Nokea
Postoperatively, which intervention should be completed before turning the client onto the nonoperative side?
- A. Placing pillows between the client's legs
- B. Having the client point the toes downward
- C. Having the client's knee on the side
- D. Elevating the head of the client's bed
Correct Answer: A
Rationale: Placing pillows between the legs before turning prevents adduction of the operative hip, reducing the risk of dislocation in a client with a hip prosthesis. The other actions do not directly address hip stability.
You may also like to solve these questions
The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit?
- A. Severe bone deformity.
- B. Joint stiffness.
- C. Waddling gait.
- D. Swan-neck fingers.
Correct Answer: B
Rationale: Joint stiffness, especially in the morning, is a hallmark of OA due to cartilage loss. Severe deformity and swan-neck fingers are more typical of rheumatoid arthritis, and waddling gait is nonspecific.
Which of the following might interfere with the effectiveness of Russell's traction?
- A. The rope is strung tautly from pulley to pulley.
- B. The trapeze is hanging above the client's chest.
- C. The rope is knotted at the location of a pulley.
- D. The weight is about 24'' (61 cm) from the floor.
Correct Answer: C
Rationale: A knotted rope at the pulley disrupts smooth movement, reducing traction effectiveness by altering the pull. Taut ropes, a properly placed trapeze, and weights hanging freely are correct for effective traction.
The nurse is caring for an 80-year-old client admitted with a fractured right femoral neck who is oriented x3. Which intervention should the nurse implement first?
- A. Check for a positive Homans' sign.
- B. Encourage the client to take deep breaths and cough.
- C. Determine the client's normal orientation status.
- D. Monitor the client's Buck's traction.
Correct Answer: C
Rationale: Confirming baseline orientation ensures accurate neurological assessment in an elderly fracture patient. Homans’ sign, breathing exercises, and traction monitoring follow.
When the nurse assesses the client, which finding is the best indication that the shoulder has been dislocated?
- A. The client is experiencing intense pain.
- B. The client is receiving intense pain.
- C. The client is hesitant to move the arm.
- D. The affected arm is longer than the other.
Correct Answer: D
Rationale: A dislocated shoulder often results in the affected arm appearing longer due to the humeral head being displaced from the glenoid fossa, altering the arm's alignment. Pain and hesitancy to move are common but less specific, and 'receiving intense pain' is a typographical error.
Which assessment finding is the best indication that the client in halo traction is developing a serious complication?
- A. The client experiences orthostatic hypotension.
- B. The client needs assistance with shaving.
- C. The client cannot open the mouth widely.
- D. The client complains about irritation under the axillae.
Correct Answer: C
Rationale: Inability to open the mouth widely may indicate cranial nerve compression or device misalignment, a serious complication requiring immediate attention. The other findings are less urgent or unrelated.