Nokea
The nurse advises the client on the need for maintenance of the bandage. When should the nurse advise the client with a sprained ankle to rewrap the elastic bandage?
- A. When the toes appear pink
- B. When the ankle feels painful
- C. When the toes look swollen
- D. When the joint feels stiff
Correct Answer: C
Rationale: Swollen toes indicate compromised circulation or inadequate compression, necessitating rewrapping to ensure proper fit and pressure. Pink toes suggest normal circulation, pain may not always indicate bandage issues, and joint stiffness is expected with a sprain but not directly related to bandage maintenance.
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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.
The client with a cervical neck injury as a result of a motor-vehicle accident is complaining of unrelieved pain after administration of a narcotic analgesic. Which alternative method of pain control is an independent nursing action?
- A. Medicate the client with a muscle relaxant.
- B. Heat alternating with ice applied by a physical therapist.
- C. Watch television or listen to music.
- D. Discuss surgical options with the health-care provider.
Correct Answer: C
Rationale: Distraction via TV or music is an independent nursing action to manage pain. Muscle relaxants require a prescription, heat/ice involves PT, and surgical discussions are physician-driven.
The physician orders prednisone for a client with rheumatoid arthritis for painful wrists and joints. Which instruction is it essential for the nurse to give the client?
- A. Take the pills with milk or food.'
- B. Be sure to take the medication between meals.'
- C. Stop the pills at once if your face begins to get puffy.'
- D. Your urine may turn pinkish while taking this.'
Correct Answer: A
Rationale: Taking prednisone with food or milk reduces gastrointestinal irritation, a key instruction for safe administration.
What is the purpose of the continuous passive motion (CPM) machine that the nurse should explain while teaching the client?
- A. A CPM machine is used to strengthen the leg muscles.
- B. A CPM machine is used to relieve foot swelling.
- C. A CPM machine is used to reduce surgical pain.
- D. A CPM machine is used to restore joint function.
Correct Answer: D
Rationale: CPM promotes joint mobility and prevents stiffness post-arthroplasty.
When the nurse observes the client walking, which assessment finding indicates the need for more instruction regarding the use of the cane?
- A. The tip of the cane is covered with a rubber cap.
- B. The client wears athletic shoes with nonskid soles.
- C. The client uses the cane on the painful side.
- D. The client looks straight ahead when walking.
Correct Answer: C
Rationale: The cane should be used on the unaffected side to support the painful hip, distributing weight appropriately. Using it on the painful side reduces its effectiveness, requiring further instruction.