Nokea
The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement?
- A. Instruct the client to push the residual limb against a pillow.
- B. Demonstrate how to apply an elastic bandage around the residual limb.
- C. Encourage the client to apply vitamin B12 to the surgical incision.
- D. Teach the client to elevate the residual limb at least three (3) times a day.
Correct Answer: A
Rationale: Pushing the residual limb against a pillow toughens skin for prosthesis use. Elastic bandages reduce edema, vitamin B12 is irrelevant, and elevation is for swelling, not toughening.
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The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse?
- A. Capillary refill time is less than three (3) seconds.
- B. Pain is not relieved by the patient-controlled analgesia.
- C. Left fingers are edematous and the left hand is purple.
- D. Warm and dry skin on left fingers distal to the elastic bandage.
Correct Answer: C
Rationale: Edema and purple discoloration indicate neurovascular compromise, requiring immediate intervention. Normal refill, unrelieved pain, and warm skin are less urgent.
The nurse is admitting a female client who is complaining of severe back pain radiating down the left leg whenever she tries to ambulate. The concepts of impaired mobility and comfort are implemented on the care map. Which nursing interventions should the nurse implement?
- A. Assist the client when ambulating to the bathroom and administer medications based on the pain scale.
- B. Place the client on strict bedrest and have the client use a regular bedpan for elimination of urine and feces.
- C. Ambulate the client in the hallway at least four (4) times per day and discourage the use of pharmacological pain relief.
- D. Request the health-care provider (HCP) to assist the client in ambulating in the hallway so the HCP can observe the client’s pain.
Correct Answer: A
Rationale: Assisting with ambulation and pain medication addresses mobility and comfort in sciatica. Strict bedrest hinders recovery, excessive ambulation without pain control is unsafe, and HCP observation is unnecessary.
The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit?
- A. Severe bone deformity.
- B. Joint stiffness.
- C. Waddling gait.
- D. Swan-neck fingers.
Correct Answer: B
Rationale: Joint stiffness, especially in the morning, is a hallmark of OA due to cartilage loss. Severe deformity and swan-neck fingers are more typical of rheumatoid arthritis, and waddling gait is nonspecific.
Postoperatively, which intervention should be completed before turning the client onto the nonoperative side?
- A. Placing pillows between the client's legs
- B. Having the client point the toes downward
- C. Having the client's knee on the side
- D. Elevating the head of the client's bed
Correct Answer: A
Rationale: Placing pillows between the legs before turning prevents adduction of the operative hip, reducing the risk of dislocation in a client with a hip prosthesis. The other actions do not directly address hip stability.
Which activity is best to begin implementing immediately after the client's surgery?
- A. Standing at the side of the bed
- B. Balancing between parallel bars
- C. Lifting oneself with the trapeze
- D. Transferring from the bed to a chair
Correct Answer: C
Rationale: Lifting with a trapeze strengthens upper body muscles safely immediately post-surgery, preparing for crutch use without stressing the stump. Other activities are more advanced.