Nokea
The client is an elderly man who has had diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation?
- A. Encouraging deep breathing
- B. Asking him if he understands the full effects of the planned surgery
- C. Discussing the effects of diabetes on the vascular system
- D. Having a recovered amputee visit him
Correct Answer: D
Rationale: A visit from a recovered amputee provides peer support, helping the client adjust by seeing a positive outcome.
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Later the client says, 'I know my arm isn't there, but I feel it throbbing.' 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 a common sensation of pain in the amputated limb due to nerve endings firing, accurately describing the client's experience. The other options misattribute the cause.
The occupational health nurse is planning health promotion activities for a group of factory workers. Which activity is an example of primary prevention for clients at risk for low back pain?
- A. Teach back exercises to workers after returning from an injury.
- B. Place signs in the work area about how to perform first aid.
- C. Start a weight-reduction group to meet at lunchtime.
- D. Administer a nonnarcotic analgesic to a client complaining of back pain.
Correct Answer: C
Rationale: Weight reduction reduces spinal stress, a primary prevention strategy for low back pain. Post-injury exercises are secondary, first aid signs are tertiary, and analgesics treat symptoms, not prevent.
The home health nurse is caring for clients who had a THR through the posterior surgical approach 2 weeks ago. It is most important for the nurse to intervene immediately for which client?
- A. After a THR, the client should not flex the hip greater than 90 degrees or have adduction of the hip because it can cause hip dislocation. Wearing socks that do not have grippers on the bottom increases the client's risk for a fall.
- B. After a THR the client may sit at 90 degrees.
- C. After a THR the client may lie supine.
- D. After a THR the client may be up. However, this client should be wearing shoes or gripper socks or slippers to prevent a fall.
Correct Answer: A
Rationale: A. After a THR, the client should not flex the hip greater than 90 degrees or have adduction of the hip because it can cause hip dislocation. Wearing socks that do not have grippers on the bottom increases the client's risk for a fall.
The nurse is to administer nafcillin 500 mg intravenously to the client with osteomyelitis. A vial of 1 g of powdered nafcillin is to be reconstituted with 3.4 mL of 0.9% NaCl. How many milliliters should the nurse plan to administer?
- A. 1.7 mL
Correct Answer: A
Rationale: Rationale: 500 mg / 1,000 mg = x / 3.4 mL; x = 1.7 mL. The nurse should prepare 1.7 mL nafcillin (Nallpen).
The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement?
- A. Monitor the continuous passive motion machine.
- B. Apply thigh-high TED hose bilaterally.
- C. Place the abductor pillow between the legs.
- D. Encourage the family to perform ADLs for the client.
Correct Answer: A
Rationale: Monitoring the CPM machine ensures proper knee flexion/extension post-TKR. TED hose are standard, abductor pillows are for THR, and family ADL performance hinders independence.