Nokea
The client has returned to the nursing unit following a right below-the-knee amputation. How should the nurse position the client?
- A. Supine with head turned to the side
- B. With shock blocks placed under the foot of the bed
- C. Semi-sitting position with knees bent
- D. Left lateral with pillows between the knees
Correct Answer: C
Rationale: A semi-sitting position promotes comfort, reduces edema, and facilitates breathing post-amputation.
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The nurse documents the admission assessment for the client who is to have a left total hip arthroplasty to treat chronic degenerative joint disease. Which statements indicate that the client uses alternative therapies for CA treatment? Select all that apply.
- A. I take ibuprofen every 4 to 6 hours.'
- B. I wear a copper bracelet all the time.'
- C. I take glucosamine sulfate 1000 mg daily.'
- D. I apply special magnets to the hip joint.'
- E. I sleep on the unaffected hip, turning often.'
Correct Answer: B,C,D
Rationale: B. Wearing a copper bracelet is an alternative therapy used by some with CA for pain control and reduction of joint stiffness. C. Taking glucosamine sulfate is an alternative therapy used by some with CA. Glucosamine is taken to modify cartilage structure, but studies supporting this have been inconclusive. D. Using magnets designed for body application is an alternative therapy used by some with CA for pain control and reduction of joint stiffness.
Which of the following would the nurse identify as the highest priority when documenting the postoperative circulation status of the recently casted extremity?
- A. Adequate neurovascular functioning
- B. Minimal pain on movement
- C. Vital signs within normal limits
- D. No drainage noted on the cast
Correct Answer: A
Rationale: Adequate neurovascular functioning (circulation, sensation, and movement) is the highest priority to ensure no complications like compartment syndrome or vascular compromise, which can lead to tissue damage. Pain, vital signs, and drainage are secondary.
Which interventions should the nurse implement for a child with a newly applied fiberglass hip-Spica cast?
- A. Use a hair dryer on a low setting to help dry the cast.
- B. Place on a Bradford frame for elevation off the bed.
- C. Place pillows to support the child's lower extremities.
- D. Turn the child every 2 hours and monitor the CMS.
- E. Petal the perineal area and other edges of the cast.
Correct Answer: C,D,E
Rationale: Pillows provide support, turning prevents pressure sores, and petaling protects skin around cast edges.
In which conditions might the nurse assess for the presence of papilledema?
- A. Eczema
- B. Craniosynostosis
- C. Shaken baby syndrome
- D. Hydrocephalus
- E. Chest trauma
Correct Answer: B,C,D
Rationale: Papilledema, indicating increased intracranial pressure, can be associated with craniosynostosis, shaken baby syndrome, and hydrocephalus.
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.