Nokea
The client has a fractured right ankle that has just been casted. The nurse is instructing the client in crutch walking techniques. Which method is most appropriate?
- A. Move the right crutch, then the left foot, then the left crutch, and finally the right foot.
- B. Balance weight on the left foot and move right foot and both crutches forward, then bear weight on both crutches and move the left foot forward.
- C. Move the right crutch and left foot forward together; then move the left crutch and right foot.
- D. Move the right crutch and right foot together; then move the left crutch and the left foot.
Correct Answer: A
Rationale: The correct crutch walking technique (three-point gait) involves moving the right crutch, then the left foot, followed by the left crutch, and finally the right foot, protecting the fractured ankle.
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The HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication?
- A. It will help decrease the inflammation in the joints.
- B. It improves tissue function and retards breakdown of cartilage.
- C. It is a potent medication which decreases the client's joint pain.
- D. It increases the production of synovial fluid in the joint.
Correct Answer: B
Rationale: Glucosamine and chondroitin support cartilage health, slowing OA progression. They have limited anti-inflammatory effects, are not potent analgesics, and do not increase synovial fluid.
The nurse writes a concept of 'impaired mobility' for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply.
- A. Request a physical therapy referral.
- B. Administer enoxaparin (Lovenox) subcutaneously.
- C. Utilize a gait belt when ambulating the client.
- D. Assess the client’s pain levels on a 1-to-10 scale.
- E. Provide a high-carbohydrate, high-fat, high-sodium diet.
Correct Answer: A,B,C,D
Rationale: PT referral, enoxaparin, gait belt, and pain assessment promote mobility and prevent complications in hip fracture. High-carb/fat/sodium diet is inappropriate.
The client one (1) day postoperative total hip replacement complains of hearing a 'popping sound' when turning. Which assessment data should the nurse report immediately to the surgeon?
- A. Dark red-purple discoloration.
- B. Equal length of lower extremities.
- C. Groin pain in the affected leg.
- D. Edema at the incision site.
Correct Answer: C
Rationale: Groin pain with a popping sound suggests hip dislocation, requiring immediate surgeon notification. Discoloration, equal leg length, and edema are less urgent.
The nurse supervises a nursing assistant who is applying the client's antiembolism stockings. What is the correct technique for applying these stockings?
- A. The nursing assistant applies the stockings before getting the client out of bed.
- B. The nursing assistant applies the stockings just before helping the client do leg exercises.
- C. The nursing assistant applies the stockings after nursing that the client's legs are cool.
- D. The nursing assistant applies the stockings at night before the client's bedtime.
Correct Answer: A
Rationale: Applying antiembolism stockings before the client gets out of bed ensures compression is in place during upright positions when venous pooling is most likely. Applying them later or based on leg temperature is less effective.
While caring for multiple clients, the nurse delegates client skin care to the UAP on a musculoskeletal unit. Which client is most appropriate for the nurse to delegate skin care to the UAP?
- A. The client with osteomyelitis of the tibia who needs a wound dressing change
- B. The client with an inoperable hip fracture who is in Buck's traction
- C. The client with a pelvic fracture who is in skeletal traction
- D. The client with a femur fracture who has an external fixator in place
Correct Answer: B
Rationale: B. Buck's traction is skin traction. Because there is no open site that needs care with this type of traction, it would be appropriate to delegate skin care.