Nokea
The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first?
- A. Assess the nailbeds for capillary refill time.
- B. Remove the client's clothing from the arm.
- C. Call radiology for a STAT x-ray of the extremity.
- D. Prepare the client for the application of a cast.
Correct Answer: A
Rationale: Assessing capillary refill evaluates neurovascular status, the priority in arm injury to detect compromise. Clothing removal, x-rays, and casting follow assessment.
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Which illustration demonstrates abduction for a 10-year-old who had an SCI?
- A. ROM-1.png
- B. ROM-2.png
- C. ROM-3.png
- D. ROM-4.png
Correct Answer: A
Rationale: Abduction involves moving a limb away from the body's midline, as shown in the correct illustration.
What should the nurse emphasize when preparing to teach the child and family about the treatment for Legg-Calvé-Perthes disease?
- A. Once treatment starts, it will likely continue for about 6 months.
- B. The treatment goal is a pain-free joint with full range of motion.
- C. Activities requiring hip adduction are encouraged for joint placement.
- D. Most of the treatments will be completed while the child is hospitalized.
Correct Answer: B
Rationale: The primary goal of treatment for Legg-Calvé-Perthes disease is to achieve a pain-free joint with full range of motion.
The client and spouse were involved in a motorcycle accident in which the spouse was killed. The client, being treated for multiple rib fractures and a broken leg, asks the nurse in which room his wife is located. Which response is most appropriate?
- A. Unfortunately, your wife is not in the hospital at this time.'
- B. I'm sorry, but your wife did not survive the motorcycle accident.'
- C. Let me get your family so that you can talk to them about your wife.'
- D. The doctor will be talking to you to let you know where she is located.'
Correct Answer: B
Rationale: B. Because the nurse-client relationship is built on trust, the nurse should not withhold information from the client. The nurse should disclose that the spouse did not survive and be available for support.
The client just underwent a left THR. After a family member assists the client with repositioning in bed, the client states hearing a 'pop' and has increased pain at the surgical site. Which is the most appropriate initial action by the nurse?
- A. Check the position of the left lower extremity.
- B. Elevate the head of the client's bed.
- C. Adjust the pillow used for abduction.
- D. Administer the prescribed pain medication.
Correct Answer: A
Rationale: A. The nurse's initial action should be to check the extremity's position. Improper movement and repositioning can cause prosthesis dislocation; an audible pop and increased pain are signs of possible dislocation.
The client diagnosed with OA is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which instruction should the nurse teach the client?
- A. Take the medication on an empty stomach.
- B. Make sure to taper the medication when discontinuing.
- C. Apply the medication topically over the affected joints.
- D. Notify the health-care provider if vomiting blood.
Correct Answer: D
Rationale: Vomiting blood indicates GI bleeding, a serious NSAID side effect requiring immediate HCP notification. NSAIDs should be taken with food, tapering is not typical, and topical NSAIDs are distinct.