner wires and Steinmann pins are typically used for skeletal traction in other areas, such as limbs. A Thomas splint is used for femoral fractures and is a form of skin traction, not skeletal traction.
The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?
- A. Scrubbing the drainage from around the pin site
- B. Obtaining a culture
- C. Applying iodine-based solution
- D. Apply ointment to the pin site.
Correct Answer: B
Rationale: A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?
- A. Arthrodesis
- B. Hemiarthroplasty
- C. Total arthroplasty
- D. Osteotomy
Correct Answer: C
Rationale: A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone's alignment, thereby improving function and relieving pain.
The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician?
- A. Blood pressure of 140/90 mm Hg
- B. Crackles in the lung bases
- C. SUBJECT: Client complains of pain in the affected rib area when taking a deep breath
- D. Heart rate of 94 beats/minute
Correct Answer: B
Rationale: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.
A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize?
- A. Client complains of tingling and numbness in the right shoulder.
- B. Right shoulder is elevated above the left.
- C. Client complains of pain in the unaffected shoulder.
- D. Right shoulder slopes downward and droops inward.
Correct Answer: D
Rationale: The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.