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The LPN is reporting observations and cares to the RN. Based on the LPN's report, which client should the RN assess immediately?
- A. The client, 2 hours post-total knee replacement, has 100 mL bloody drainage in the autotransfusion drainage system container.
- B. The client with a crush injury to the arm was given another analgesic and a skeletal muscle relaxant for throbbing, unrelenting pain.
- C. The client in a new body cast was turned every 2 hours and is being supported with waterproof pillows.
- D. The client with a left leg external fixator has serous drainage from the pin sites, and pulses are present by Doppler.
Correct Answer: B
Rationale: B. The RN should assess this client immediately. Throbbing, unrelenting pain could be the first sign of compartment syndrome. The neurovascular status of the extremity should be assessed. Unrelieved pressure can lead to compromised circulation and avascular necrosis.
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Which nursing instruction is most beneficial to minimize stress on the client's painful joints?
- A. Maintain a normal weight.
- B. Apply a topical analgesic cream.
- C. Take a calcium supplement.
- D. Become more physically active.
Correct Answer: A
Rationale: Maintaining normal weight reduces joint stress, especially in osteoarthritis.
Which nursing observation provides the best indication that the halo-cervical traction device is applied appropriately?
- A. The client has full range of motion in the neck.
- B. The client's neck pain is within a tolerable level.
- C. The client can speak and hear at preinjury levels.
- D. The client reports the ability to see straight ahead.
Correct Answer: D
Rationale: The ability to see straight ahead indicates proper alignment of the halo device, ensuring the cervical spine is stabilized correctly. Full neck motion contradicts the purpose, and pain or speech/hearing are less specific.
The nurse documents the admission assessment for the client who is to have a left total hip arthroplasty to treat chronic degenerative joint disease. Which statements indicate that the client uses alternative therapies for CA treatment? Select all that apply.
- A. I take ibuprofen every 4 to 6 hours.'
- B. I wear a copper bracelet all the time.'
- C. I take glucosamine sulfate 1000 mg daily.'
- D. I apply special magnets to the hip joint.'
- E. I sleep on the unaffected hip, turning often.'
Correct Answer: B,C,D
Rationale: B. Wearing a copper bracelet is an alternative therapy used by some with CA for pain control and reduction of joint stiffness. C. Taking glucosamine sulfate is an alternative therapy used by some with CA. Glucosamine is taken to modify cartilage structure, but studies supporting this have been inconclusive. D. Using magnets designed for body application is an alternative therapy used by some with CA for pain control and reduction of joint stiffness.
In which conditions might the nurse assess for the presence of papilledema?
- A. Eczema
- B. Craniosynostosis
- C. Shaken baby syndrome
- D. Hydrocephalus
- E. Chest trauma
Correct Answer: B,C,D
Rationale: Papilledema, indicating increased intracranial pressure, can be associated with craniosynostosis, shaken baby syndrome, and hydrocephalus.
When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying on the side
- D. Standing to shower
Correct Answer: D
Rationale: Standing to shower is least desirable post-below-the-knee amputation due to the risk of falls and weight-bearing on the stump, which could disrupt healing. Other positions are safer.