Nokea
The nurse is assessing the client who is postoperative total knee replacement. Which assessment data warrant immediate intervention?
- A. T 99°F, HR 80, RR 20, and BP 128/76.
- B. Pain in the unaffected leg during dorsiflexion of the ankle.
- C. Bowel sounds heard intermittently in four quadrants.
- D. Diffuse, crampy abdominal pain.
Correct Answer: B
Rationale: Pain on dorsiflexion (Homans’ sign) suggests DVT, a serious post-TKR complication requiring immediate intervention. Normal vitals, bowel sounds, and abdominal pain are less urgent.
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The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse?
- A. Capillary refill time is less than three (3) seconds.
- B. Pain is not relieved by the patient-controlled analgesia.
- C. Left fingers are edematous and the left hand is purple.
- D. Warm and dry skin on left fingers distal to the elastic bandage.
Correct Answer: C
Rationale: Edema and purple discoloration indicate neurovascular compromise, requiring immediate intervention. Normal refill, unrelieved pain, and warm skin are less urgent.
When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying prone
- D. Standing to shower
Correct Answer: C
Rationale: Prone positioning stresses the stump and impairs healing.
Which assessment finding is the best indication that the client in halo traction is developing a serious complication?
- A. The client experiences orthostatic hypotension.
- B. The client needs assistance with shaving.
- C. The client cannot open the mouth widely.
- D. The client complains about irritation under the axillae.
Correct Answer: C
Rationale: Inability to open the mouth widely may indicate cranial nerve compression or device misalignment, a serious complication requiring immediate attention. The other findings are less urgent or unrelated.
The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP order should the nurse question?
- A. Maintain heparin to achieve a therapeutic level.
- B. Initiate and monitor intravenous fluids.
- C. Keep the O2 saturation higher than 93%
- D. Administer an intravenous loop diuretic.
Correct Answer: D
Rationale: Loop diuretics are inappropriate for fat embolism syndrome, as they may worsen hypovolemia. Heparin, fluids, and oxygen saturation are standard treatments.
When the nurse is documenting the client's progress while using a continuous passive motion (CPM) machine, which assessment data are essential to include?
- A. Degree of flexion, number of cycles, and condition of the skin
- B. Degree of flexion, number of cycles, and amount of time the client used the machine
- C. Degree of flexion, number of cycles, and characteristics of drainage from the wound
- D. Degree of flexion, number of cycles, and presence and quality of arterial pulses
Correct Answer: B
Rationale: Flexion degree, cycles, and usage time measure CPM effectiveness.