Nokea
The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)?
- A. Allow the client to stay in bed until the pain becomes bearable.
- B. Tell the UAP to give the client a bed bath this morning.
- C. Try to encourage the client to get up and go to the shower.
- D. Notify the family the client is refusing to be bathed.
Correct Answer: C
Rationale: Encouraging the client to shower promotes mobility, which reduces OA stiffness, while addressing pain. Bed rest worsens stiffness, bed baths enable immobility, and family notification is unnecessary.
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The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing?
- A. Fat embolism.
- B. Compartment syndrome.
- C. Pressure ulcer under the cast.
- D. Surgical incision infection.
Correct Answer: B
Rationale: Severe pain and numbness in a casted arm suggest compartment syndrome, a medical emergency. Fat embolism, pressure ulcers, and infections present differently.
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.
The physician orders that the client with a hip prosthesis may be out of bed to sit in a chair. How should the nurse position the chair to facilitate transferring the client to the side?
- A. At the end of the bed
- B. Perpendicular to the bed
- C. Parallel with the bed
- D. Against a side wall
Correct Answer: C
Rationale: Positioning the chair parallel to the bed allows the client to transfer safely to the nonoperative side, maintaining hip alignment and minimizing the risk of dislocation during the transfer.
The client is prescribed Fosamax, a bisphosphonate. Which information should the nurse teach?
- A. Take this medication with a full glass of water.
- B. Take with breakfast to prevent gastrointestinal upset.
- C. Use sunscreen to prevent sensitivity to sunlight.
- D. This medication increases calcium reabsorption.
Correct Answer: A
Rationale: Fosamax is taken with water to prevent esophageal irritation. Food reduces absorption, photosensitivity is not a side effect, and it inhibits bone resorption, not calcium reabsorption.
The nurse finds small, fluid-filled lesions on the margins of the client’s surgical dressing. Which statement is the most appropriate scientific rationale for this occurrence?
- A. These were caused by the cautery unit in the operating room.
- B. These are papular wheals from herpes zoster.
- C. These are blisters from the tape used to anchor the dressing.
- D. These macular lesions are from a latex allergy.
Correct Answer: C
Rationale: Tape blisters are common around surgical dressings due to skin irritation. Cautery causes burns, herpes zoster is unrelated, and latex allergies cause diffuse reactions.