Nokea
The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing?
- A. Fat embolism.
- B. Compartment syndrome.
- C. Pressure ulcer under the cast.
- D. Surgical incision infection.
Correct Answer: B
Rationale: Severe pain and numbness in a casted arm suggest compartment syndrome, a medical emergency. Fat embolism, pressure ulcers, and infections present differently.
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Which laboratory test value, if elevated, is the best diagnostic indicator of rheumatoid arthritis?
- A. Erythrocyte sedimentation rate (ESR)
- B. Partial thromboplastin time (PTT)
- C. Partial thromboplastin time (PTT)
- D. Blood urea nitrogen (BUN)
Correct Answer: A
Rationale: An elevated ESR indicates inflammation, a hallmark of rheumatoid arthritis, making it a key diagnostic marker. PTT and BUN are unrelated to rheumatoid arthritis diagnosis.
The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement?
- A. Assess the client's nutritional status.
- B. Refer the client to an occupational therapist.
- C. Determine if the client is allergic to IVP dye.
- D. Start a 22-gauge Angiocath in the right arm.
Correct Answer: A
Rationale: Nutritional status assessment ensures adequate healing post-amputation, critical in diabetes. OT referral is postoperative, IVP dye is irrelevant, and a 22-gauge IV is too small for surgery.
Until a translator is available, which nursing action is best when teaching the client who speaks English as a second language about body mechanics?
- A. Speak slowly while looking at the client.
- B. Write the instructions on paper.
- C. See the client and the patient.
- D. Have the client watch a video.
Correct Answer: A
Rationale: Speaking slowly while maintaining eye contact enhances comprehension for a non-native speaker, using nonverbal cues to reinforce verbal instructions until a translator is available.
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll placed along the hip prevents external rotation of the operative leg, maintaining proper alignment post-hip replacement. The other options do not specifically address rotation.
The physician orders that the client with a hip prosthesis may be out of bed to sit in a chair. How should the nurse position the chair to facilitate transferring the client to the side?
- A. At the end of the bed
- B. Perpendicular to the bed
- C. Parallel with the bed
- D. Against a side wall
Correct Answer: C
Rationale: Positioning the chair parallel to the bed allows the client to transfer safely to the nonoperative side, maintaining hip alignment and minimizing the risk of dislocation during the transfer.