Nokea
The home health nurse is caring for clients who had a THR through the posterior surgical approach 2 weeks ago. It is most important for the nurse to intervene immediately for which client?
- A. After a THR, the client should not flex the hip greater than 90 degrees or have adduction of the hip because it can cause hip dislocation. Wearing socks that do not have grippers on the bottom increases the client's risk for a fall.
- B. After a THR the client may sit at 90 degrees.
- C. After a THR the client may lie supine.
- D. After a THR the client may be up. However, this client should be wearing shoes or gripper socks or slippers to prevent a fall.
Correct Answer: A
Rationale: A. After a THR, the client should not flex the hip greater than 90 degrees or have adduction of the hip because it can cause hip dislocation. Wearing socks that do not have grippers on the bottom increases the client's risk for a fall.
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The client is admitted to the ED after a sports injury. The client verbalizes extreme shoulder pain, and the nurse sees that the client's right arm is shorter than the left. What should the nurse do initially? Select all that apply.
- A. Lift the right arm to support it with a pillow.
- B. Apply a covered ice pack to the left shoulder.
- C. Prepare the client for immediate surgical repair.
- D. Check the pulses and sensation of the right arm.
- E. Prepare to administer an analgesic as prescribed
- F. Inspect the left shoulder for swelling and bruising.
Correct Answer: D,E
Rationale: D. Assessment of pulses and sensation is important because compression of nerves and blood vessels can occur with shoulder dislocation. A shortened arm on the right indicates that the right shoulder is affected. E. The client is in severe pain and requires pain control.
The client has been flat in bed in traction for two weeks, and she is to be allowed out of bed for the first time today. What must the nurse be particularly alert for when getting the client out of bed?
- A. Renal complications
- B. Depression
- C. Orthostatic hypotension
- D. Skin breakdown
Correct Answer: C
Rationale: Prolonged bed rest increases the risk of orthostatic hypotension when first mobilizing, requiring careful monitoring.
Which statement should the nurse include when teaching parents about bacterial meningitis?
- A. Symptoms of meningitis often develop over time, making it easier to diagnose than other infections.
- B. Having a seizure associated with a high temperature usually indicates a problem other than meningitis.
- C. High-risk children 2 to 10 years and other children 11 years and older should receive the meningococcal conjugate vaccine (MCV4).
- D. Intravenous antibiotics are administered to family members who may have been in close contact with the child.
Correct Answer: C
Rationale: The meningococcal conjugate vaccine (MCV4) is recommended for high-risk children and those 11 years and older to prevent bacterial meningitis.
The client is an elderly man who has had diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation?
- A. Encouraging deep breathing
- B. Asking him if he understands the full effects of the planned surgery
- C. Discussing the effects of diabetes on the vascular system
- D. Having a recovered amputee visit him
Correct Answer: D
Rationale: A visit from a recovered amputee provides peer support, helping the client adjust by seeing a positive outcome.
Which technique is the best strategy for assessing circulation in the leg in Buck's traction?
- A. Observe whether the client can wiggle or move the toes.
- B. Palpate for pulsation of the dorsalis pedis artery.
- C. Take the client's blood pressure with a thigh cuff positioned on the affected leg.
- D. Determine whether the client can feel sharp and dull sensations.
Correct Answer: B
Rationale: Palpating the dorsalis pedis pulse directly assesses arterial circulation in the leg, providing the most accurate indication of blood flow. Toe movement and sensation are less specific, and blood pressure measurement is not relevant.