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The client with a lower leg amputation has edema, so the NA elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated?
- A. Thank the nursing assistant (NA) for being so observant and intervening appropriately to treat the client's edema of the residual limb.
- B. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
- C. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals, the leg should not be elevated.
- D. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
Correct Answer: B
Rationale: B. The nurse should perform this action. Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.
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A femoral head replacement was performed on an elderly client. Postoperatively, the nurse positions the client with an abductor pillow between the client's legs. What is the primary reason for this?
- A. This position will promote greater comfort.
- B. Abduction promotes greater circulation to the hip joint.
- C. Abduction will prevent the prosthesis from snapping out of the socket.
- D. This position will help to prevent pressure on the sciatic nerve.
Correct Answer: C
Rationale: An abductor pillow maintains abduction, preventing prosthesis dislocation post-femoral head replacement.
Postoperatively, the client screams obscenities at the nurse after realizing that the injured forearm is missing. Which nursing action is most appropriate at this time?
- A. Leave until the client works through the anger.
- B. Stay quietly with the client at the bedside.
- C. Tell the client to gain emotional control.
- D. Call the physician and request a sedative.
Correct Answer: B
Rationale: Staying quietly with the client provides emotional support during a grief reaction to amputation, promoting trust. Leaving, reprimanding, or medicating without engagement dismisses the client's feelings.
Which signs/symptoms indicate to the nurse the client has developed osteoporosis?
- A. The client has lost one (1) inch in height.
- B. The client has lost 12 pounds in the last year.
- C. The client's hands are painful to the touch.
- D. The client's serum uric acid level is elevated.
Correct Answer: A
Rationale: Height loss indicates vertebral compression fractures, a common osteoporosis sign. Weight loss, hand pain, and uric acid elevation are unrelated.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate therapy?
- A. Constipation
- B. Dry mouth
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores are a common side effect of methotrexate due to its effect on mucosal cells.
Which intervention should the nurse implement for a hospitalized child with autism?
- A. Hold and stroke the child while doing the assessment
- B. Play the radio or turn on the television for distraction
- C. Have the parent bring the child's favorite toy from home
- D. Provide plenty of age-appropriate foods on the meal tray
Correct Answer: C
Rationale: Bringing a favorite toy can provide comfort and reduce anxiety for a child with autism in a hospital setting.