Nokea
It is necessary to pull the client, who is in Russell's traction, up in bed. Which action should the nurse take?
- A. Leave the weights in place.
- B. Remove the weights completely.
- C. Reduce the weight of the traction by one half.
- D. Have one nurse lift the weights while the others pull the client.
Correct Answer: A
Rationale: Leaving weights in place maintains continuous traction, preventing misalignment during repositioning.
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To which member of the health-care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub?
- A. Physiatrist.
- B. Social worker.
- C. Physical therapist.
- D. Counselor.
Correct Answer: C
Rationale: A physical therapist can teach adaptive techniques and exercises to improve bathtub mobility for OA. Physiatrists focus on rehabilitation plans, social workers address resources, and counselors focus on mental health.
Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply.
- A. Apply an immobilizer snugly to prevent edema.
- B. Apply an ice pack for 10 minutes and remove for 20 minutes.
- C. Place the extremity in the dependent position to allow drainage.
- D. Obtain an x-ray of the ankle after applying the immobilizer.
- E. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.
Correct Answer: B,D,E
Rationale: Ice reduces swelling, x-ray confirms fracture, and tetanus prevents infection in open fractures. Tight immobilizers risk neurovascular compromise, and dependent positioning worsens edema.
The nurse is caring for a client who has just had a cast applied. Which statement best describes the expected client outcome relative to the circulatory system for a client with a cast?
- A. There will be no increase in pain in the extremity.
- B. The client will have no circulatory impairment.
- C. The integrity of the cast will be maintained.
- D. The client will report any feelings of skin irritation.
Correct Answer: B
Rationale: The primary circulatory outcome is preventing impairment, such as swelling or color changes. Pain relates to neurological issues, cast integrity is unrelated to circulation, and skin irritation is not a circulatory indicator.
The client is admitted to the hospital for a diagnostic workup. The client has vague symptoms of malaise, coughing, chest discomfort, low-grade fever, diffuse rashes, and musculoskeletal aches and pains. A diagnosis of probable lupus erythematosus has been made. The night nurse finds the client crying and saying, 'I would rather die than suffer with this disease for the rest of my life.' Which response by the nurse would be most therapeutic at this time?
- A. Telling the client there are support groups to join after discharge
- B. Offering to stay with the client to discuss concerns and questions
- C. Advising the client to write concerns on paper to discuss with the doctors and nurses tomorrow
- D. Offering the client a back rub and a warm cup of milk
Correct Answer: B
Rationale: Offering to stay and discuss concerns is therapeutic, providing emotional support and addressing the client's fears.
Which nursing instruction about heating pads is essential to include in the client's teaching plan?
- A. Use the lowest setting on the heating pad.
- B. Place the heating pad directly on the skin.
- C. Cover the heating pad with plastic during use.
- D. Apply the heating pad for 2 hours at a time.
Correct Answer: A
Rationale: Using the lowest setting on the heating pad minimizes the risk of burns, especially in older clients with potentially reduced skin sensitivity. Direct skin contact, plastic covers, or prolonged use increase burn risk.