Nokea
The 32-year-old male client with a traumatic left AKA is being discharged from the rehabilitation department. Which discharge instructions should be included in the teaching? Select all that apply.
- A. Report any pain not relieved with analgesics.
- B. Eat a well-balanced diet and increase protein intake.
- C. Be sure to attend all outpatient rehabilitation appointments.
- D. Encourage the client to attend a support group for amputations.
- E. Stay at home as much as possible for the first couple of months.
Correct Answer: A,B,C,D
Rationale: Reporting unrelieved pain, high-protein diet, rehab appointments, and support groups promote healing and adaptation. Staying home hinders recovery and socialization.
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Which statement made by the family member indicates the need for further teaching?
- A. The hand should be elevated higher than the elbow.
- B. The knot should be tied at the back of the neck.
- C. The elbow should be flexed within the sling.
- D. The sling is used to elevate and support the arm.
Correct Answer: B
Rationale: Tying the knot at the back of the neck may cause discomfort or pressure on the cervical spine. The knot should be tied to the side to avoid this. The other statements correctly describe the proper use of a triangular sling for shoulder immobilization.
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll prevents external rotation, maintaining hip alignment.
The nurse identifies the concept of impaired functional ability for a client diagnosed with rheumatoid arthritis. Which intervention should the nurse implement?
- A. Teach the client to apply antiembolism (TED) hose.
- B. Administer the nonsteroidal medication before the morning meal.
- C. Encourage the client to perform low-impact exercises daily.
- D. Refer the client to occupational therapy for gait training.
Correct Answer: C
Rationale: Low-impact exercises maintain joint function in RA, addressing impaired ability. TED hose are for DVT, NSAIDs are for pain, and OT is for specific tasks, not gait.
The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement?
- A. Refer the client to physical therapy at home.
- B. Refer the client to an assistive living facility.
- C. Refer the client to a workforce commission for job training.
- D. Refer the client to the dietitian.
Correct Answer: A
Rationale: Home PT restores hand/forearm function post-crushing injury. Assisted living, job training, and dietitian referrals are premature or unrelated.
The nurse is working with an unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention?
- A. The UAP feeds a client two (2) days postoperative cervical laminectomy a regular diet.
- B. The UAP calls for help when turning to the side a client who is post-lumbar laminectomy.
- C. The UAP is helping the client who weighs 300 pounds and is diagnosed with back pain to the chair.
- D. The UAP places the call light within reach of the client who had a disk fusion.
Correct Answer: A
Rationale: A regular diet post-cervical laminectomy risks aspiration if swallowing is impaired; this requires immediate intervention. Calling for help, assisting a heavy client, and placing the call light are appropriate.