Nokea
The following scenario applies to the next 1 items
The nurse cares for a client who sustained a femur fracture twelve hours ago
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Nurses’ Notes
Client reports shortness of breath and stated, ‘something is not right.’ The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air. Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.
The client is demonstrating signs and symptoms of
- A. Pulmonary embolism
- B. Myocardial infarction
- C. Fat embolism syndrome
- D. Compartment syndrome
Correct Answer: C
Rationale: Fat embolism syndrome is likely after a femur fracture, with symptoms like shortness of breath, bilateral crackles, chest pain, and petechiae on the torso. Pulmonary embolism and myocardial infarction are less directly tied to fractures, and compartment syndrome affects the limb.
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The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make?
- A. You should ride a bicycle instead of driving a car.'
- B. Report any fever or drainage at the pin sites.'
- C. Always keep the wrench taped to the front of the vest.'
- D. When getting out of bed, roll to your side and push on the mattress.'
- E. Wear a cotton t-shirt under the vest to absorb any moisture.'
Correct Answer: B, C, E
Rationale: Report fever or drainage for infection, keep the wrench taped for emergency adjustments, and wear a cotton t-shirt for comfort. Bicycling risks falls, and rolling to the side is safe but not the only method.
The nurse is assessing a client who reports left knee pain after playing baseball. The nurse should initially
- A. Feel the knee for warmth.
- B. Inspect the knee for any swelling.
- C. Palpate for crepitus in the knee.
- D. Have the client perform active range of motion in the knee.
Correct Answer: B
Rationale: Initial assessment starts with inspection for swelling, a visible sign of injury or inflammation post-activity. Warmth, crepitus, and range of motion are assessed next but are not the first step.
The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take?
- A. Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg)
- B. Turn the client using a foam wedge every two hours
- C. Ensure that a client's heels are supported with a pillow
- D. Elevate the foot of the bed to provide counter traction
Correct Answer: D
Rationale: Elevating the foot of the bed provides counter traction to maintain alignment in Buck traction. Excessive weight risks injury, turning disrupts traction, and heel support is good but not the priority.
Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington's disease, which has developed contractures?
- A. The patient will monitor for signs of skin breakdown as a result of the contractures.
- B. The patient will learn to reposition himself in bed and in his chair without assistance.
- C. The patient will participate in range of motion exercises to reduce the effects of contractures.
- D. The patient will verbalize the effects of contractures on activities of daily living.
Correct Answer: C
Rationale: For a patient with Huntington's disease and contractures, participating in range of motion exercises is an appropriate outcome to help maintain joint mobility and reduce the severity of contractures. Monitoring for skin breakdown is important but not the primary outcome. Independent repositioning may not be feasible due to the progressive nature of Huntington's, and verbalizing effects is less actionable than active intervention.
The following scenario applies to the next 1 items
Item 1 of 1
History and Physical
17-year-old male arrives at the emergency department following playing baseball. He slid into a base, felt a ‘pop’, and had pain in his right ankle. The client reports pain of 7 out of 10 in his right ankle, which is described as throbbing. Right pedal pulse was 2+, and the sensation was intact. The client had a limited and painful range of motion in his ankle. Significant swelling and bruising in the ankle were observed.
The client does not have a medical or surgical history. He takes no medications.
Diagnostic Results
X-Ray: bimalleolar fracture of the right ankle
Orders
Crutches
Non-weight bearing status
Apply a splint to the ankle
Acetaminophen-Oxycodone 5/325 mg PO
While teaching the client how to use crutches, the nurse should instruct the client to ambulate using the
- A. Two-point gait
- B. Three-point gait
- C. Four-point gait
- D. Ankle having to be splinted.
- E. Non-weight bearing status.
- F. Prescribed pain medication.
Correct Answer: B
Rationale: A three-point gait is appropriate for non-weight bearing status, as with a splinted bimalleolar fracture, allowing the client to keep weight off the injured ankle using crutches and the unaffected leg.