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 supports the client emotionally during grief.
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The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement?
- A. Monitor the continuous passive motion machine.
- B. Apply thigh-high TED hose bilaterally.
- C. Place the abductor pillow between the legs.
- D. Encourage the family to perform ADLs for the client.
Correct Answer: A
Rationale: Monitoring the CPM machine ensures proper knee flexion/extension post-TKR. TED hose are standard, abductor pillows are for THR, and family ADL performance hinders independence.
The nurse working on a medical-surgical floor feels a pulling in the back when lifting a client up in the bed. Which should be the first action taken by the nurse?
- A. Continue working until the shift is over and then try to sleep on a heating pad.
- B. Go immediately to the emergency department for treatment and muscle relaxants.
- C. Inform the charge nurse and nurse manager on duty and document the occurrence.
- D. See a private health-care provider on the nurse's off time but charge the hospital.
Correct Answer: C
Rationale: Reporting and documenting the injury ensures workplace safety protocols and workers’ compensation processes are followed. Continuing work risks further injury, ED is premature, and private care is secondary.
Which is the best technique for the nurse to use when applying the elastic bandage to the client's lower extremity?
- A. Making figure-eight turns with the bandage
- B. Making spiral-reverse turns with the bandage
- C. Making recurrent turns with the bandage
- D. Making spica turns with the bandage
Correct Answer: A
Rationale: The figure-eight technique provides even compression and support around the ankle joint, stabilizing it while allowing some flexibility. Spiral-reverse turns are better for cylindrical limbs, recurrent turns are used for stumps, and spica turns are typically for larger joints like the hip or shoulder.
The nurse starting the shift is determining priorities for the day. Prioritize the order that the nurse should plan to assess the four clients.
- A. Client who had a left BKA and has left foot pain of 6 on a 0 to 10 scale
- B. Client who has a right lower leg cast whose right foot is cold to the touch
- C. Client who had a THR and 200-mL wound drain output during the past 8 hours
- D. Client who had a spinal fusion and has not voided since the urinary catheter removal 4 hours ago
Correct Answer: B,A,D,C
Rationale: B. The client who has a right lower leg cast whose right foot is cold to the touch should be assessed first. The data could indicate compartment syndrome, which is an emergent condition. A. The client who had a left BKA and has left foot pain of 6 on a 0 to 10 scale should be assessed second because pain is a priority in a postoperative client and should be addressed in a timely manner, but this is not an emergent situation. D. The client who had a spinal fusion and has not voided since the urinary catheter removal 4 hours ago should be assessed third for the presence of urinary retention. Usually the client should void within 6 hours after a urinary catheter has been removed. C. The client who had a THR and 200-mL wound drain output during the past 8 hours should be assessed last. This amount of output is a common finding following a THR due to the vascular nature of the operative site.
When implementing the care plan, the nurse should encourage the major intake of fluids at which time of the day?
- A. Before bedtime
- B. Early evening
- C. In the morning
- D. Midafternoon
Correct Answer: C
Rationale: Morning fluid intake promotes hydration and uric acid excretion throughout the day.