Nokea
The client with DM is admitted with possible osteomyelitis secondary to an ankle wound. The client's ankle is painful, red, swollen, and warm, and the wound is persistently draining. The client's temperature is 102.2°F (39°C). Based on the client's status, which HCP order should the nurse plan to defer until later?
- A. Obtain a culture of the ankle wound.
- B. Administer ceftriaxone 1 g IV q12h.
- C. Apply splint to immobilize the ankle.
- D. Teach on IV antibiotic self-administration.
Correct Answer: D
Rationale: D. The nurse should defer teaching. Pain and an elevated temperature are barriers to learning.
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In this case, from whom is it most appropriate for the physician, with the nurse as a witness, to obtain consent to perform the surgical procedure?
- A. The client
- B. The client's physician
- C. The client's youth leader
- D. The client's parent
Correct Answer: D
Rationale: A 17-year-old is typically a minor, requiring parental consent for surgical procedures unless emancipated or in an emergency where consent cannot be obtained. The client, physician, or youth leader cannot provide legal consent.
The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client?
- A. The occupational therapist.
- B. The physiatrist.
- C. The recreational therapist.
- D. The home health nurse.
Correct Answer: D
Rationale: A home health nurse monitors recovery, manages complications, and supports mobility post-TKR. OT, physiatrists, and recreational therapists are less critical at discharge.
The client is admitted to the hospital for a diagnostic workup. The client has vague symptoms of malaise, coughing, chest discomfort, low-grade fever, diffuse rashes, and musculoskeletal aches and pains. A diagnosis of probable lupus erythematosus has been made. The night nurse finds the client crying and saying, 'I would rather die than suffer with this disease for the rest of my life.' Which response by the nurse would be most therapeutic at this time?
- A. Telling the client there are support groups to join after discharge
- B. Offering to stay with the client to discuss concerns and questions
- C. Advising the client to write concerns on paper to discuss with the doctors and nurses tomorrow
- D. Offering the client a back rub and a warm cup of milk
Correct Answer: B
Rationale: Offering to stay and discuss concerns is therapeutic, providing emotional support and addressing the client's fears.
Which assessment finding warrants immediate action by the nurse when a client is in Buck's traction?
- A. The traction weights are hanging above the floor.
- B. The leg is in line with the pull of the traction.
- C. The right is about is to be the two.
- D. The rope is in the groove of the traction pulley.
Correct Answer: A
Rationale: Traction weights must hang freely to maintain proper pull. If they are above the floor (e.g., resting on something), the traction is ineffective, requiring immediate correction to ensure proper alignment and healing.
The Muslim client practicing Islam is hospitalized following surgical repair of a hip fracture. The client informs the nurse about wishing to observe Ramadan, which is occurring now. Which statement by the nurse is respectful of the client's faith beliefs?
- A. I'm going to uncover your hip and leg now to check the incision and your pulses.'
- B. A dietitian helps to plan your meals so that meat and dairy products are not together.'
- C. I've asked that physical therapy be postponed until around 3 p.m., when Ramadan ends.'
- D. I should let the care team know not to bring food or beverages from sunrise to sunset.'
Correct Answer: D
Rationale: D. During the month of Ramadan, those of the Islamic faith do not eat or drink from sunrise to sunset.