Nokea
The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, 'Why do I need to lie on my stomach?' Which statement is the most appropriate statement by the nurse?
- A. This position will help your lungs expand better.'
- B. Lying on your stomach will help prevent contractures.'
- C. Many times this will help decrease pain in the limb.'
- D. The position will take pressure off your backside.'
Correct Answer: B
Rationale: Prone positioning prevents hip flexor contractures post-BKA, promoting mobility. Lung expansion, pain relief, and pressure relief are secondary or unrelated.
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Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is common post-amputation, arising from nerve endings.
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.
While caring for multiple clients, the nurse delegates client skin care to the UAP on a musculoskeletal unit. Which client is most appropriate for the nurse to delegate skin care to the UAP?
- A. The client with osteomyelitis of the tibia who needs a wound dressing change
- B. The client with an inoperable hip fracture who is in Buck's traction
- C. The client with a pelvic fracture who is in skeletal traction
- D. The client with a femur fracture who has an external fixator in place
Correct Answer: B
Rationale: B. Buck's traction is skin traction. Because there is no open site that needs care with this type of traction, it would be appropriate to delegate skin care.
The nurse is assessing the client diagnosed with a left femoral neck fracture. Which findings should the nurse expect? Select all that apply.
- A. Left leg is in an abducted position.
- B. Left leg is externally rotated.
- C. Left leg is shorter than the right.
- D. Pain is in the lateral left knee.
- E. Pain is in the groin area.
Correct Answer: B,C,E
Rationale: B. With a left femoral neck fracture, the leg is externally rotated. C. With a left femoral neck fracture, the leg is shortened. E. With a left femoral neck fracture, pain is experienced in the groin area.
The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention?
- A. The client’s hemoglobin is 8.1 g/dL.
- B. The client’s white blood cell count is 9,000/mm3.
- C. The client’s creatinine level is 0.8 mg/dL.
- D. The client’s potassium level is 4.2 mEq/L.
Correct Answer: A
Rationale: Hemoglobin of 8.1 g/dL indicates significant blood loss, requiring urgent intervention post-shoulder replacement. Other values are normal.