Nokea
The client with a cervical neck injury as a result of a motor-vehicle accident is complaining of unrelieved pain after administration of a narcotic analgesic. Which alternative method of pain control is an independent nursing action?
- A. Medicate the client with a muscle relaxant.
- B. Heat alternating with ice applied by a physical therapist.
- C. Watch television or listen to music.
- D. Discuss surgical options with the health-care provider.
Correct Answer: C
Rationale: Distraction via TV or music is an independent nursing action to manage pain. Muscle relaxants require a prescription, heat/ice involves PT, and surgical discussions are physician-driven.
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The client has a fractured right ankle that has just been casted. The nurse is instructing the client in crutch walking techniques. Which method is most appropriate?
- A. Move the right crutch, then the left foot, then the left crutch, and finally the right foot.
- B. Balance weight on the left foot and move right foot and both crutches forward, then bear weight on both crutches and move the left foot forward.
- C. Move the right crutch and left foot forward together; then move the left crutch and right foot.
- D. Move the right crutch and right foot together; then move the left crutch and the left foot.
Correct Answer: A
Rationale: The correct crutch walking technique (three-point gait) involves moving the right crutch, then the left foot, followed by the left crutch, and finally the right foot, protecting the fractured ankle.
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.
The HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication?
- A. It will help decrease the inflammation in the joints.
- B. It improves tissue function and retards breakdown of cartilage.
- C. It is a potent medication which decreases the client's joint pain.
- D. It increases the production of synovial fluid in the joint.
Correct Answer: B
Rationale: Glucosamine and chondroitin support cartilage health, slowing OA progression. They have limited anti-inflammatory effects, are not potent analgesics, and do not increase synovial fluid.
The nurse supervises a nursing assistant who is applying the client's antiembolism stockings. What is the correct technique for applying these stockings?
- A. The nursing assistant applies the stockings before getting the client out of bed.
- B. The nursing assistant applies the stockings just before helping the client do leg exercises.
- C. The nursing assistant applies the stockings after nursing that the client's legs are cool.
- D. The nursing assistant applies the stockings at night before the client's bedtime.
Correct Answer: A
Rationale: Applying antiembolism stockings before the client gets out of bed ensures compression is in place during upright positions when venous pooling is most likely. Applying them later or based on leg temperature is less effective.
The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
- A. Help the client with a two (2)-day postop amputation put on the prosthesis.
- B. Request the UAP double-check a unit of blood to be hung.
- C. Change the surgical dressing on the client with a Syme's amputation.
- D. Ask the UAP to take the client to the physical therapy department.
Correct Answer: D
Rationale: Transporting a client to PT is within UAP scope. Prosthesis application, blood verification, and dressing changes require nursing judgment.