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The nurse gently elevates the client's newly casted arm on a pillow and explains that this is necessary for the first 24 to 48 hours after casting. What is the chief purpose of this action?
- A. It helps a damp cast to dry more evenly.
- B. It reduces the amount of pain medication needed.
- C. Venous return is enhanced, and edema is decreased.
- D. It is more comfortable than keeping the arm dependent.
Correct Answer: C
Rationale: Elevation enhances venous return and reduces edema, the primary reason for this action. It does not directly affect cast drying, pain medication needs, or comfort alone.
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Which nursing instruction about heating pads is essential to include in the client's teaching plan?
- A. Set the heating pad to the highest setting.
- B. Place the heating pad directly on the skin.
- C. Cover the heating pad with plastic during use.
- D. Apply the heating pad for 2 hours at a time.
Correct Answer: A
Rationale: A low setting prevents burns while providing therapeutic heat.
The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis?
- A. X-ray of the femur.
- B. Serum alkaline phosphatase.
- C. Dual-energy x-ray absorptiometry (DEXA).
- D. Serum bone Gla-protein test.
Correct Answer: C
Rationale: DEXA is the gold standard for osteoporosis diagnosis, measuring bone mineral density. X-rays detect fractures, alkaline phosphatase is nonspecific, and bone Gla-protein is not diagnostic.
The nurse starting the shift is determining priorities for the day. Prioritize the order that the nurse should plan to assess the four clients.
- A. Client who had a left BKA and has left foot pain of 6 on a 0 to 10 scale
- B. Client who has a right lower leg cast whose right foot is cold to the touch
- C. Client who had a THR and 200-mL wound drain output during the past 8 hours
- D. Client who had a spinal fusion and has not voided since the urinary catheter removal 4 hours ago
Correct Answer: B,A,D,C
Rationale: B. The client who has a right lower leg cast whose right foot is cold to the touch should be assessed first. The data could indicate compartment syndrome, which is an emergent condition. A. The client who had a left BKA and has left foot pain of 6 on a 0 to 10 scale should be assessed second because pain is a priority in a postoperative client and should be addressed in a timely manner, but this is not an emergent situation. D. The client who had a spinal fusion and has not voided since the urinary catheter removal 4 hours ago should be assessed third for the presence of urinary retention. Usually the client should void within 6 hours after a urinary catheter has been removed. C. The client who had a THR and 200-mL wound drain output during the past 8 hours should be assessed last. This amount of output is a common finding following a THR due to the vascular nature of the operative site.
The client, who is diagnosed with CA, tells the clinic nurse about the inability to ambulate and about staying on bedrest due to hip stiffness. In addition to teaching the client measures to reduce joint stiffness, which referral for the client should the nurse plan to discuss with the HCP?
- A. Psychiatrist
- B. Social worker
- C. Physical therapist
- D. Arthritis Foundation
Correct Answer: C
Rationale: C. The nurse should plan to discuss a referral to a physical therapist (PT). The PT can assist the client in adopting self-management strategies and teach isometric, postural, and aerobic exercises that prevent joint overuse.
Which intervention should the nurse implement when caring for the child with an Ilizarov external fixator applied to a lower extremity for bone lengthening?
- A. Loosening the bolts and lengthening the rods on the fixator every other day
- B. Cleansing the external fixator pin sites with sterile saline twice daily
- C. Discouraging the child from bearing any weight on the involved extremity
- D. Removing sections of the fixator apparatus when the child is positioned in bed
Correct Answer: B
Rationale: Regular cleansing of pin sites with sterile saline prevents infection in an Ilizarov fixator.