Nokea
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
- A. Adjust the patient-controlled analgesia (PCA) machine for a lower dose.
- B. Ensure the weights of the Buck's traction are off the floor and hang freely.
- C. Raise the head of the bed to 45 degrees and the foot to 15 degrees.
- D. Turn the client on the affected leg using pillows to support the other leg.
Correct Answer: B
Rationale: Proper Buck’s traction alignment (weights off floor) reduces pain from misalignment. Adjusting PCA, bed positioning, or turning may worsen pain or are inappropriate.
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When the nurse examines the client, which body part is usually affected by gout?
- A. Great toe
- B. Index finger
- C. Sacrococcygeal vertebrae
- D. Temporomandibular joint
Correct Answer: A
Rationale: Gout typically affects the great toe (first metatarsophalangeal joint) due to uric acid crystal deposition, causing acute pain and swelling. Other areas are less commonly involved.
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.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Do you have any stomach pain or black stools?
- B. Are you experiencing any joint swelling?
- C. Have you noticed any changes in your vision?
- D. Are you feeling more tired than usual?
Correct Answer: A
Rationale: Stomach pain or black stools indicate gastrointestinal bleeding, a serious NSAID side effect.
The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client?
- A. The client will maintain vital signs within normal limits.
- B. The client will have a decrease in muscle spasms in the affected leg.
- C. The client will have no signs or symptoms of infection.
- D. The client will be able to ambulate down to the nurse’s station.
Correct Answer: D
Rationale: Ambulation to the nurse’s station is a long-term goal post-ORIF, indicating restored mobility. Vital signs, spasms, and infection are short-term or secondary.
The 27-year-old client has a right above-the-elbow amputation secondary to a boating accident. Which statement to the rehabilitation nurse indicates the client has accepted the amputation?
- A. I am going to sue the guy who hit my boat.'
- B. The therapist is going to help me get retrained for another job.'
- C. I decided not to get a prosthesis. I don't think I need it.'
- D. My wife is so worried about me and I wish she weren't.'
Correct Answer: B
Rationale: Planning job retraining indicates acceptance and adaptation to amputation. Lawsuits, prosthesis refusal, and concern for others suggest denial or unresolved grief.