Nokea
The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client?
- A. The client will maintain vital signs within normal limits.
- B. The client will have a decrease in muscle spasms in the affected leg.
- C. The client will have no signs or symptoms of infection.
- D. The client will be able to ambulate down to the nurse’s station.
Correct Answer: D
Rationale: Ambulation to the nurse’s station is a long-term goal post-ORIF, indicating restored mobility. Vital signs, spasms, and infection are short-term or secondary.
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The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests should the nurse expect the health-care provider to order to R/O osteoarthritis?
- A. Full-body magnetic resonance imaging scan.
- B. Serum studies for synovial fluid amount.
- C. X-ray of the affected joints.
- D. Serum erythrocyte sedimentation rate (ESR).
Correct Answer: C
Rationale: X-rays reveal OA characteristic joint space narrowing and osteophytes. MRI is excessive, synovial fluid studies are not routine, and ESR is for inflammatory conditions, not OA.
The physician orders that the client with a hip prosthesis may be out of bed to sit in a chair. How should the nurse position the chair to facilitate transferring the client to the side?
- A. At the end of the bed
- B. Perpendicular to the bed
- C. Parallel with the bed
- D. Against a side wall
Correct Answer: C
Rationale: Positioning the chair parallel to the bed allows the client to transfer safely to the nonoperative side, maintaining hip alignment and minimizing the risk of dislocation during the transfer.
Which evidence is the best indication that the client who had a knee arthroplasty is recovering according to expected outcomes and no longer needs the continuous passive motion (CPM) machine?
- A. The client has minimal pain when ambulating.
- B. The client can flex the operative knee 90 degrees.
- C. The client can tolerate full weight bearing.
- D. The edges of the client's surgical wound are approximated.
Correct Answer: B
Rationale: 90-degree knee flexion indicates restored joint function, a key recovery milestone.
When the nurse examines the client, which body part is usually affected by gout?
- A. Great toe
- B. Index finger
- C. Sacrococcygeal vertebrae
- D. Temporomandibular joint
Correct Answer: A
Rationale: Gout typically affects the great toe (first metatarsophalangeal joint) due to uric acid crystal deposition, causing acute pain and swelling. Other areas are less commonly involved.
The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement?
- A. Assess the client's nutritional status.
- B. Refer the client to an occupational therapist.
- C. Determine if the client is allergic to IVP dye.
- D. Start a 22-gauge Angiocath in the right arm.
Correct Answer: A
Rationale: Nutritional status assessment ensures adequate healing post-amputation, critical in diabetes. OT referral is postoperative, IVP dye is irrelevant, and a 22-gauge IV is too small for surgery.