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The client has an external fixator for reduction of a tibia fracture. The nurse is evaluating the client's effectiveness in ambulating with crutches. Place an X on each of the three areas where the client should be bearing weight When crutch walking.
- A. The client should be bearing weight on the hand grips when bringing legs forward. When moving crutches, the weight should be borne on the unaffected leg.
Correct Answer: image
Rationale: The client should be bearing weight on the hand grips when bringing legs forward and on the unaffected leg when moving crutches to ensure proper crutch-walking technique and stability.
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The client is scheduled for a computed tomography (CT) scan. Which question is most important for the nurse to ask before the procedure?
- A. On a scale of 1 to 10, how do you rate your pain?'
- B. Do you feel uncomfortable in enclosed spaces?'
- C. Are you allergic to seafood or iodine?'
- D. Have you signed a permit for this procedure?'
Correct Answer: C
Rationale: Iodine/seafood allergies are critical to assess before CT with contrast to prevent anaphylaxis. Claustrophobia, pain, and consent are secondary.
The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first?
- A. Notify the client's surgeon immediately.
- B. Assess the client's blood pressure and pulse.
- C. Reinforce the dressing with additional dressing.
- D. Check the client's last hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: Reinforcing the dressing controls bleeding, the priority in hemorrhage. Notifying the surgeon, assessing vitals, and checking labs are secondary.
The nurse explains that the primary reason for the client's increased risk for altered skin integrity due to a T12 SCI is which factor?
- A. The inability to perceive extremes in temperature leading to burns
- B. The inability to feel skin irritation such as wrinkled linens or clothing
- C. The increased likelihood of bowel and bladder dysfunction and skin irritation
- D. The circulatory changes that cause vasoconstriction and decreased blood supply
Correct Answer: B
Rationale: Loss of sensation below T12 prevents the perception of skin irritants, increasing the risk of pressure ulcers.
The nurse is caring for the client who had a surgical repair of a right Dupuytren's contracture. Which intervention should the nurse plan?
- A. Elevate the right lower extremity above the level of the heart
- B. Assist the client with bathing, dressing, grooming, and toileting
- C. Instruct about wearing low-heeled and properly fitting shoes
- D. Frequently rewrap the elastic bandage on the right extremity
Correct Answer: B
Rationale: B. Independent self-care is impaired for a few days after surgery because the hand is bandaged. The nurse should plan that the client receive assistance with personal care and ADLs.
The nurse notes during an annual health screening for the 78-year-old client that the client is 1.5 inches shorter than at last year's visit. Which initial screening might the nurse best anticipate for this client?
- A. Bone mineral density (BMD) test
- B. An x-ray of both hips and spine
- C. A bone scan of the hips and spine
- D. A physical check for scoliosis
Correct Answer: A
Rationale: A. BMD testing will best determine if the loss of height is due to osteoporosis, a common finding with aging.