Nokea
The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement?
- A. Assess the client's nutritional status.
- B. Refer the client to an occupational therapist.
- C. Determine if the client is allergic to IVP dye.
- D. Start a 22-gauge Angiocath in the right arm.
Correct Answer: A
Rationale: Nutritional status assessment ensures adequate healing post-amputation, critical in diabetes. OT referral is postoperative, IVP dye is irrelevant, and a 22-gauge IV is too small for surgery.
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The client is 12-hours post-lumbar laminectomy. Which nursing interventions should be implemented?
- A. Assess ability to void and log roll the client every two (2) hours.
- B. Medicate with IV steroids and keep the bed in a Trendelenburg position.
- C. Place sandbags on each side of the head and give cathartic medications.
- D. Administer IV anticoagulants and place on O2 at eight (8) L/min.
Correct Answer: A
Rationale: Post-lumbar laminectomy, assessing voiding prevents urinary retention, and log rolling maintains spinal alignment. Steroids/Trendelenburg, sandbags/cathartics, and anticoagulants/O2 are inappropriate without specific indications.
Which evidence is the best indication that the client who had a knee arthroplasty is recovering according to expected outcomes and no longer needs the continuous passive motion (CPM) machine?
- A. The client has minimal pain when ambulating.
- B. The client can flex the operative knee 90 degrees.
- C. The client can tolerate full weight bearing.
- D. The edges of the client's surgical wound are approximated.
Correct Answer: B
Rationale: 90-degree knee flexion indicates restored joint function, a key recovery milestone.
Which is the best method to assess circulation in the casted extremity?
- A. Ask the client to wiggle the fingers.
- B. Feel the cast to determine if it is unusually hot or cold.
- C. Depress the client's nail beds, and document the client's knee on the center to return.
- D. See if there is enough room to insert a finger between the cast and the extremity.
Correct Answer: C
Rationale: Depressing the nail beds to assess capillary refill (color return within 2-3 seconds) is the most reliable method to evaluate circulation in a casted extremity, indicating adequate blood flow. Wiggling fingers assesses motor function, not circulation directly, and the other options are less specific.
The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report?
- A. The 84-year-old female with a fractured right femoral neck in Buck’s traction.
- B. The 64-year-old female with a left total knee replacement who has confusion.
- C. The 88-year-old male post-right total hip replacement with an abduction pillow.
- D. The 50-year-old postop client with a continuous passive motion (CPM) device.
Correct Answer: B
Rationale: Confusion post-TKR may indicate neurological or metabolic complications, requiring urgent assessment. Fractures, THR, and CPM use are stable.
When the client asks the nurse what is meant by the term manipulation, which explanation is most accurate?
- A. Manipulation involves making an incision to realign the bones.
- B. Manipulation involves the insertion of a pin or wire into the joint.
- C. Manipulation repositions the bone ends manually.
- D. Manipulation strengthens the joint with exercise.
Correct Answer: C
Rationale: Manipulation for a dislocated shoulder involves manually repositioning the bone ends into their normal alignment without surgical intervention. Incisions or pins are used in surgical procedures, and exercise is for rehabilitation, not repositioning.