Nokea
The client one (1) day postoperative total hip replacement complains of hearing a 'popping sound' when turning. Which assessment data should the nurse report immediately to the surgeon?
- A. Dark red-purple discoloration.
- B. Equal length of lower extremities.
- C. Groin pain in the affected leg.
- D. Edema at the incision site.
Correct Answer: C
Rationale: Groin pain with a popping sound suggests hip dislocation, requiring immediate surgeon notification. Discoloration, equal leg length, and edema are less urgent.
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Which action by the nurse would be most appropriate for a child newly diagnosed with Reye's syndrome?
- A. Determining if the child had a bacterial infection recently
- B. Placing the child in a private room with droplet precautions
- C. Taking the child to the unit's play area to interact with others
- D. Assessing for signs of bleeding and for prolonged bleeding time
Correct Answer: D
Rationale: Assessing for bleeding is critical in Reye's syndrome due to liver dysfunction and potential coagulopathy.
The physician orders passive range-of-motion (ROM) exercises for an elderly client on bed rest. Which statement regarding the performance of ROM exercises is correct?
- A. ROM exercises should be completed independently with verbal cues from the nurse.
- B. Force may be needed during ROM exercises to achieve maximum benefit.
- C. Support should be maintained to the proximal and distal areas of the joint during movement.
- D. ROM exercises should be performed until the client verbalizes discomfort.
Correct Answer: C
Rationale: Supporting the proximal and distal areas of the joint during passive ROM exercises ensures controlled, safe movement, preventing injury. Independent completion, force, or continuing until discomfort risks harm.
A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply.
- A. The client requests pain medication to sleep.
- B. The client has eupnea and normal sinus rhythm.
- C. The client has petechiae over the neck and chest.
- D. The client has a high arterial oxygen level.
- E. The client has yellow globules floating in the urine.
Correct Answer: C,E
Rationale: Petechiae and yellow globules suggest fat embolism syndrome, requiring immediate intervention. Pain medication, normal breathing, and high oxygen are not urgent.
The nurse writes a concept of 'impaired mobility' for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply.
- A. Request a physical therapy referral.
- B. Administer enoxaparin (Lovenox) subcutaneously.
- C. Utilize a gait belt when ambulating the client.
- D. Assess the client’s pain levels on a 1-to-10 scale.
- E. Provide a high-carbohydrate, high-fat, high-sodium diet.
Correct Answer: A,B,C,D
Rationale: PT referral, enoxaparin, gait belt, and pain assessment promote mobility and prevent complications in hip fracture. High-carb/fat/sodium diet is inappropriate.
The client has returned to the nursing unit following a right below-the-knee amputation. How should the nurse position the client?
- A. Supine with head turned to the side
- B. With shock blocks placed under the foot of the bed
- C. Semi-sitting position with knees bent
- D. Left lateral with pillows between the knees
Correct Answer: C
Rationale: A semi-sitting position promotes comfort, reduces edema, and facilitates breathing post-amputation.