Nokea
Postoperatively, the client screams obscenities at the nurse after realizing that the injured forearm is missing. Which nursing action is most appropriate at this time?
- A. Leave until the client works through the anger.
- B. Stay quietly with the client at the bedside.
- C. Tell the client to gain emotional control.
- D. Call the physician and request a sedative.
Correct Answer: B
Rationale: Staying quietly with the client provides emotional support during a grief reaction to amputation, promoting trust. Leaving, reprimanding, or medicating without engagement dismisses the client's feelings.
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The nurse assesses the client 6 hours following a lumbar spinal fusion. The client has a throbbing headache, but VS and CMS of the lower extremities are WNL. The lungs have fine basilar crackles. The back dressing has a dime-sized bloody spot surrounded by clear yellow drainage. Which nursing action demonstrates the nurse's best clinical judgment?
- A. Give prescribed morphine sulfate IV
- B. Have the client cough and deep breathe
- C. Reinforce the incisional dressing
- D. Notify the health care provider
Correct Answer: D
Rationale: D. A bloody area surrounded by clear yellowish fluid on the dressing and the client's headache suggest a CSF leak. The nurse should notify the HCP.
Which client symptom indicates that the nurse should discontinue the medication and notify the physician even if the client's pain is unrelieved?
- A. Vomiting
- B. Dizziness
- C. Drowsiness
- D. Headache
Correct Answer: A
Rationale: Vomiting is a sign of colchicine toxicity, requiring immediate cessation.
The client with a lower leg amputation has edema, so the NA elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated?
- A. Thank the nursing assistant (NA) for being so observant and intervening appropriately to treat the client's edema of the residual limb.
- B. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
- C. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals, the leg should not be elevated.
- D. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
Correct Answer: B
Rationale: B. The nurse should perform this action. Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.
The nurse assesses the client 4 hours following a left TKR. The client has a knee immobilizer in place with medial and lateral packs that are warm. An autotransfusion wound drainage system has 350 mL collected. The client has not voided since before surgery but does not express a need. Which interventions should the nurse plan to implement at this time? Select all that apply.
- A. Reinfuse the salvaged blood from the wound drainage system.
- B. Remove the immobilizer to place the knee in 90-degree flexion.
- C. Stand the client at the bedside to facilitate bladder emptying.
- D. Place the left leg in a continuous passive motion device (CPM).
- E. Replace the warm packs in the knee immobilizer with ice packs.
Correct Answer: A,E
Rationale: A. An autotransfusion drainage system is used in the immediate postoperative period if extensive bleeding is anticipated. Collected drainage can be reinfused up to 6 hours postoperative. E. Ice packs, used to reduce swelling and control bleeding, are replaced every 2 hours. If they have warmed, they need to be replaced.
The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the discharge teaching?
- A. I need to keep my leg elevated on two pillows for the first 24 hours.'
- B. I must wear my sequential compression device all the time.'
- C. I can remove the cast for one (1) hour so I can take a shower.'
- D. I will be able to walk on my cast and not have to use crutches.'
Correct Answer: A
Rationale: Elevating the leg reduces swelling post-casting, indicating understanding. SCDs are for DVT, cast removal is unsafe, and walking without crutches depends on the fracture.