Nokea
The nurse is assessing a client who reports left knee pain after playing baseball. The nurse should initially
- A. Feel the knee for warmth.
- B. Inspect the knee for any swelling.
- C. Palpate for crepitus in the knee.
- D. Have the client perform active range of motion in the knee.
Correct Answer: B
Rationale: Initial assessment starts with inspection for swelling, a visible sign of injury or inflammation post-activity. Warmth, crepitus, and range of motion are assessed next but are not the first step.
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Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington's disease, which has developed contractures?
- A. The patient will monitor for signs of skin breakdown as a result of the contractures.
- B. The patient will learn to reposition himself in bed and in his chair without assistance.
- C. The patient will participate in range of motion exercises to reduce the effects of contractures.
- D. The patient will verbalize the effects of contractures on activities of daily living.
Correct Answer: C
Rationale: For a patient with Huntington's disease and contractures, participating in range of motion exercises is an appropriate outcome to help maintain joint mobility and reduce the severity of contractures. Monitoring for skin breakdown is important but not the primary outcome. Independent repositioning may not be feasible due to the progressive nature of Huntington's, and verbalizing effects is less actionable than active intervention.
The following scenario applies to the next 1 items
The nurse cares for a client who sustained a femur fracture twelve hours ago
Item 1 of 1
Nurses’ Notes
Client reports shortness of breath and stated, ‘something is not right.’ The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air. Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.
The client is demonstrating signs and symptoms of
- A. Pulmonary embolism
- B. Myocardial infarction
- C. Fat embolism syndrome
- D. Compartment syndrome
Correct Answer: C
Rationale: Fat embolism syndrome is likely after a femur fracture, with symptoms like shortness of breath, bilateral crackles, chest pain, and petechiae on the torso. Pulmonary embolism and myocardial infarction are less directly tied to fractures, and compartment syndrome affects the limb.
The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take?
- A. Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg)
- B. Turn the client using a foam wedge every two hours
- C. Ensure that a client's heels are supported with a pillow
- D. Elevate the foot of the bed to provide counter traction
Correct Answer: D
Rationale: Elevating the foot of the bed provides counter traction to maintain alignment in Buck traction. Excessive weight risks injury, turning disrupts traction, and heel support is good but not the priority.
The following scenario applies to the next 1 items
The nurse is caring for an older adult 4 days postoperative hip arthroplasty.
Item 1 of 1
Nurses' Notes
0900: Assessment completed, and the client was in bed alert and oriented to person, place, time, and situation. Clear lung fields bilaterally, with an infrequent dry cough. Heart tones S1 and S2. Peripheral pulses palpable and 2+. Skin was warm and dry. Bowel sounds were normoactive and present in all four quadrants. Incision was pink, approximated with staples, with scant serous drainage. Pain rated 4/10 on the Numerical Pain Rating Scale. Client refused to ambulate to the bedside chair for breakfast.
1159: Client informed nurse of their refusal to participate in physical therapy. Once up with PT, the client reported intense pain. The client reports that they have intense 'heaviness' in their left calf and that she needs a 'water pill' because it is swollen. The client was placed back in bed. She reports dyspnea immediately after failed ambulation attempt.
Vital Signs
0900
Blood pressure 139/88 mm Hg
Heart rate 77/min
Respiratory rate 21/min
Temperature 99°F (37.2°C)
Pulse oximetry 92% on room air
1200
Blood pressure 149/91 mm Hg
Heart rate 87/min
Respiratory rate 24/min
Temperature 99°F (37.2°C)
Pulse oximetry 90% on room air
Medical History
• hyperlipidemia
• generalized anxiety disorder
• irritable bowel syndrome
• chronic obstructive pulmonary disease
• diabetes mellitus (type two)
• osteoarthritis
The nurse should recognize that the client may be experiencing
- A. Wound infection
- B. Hypoxia
- C. Venous thromboembolism
- D. Wound dehiscence
- E. Left lower extremity assessment.
- F. Vital signs.
- G. Pain at the surgical incision site.
Correct Answer: C, E
Rationale: Venous thromboembolism is suggested by dyspnea, elevated heart and respiratory rates, and calf swelling/tenderness post-hip arthroplasty, indicating possible deep vein thrombosis. Wound infection, hypoxia, and dehiscence are less directly supported.
The nurse is planning a staff development conference regarding contractures. Which of the following information should the nurse include? Select all that apply.
- A. Range-of-motion exercises of the extremities help prevent contractures.
- B. Splinting the extremities may increase the risk of contractures.
- C. Too many pillows under the head may cause a neck flexion contracture.
- D. Using multiple staff members to reposition a client may prevent a contracture.
- E. Contractures after a hip arthroplasty can be prevented with an abduction pillow.
Correct Answer: A, C, E
Rationale: Range-of-motion exercises maintain joint flexibility and help prevent contractures. Too many pillows under the head can cause the neck to remain flexed, increasing the risk of a flexion contracture. An abduction pillow keeps the legs properly aligned and prevents adduction contractures after hip surgery.