Nokea
The nurse is assessing a client who had a left hip replacement 36 hours ago. Which of the following indicates the prosthesis is dislocated? Select all that apply.
- A. The client reported a 'popping' sensation in the hip.
- B. The left leg is shorter than the right leg.
- C. The client has sharp pain in the groin.
- D. The client cannot move his right leg.
- E. The client cannot wiggle the toes on the left leg.
Correct Answer: A,B,C
Rationale: A popping sensation, leg shortening, and groin pain are classic signs of hip prosthesis dislocation.
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The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4°F (38°C). The nurse should assess the client further for signs of:
- A. Aortic aneurysm
- B. Deep vein thrombosis (DVT) in the left leg
- C. I.V. drug abuse
- D. Intermittent claudication
Correct Answer: B
Rationale: Left leg pain, positive Homans' sign (pain on dorsiflexion), and low-grade fever suggest deep vein thrombosis (DVT). Further assessment for swelling, redness, or warmth confirms this. Aortic aneurysm, I.V. drug abuse, and claudication present differently.
A client with colon cancer had a left hemicolectomy 3 weeks previously. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. Which of the following nutritional support methods would be most appropriate?
- A. Total parenteral nutrition through a central catheter.
- B. I.V. infusion of dextrose.
- C. Nasogastric feeding tube with protein supplement.
- D. Jejunostomy for high caloric feedings.
Correct Answer: C
Rationale: A nasogastric feeding tube with protein supplement is appropriate for short-term nutritional support post-hemicolectomy, as it delivers nutrients directly to the stomach while the client's oral intake improves.
A client refuses to remove a religious necklace before surgery despite hospital policy. The nurse's best response is:
- A. Remove the necklace during transport.
- B. Tape the necklace securely to the client's chest.
- C. Insist the client comply with policy.
- D. Notify the surgeon to cancel the procedure.
Correct Answer: B
Rationale: Taping the necklace securely respects the client's beliefs while ensuring safety by preventing the item from interfering with the surgical field.
Which of the following changes are associated with normal aging?
- A. The outer layer of skin is replaced with new cells every 3 days.
- B. Subcutaneous fat and extracellular water decrease.
- C. The dermis becomes highly vascular and assists in the regulation of body temperature.
- D. Collagen becomes elastic and strong.
Correct Answer: B
Rationale: Aging reduces subcutaneous fat and extracellular water, leading to thinner, drier skin. Cell replacement slows, vascularity decreases, and collagen loses elasticity.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition?
- A. Widening pulse pressure.
- B. Decrease in the pulse rate.
- C. Dilated, fixed pupils.
- D. Decrease in level of consciousness (LOC).
Correct Answer: A,B,C,D
Rationale: All listed changes are critical signs of increasing ICP. Widening pulse pressure (Cushing's triad), bradycardia, dilated fixed pupils, and decreased LOC indicate neurological deterioration requiring immediate notification of the health care provider for intervention.