Nokea
The client is a 73-year-old woman who fell in her home and suffered a right hip fracture. She tells the nurse that she was walking across the kitchen and felt something 'snap' in her hip and this made her fall. What type of fracture is the client most likely to have?
- A. Comminuted fracture
- B. Greenstick fracture
- C. Open fracture
- D. Pathological fracture
Correct Answer: D
Rationale: A 'snap' before falling suggests a pathological fracture, likely due to weakened bone (e.g., osteoporosis) in an elderly woman.
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The nurse advises the client on the need for maintenance of the bandage. When should the nurse advise the client with a sprained ankle to rewrap the elastic bandage?
- A. When the toes appear pink
- B. When the ankle feels painful
- C. When the toes look swollen
- D. When the joint feels stiff
Correct Answer: C
Rationale: Swollen toes indicate compromised circulation or inadequate compression, necessitating rewrapping to ensure proper fit and pressure. Pink toes suggest normal circulation, pain may not always indicate bandage issues, and joint stiffness is expected with a sprain but not directly related to bandage maintenance.
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.
The LPN is reporting observations and cares to the RN. Based on the LPN's report, which client should the RN assess immediately?
- A. The client, 2 hours post-total knee replacement, has 100 mL bloody drainage in the autotransfusion drainage system container.
- B. The client with a crush injury to the arm was given another analgesic and a skeletal muscle relaxant for throbbing, unrelenting pain.
- C. The client in a new body cast was turned every 2 hours and is being supported with waterproof pillows.
- D. The client with a left leg external fixator has serous drainage from the pin sites, and pulses are present by Doppler.
Correct Answer: B
Rationale: B. The RN should assess this client immediately. Throbbing, unrelenting pain could be the first sign of compartment syndrome. The neurovascular status of the extremity should be assessed. Unrelieved pressure can lead to compromised circulation and avascular necrosis.
A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?
Correct Answer: 30
Rationale: Concentration: 20,000 units ÷ 500 mL = 40 units/mL. Rate: 1200 units/hr ÷ 40 units/mL = 30 mL/hr.
The unlicensed assistive personnel (UAP) reports a client with a fractured femur has 'fatty globules' floating in the urinal. What intervention should the nurse implement first?
- A. Assess the client for dyspnea and altered mental status.
- B. Obtain an arterial blood gas and order a portable chest x-ray.
- C. Call the HCP for a ventilation/perfusion scan.
- D. Instruct the UAP keep the client on strict bedrest.
Correct Answer: A
Rationale: Fatty globules in urine suggest fat embolism syndrome; assessing for dyspnea and altered mental status (respiratory/neurological signs) is the priority. Diagnostics and bedrest follow.