Nokea
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.
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The nurse is caring for the client following a knee arthroscopy. What information should the nurse teach? Select all that apply.
- A. Elevate the involved extremity on pillows for 24 to 48 hours.
- B. Apply an ice pack continually to the involved joint for 24 hours.
- C. Report severe joint pain immediately to the health care provider.
- D. Resume usual activities to minimize joint stiffness and swelling.
- E. Treat pain with a mild analgesic such as acetaminophen.
Correct Answer: A,C,E
Rationale: A. Elevation will help to decrease edema. C. Severe joint pain may indicate a possible complication and should be reported immediately. E. Usually a mild analgesic such as acetaminophen (Tylenol) is sufficient for pain control following a diagnostic arthroscopy.
To immobilize the suspected fracture, how should the nurse apply a splint?
- A. Below the knee to above the hip
- B. Above the knee to below the hip
- C. Above the ankle to below the knee
- D. Below the ankle to above the knee
Correct Answer: C
Rationale: A suspected tibia fracture requires splinting from above the ankle to below the knee to stabilize the fracture site without unnecessarily immobilizing the hip or knee, which could restrict mobility or complicate transport.
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.
Which material added by the nurse is best for covering the tips of the pin to prevent injuries while the client is in skeletal leg.
- A. Gauze squares
- B. Cotton balls
- C. Cork blocks
- D. Rubber tubes
Correct Answer: C
Rationale: Cork blocks securely cover pin tips, preventing injury to the client or staff while maintaining stability. Gauze and cotton are less durable, and rubber tubes may not fit securely.
A cast has just been applied to a client's left forearm, and he has 10 lbs of Russell's traction on his left leg. Which of the following nursing concerns takes priority in the care of this client?
- A. The casted extremity may swell, and the cast will become a tourniquet.
- B. Heat conduction from the wet cast can cause burning to the skin below.
- C. Muscle atrophy of the areas involved can lead to decreased muscle tone.
- D. Skin irritation from the cast edges can cause abrasions.
Correct Answer: A
Rationale: Swelling in a newly casted extremity can cause the cast to act as a tourniquet, compromising circulation, which is the priority concern. Heat from a wet cast does not burn skin, muscle atrophy is a long-term issue, and skin irritation is less urgent.