Nokea
The client is three (3) hours postoperative left AKA. The client tells the nurse, 'My left foot is killing me. Please do something.' Which intervention should the nurse implement?
- A. Explain to the client his left leg has been amputated.
- B. Medicate the client with a narcotic analgesic immediately.
- C. Instruct the client on how to perform biofeedback exercises.
- D. Place the client's residual limb in the dependent position.
Correct Answer: B
Rationale: Phantom limb pain is treated with analgesics; narcotics provide immediate relief. Explaining the amputation dismisses pain, biofeedback is long-term, and dependent positioning is inappropriate.
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The occupational health nurse is preparing an in-service for a group of workers in a warehouse. Which information should be included to help prevent on-the-job injuries?
- A. Increase sodium and potassium in the diet during the winter months.
- B. Use the large thigh muscles when lifting and hold the weight near the body.
- C. Use soft-cushioned chairs when performing desk duties.
- D. Have the employee arrange for assistance with household chores.
Correct Answer: B
Rationale: Using thigh muscles and keeping weight close to the body promotes proper lifting mechanics, reducing back strain. Diet, chair cushioning, and household chores are unrelated to workplace injury prevention.
The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority?
- A. Presence of bruising to the right elbow
- B. Pain level rating on a 0-10 scale
- C. Sensation and pulse of the right forearm
- D. Left-handed or right-handed
Correct Answer: C
Rationale: C. Impairment of the neurovascular system is a priority. The closed reduction could cause further damage, which would be noted distal to the injury. Sensation and pulses are part of a neurovascular assessment to an extremity.
The client is taking calcium carbonate (Tums) to help prevent further development of osteoporosis. Which teaching should the nurse implement?
- A. Encourage the client to take Tums with at least eight (8) ounces of water.
- B. Teach the client to take Tums with the breakfast meal only.
- C. Instruct the client to take Tums 30 to 60 minutes before a meal.
- D. Discuss the need to get a monthly serum calcium level.
Correct Answer: A
Rationale: Taking Tums with water ensures proper absorption and prevents GI irritation. Timing with meals is flexible, pre-meal timing is unnecessary, and monthly calcium levels are not routine.
The nurse writes the problem of 'pain' for a client diagnosed with lumbar strain. Which nursing interventions should be included in the plan of care? Select all that apply.
- A. Assess pain on a 1-to-10 scale.
- B. Administer pain medication prn.
- C. Provide a regular bedpan for elimination.
- D. Assess surgical dressing every four (4) hours.
- E. Perform a position change by the log roll method every two (2) hours.
Correct Answer: A,B,E
Rationale: Pain assessment, PRN medication, and log rolling address pain and prevent exacerbation in lumbar strain. Bedpans are unnecessary, and surgical dressings are irrelevant without surgery.
Which instruction should the nurse reinforce to ensure that the exercises are done correctly?
- A. Move your toes toward and away from your head.
- B. Contract and relax your thigh muscles.
- C. The client's effect on the use of the head.
- D. Bend your knee and pull your lower leg upward.
Correct Answer: B
Rationale: Isometric quadriceps-setting exercises involve contracting and relaxing the thigh muscles without joint movement, strengthening the muscle while minimizing stress on the surgical site. The other options describe different movements.