Nokea
The client has Buck's traction to temporarily immobilize a fracture of the proximal femur prior to surgery. Which assessment finding requires the nurse to intervene immediately?
- A. Reddened area at the client's coccygeal area
- B. Voiding concentrated urine at 50 mL per hour
- C. Capillary refill 3 seconds, pedal pulses palpable
- D. Ropes, pulleys intact; 5-lb weight hangs freely
Correct Answer: A
Rationale: A. A reddened sacrum is the first sign of a pressure ulcer that is caused by pressure or friction and shear. Shear results from the weight of the skin traction pulling the client to the foot of the bed and then sliding back up in bed. Immediate interventions are required before it develops into a stage II ulcer.
You may also like to solve these questions
The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which is a modifiable risk factor for developing OA?
- A. Being overweight.
- B. Increasing age.
- C. Previous joint damage.
- D. Genetic susceptibility.
Correct Answer: A
Rationale: Excess weight increases joint stress, a modifiable risk for OA. Age, prior damage, and genetics are nonmodifiable.
Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is common post-amputation, arising from nerve endings.
The physician orders prednisone for a client with rheumatoid arthritis for painful wrists and joints. Which instruction is it essential for the nurse to give the client?
- A. Take the pills with milk or food.'
- B. Be sure to take the medication between meals.'
- C. Stop the pills at once if your face begins to get puffy.'
- D. Your urine may turn pinkish while taking this.'
Correct Answer: A
Rationale: Taking prednisone with food or milk reduces gastrointestinal irritation, a key instruction for safe administration.
When the nurse is documenting the client's progress while using a continuous passive motion (CPM) machine, which assessment data are essential to include?
- A. Degree of flexion, number of cycles, and condition of the incision
- B. Degree of flexion, number of cycles, and amount of time the client used the machine
- C. Degree of flexion, number of cycles, and characteristics of drainage from the wound
- D. Degree of flexion, number of cycles, and presence and quality of arterial pulses
Correct Answer: B
Rationale: Documenting the degree of flexion, number of cycles, and time used on the CPM machine tracks progress in restoring joint function. Incision condition, drainage, or pulses are monitored separately.
Which nursing observation provides the best indication that the halo-cervical traction device is applied appropriately?
- A. The client has full range of motion in the neck.
- B. The client's neck pain is within a tolerable level.
- C. The client can speak and hear at preinjury levels.
- D. The client reports the ability to see straight ahead.
Correct Answer: D
Rationale: The ability to see straight ahead indicates proper alignment of the halo device, ensuring the cervical spine is stabilized correctly. Full neck motion contradicts the purpose, and pain or speech/hearing are less specific.