Nokea
The client has been flat in bed in traction for two weeks, and she is to be allowed out of bed for the first time today. What must the nurse be particularly alert for when getting the client out of bed?
- A. Renal complications
- B. Depression
- C. Orthostatic hypotension
- D. Skin breakdown
Correct Answer: C
Rationale: Prolonged bed rest increases the risk of orthostatic hypotension when first mobilizing, requiring careful monitoring.
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The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Prepare the client by removing all metal objects.
- B. Inject the contrast into the intravenous site.
- C. Administer a sedative to the client to decrease anxiety.
- D. Explain why the client cannot have any breakfast.
Correct Answer: A
Rationale: Removing metal objects is a safe UAP task, ensuring MRI safety. Contrast injection, sedation, and explanations require nursing judgment.
The client who underwent a left above-the-knee amputation as a result of uncontrolled diabetes questions the nurse, asking, 'Why did this happen to me? I have always been a good person.' Which is the nurse’s most therapeutic response?
- A. Tell me about how it feels to have caused this to happen to you.'
- B. I know how you feel; having your leg cut off is sad.'
- C. Why do you think that you had to have your leg amputated?'
- D. I can see you are hurting. Would you like to talk?'
Correct Answer: D
Rationale: Acknowledging distress and offering to talk is therapeutic, validating emotions. Blaming the client, claiming empathy, or questioning beliefs is less supportive.
Which description by the nurse most accurately states the purpose of halo-cervical traction?
- A. It restricts neck movement but enables physical activity.
- B. It allows head movement while immobilizing the spine.
- C. It accelerates healing by facilitating physical therapy.
- D. It promotes faster bone repair within a shorter time span.
Correct Answer: A
Rationale: Halo-cervical traction immobilizes the cervical spine to promote healing while allowing some physical activity (e.g., walking), unlike other options that inaccurately describe its function.
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.
Which intervention should the nurse implement when caring for the child with an Ilizarov external fixator applied to a lower extremity for bone lengthening?
- A. Loosening the bolts and lengthening the rods on the fixator every other day
- B. Cleansing the external fixator pin sites with sterile saline twice daily
- C. Discouraging the child from bearing any weight on the involved extremity
- D. Removing sections of the fixator apparatus when the child is positioned in bed
Correct Answer: B
Rationale: Regular cleansing of pin sites with sterile saline prevents infection in an Ilizarov fixator.