Nokea
The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority?
- A. Presence of bruising to the right elbow
- B. Pain level rating on a 0-10 scale
- C. Sensation and pulse of the right forearm
- D. Left-handed or right-handed
Correct Answer: C
Rationale: C. Impairment of the neurovascular system is a priority. The closed reduction could cause further damage, which would be noted distal to the injury. Sensation and pulses are part of a neurovascular assessment to an extremity.
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How can the nurse best support the wet cast while the physician wraps the arm with rolls of wet plaster?
- A. By using a soft mattress
- B. By resting it on a firm surface
- C. By using the client's knee on the fingers
- D. By using the palms of the hands
Correct Answer: D
Rationale: Using the palms of the hands to support the wet cast prevents indentations that could cause pressure points, ensuring the cast maintains its shape. A soft mattress or fingers may deform the cast, and a firm surface is less precise.
The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the discharge teaching?
- A. I need to keep my leg elevated on two pillows for the first 24 hours.'
- B. I must wear my sequential compression device all the time.'
- C. I can remove the cast for one (1) hour so I can take a shower.'
- D. I will be able to walk on my cast and not have to use crutches.'
Correct Answer: A
Rationale: Elevating the leg reduces swelling post-casting, indicating understanding. SCDs are for DVT, cast removal is unsafe, and walking without crutches depends on the fracture.
The nurse is caring for the client 24 hours following total hip arthroplasty using the traditional posterior approach. Which interventions should the nurse plan to implement? Select all that apply.
- A. Place pillows or a wedge pillow between the client's legs to keep them abducted.
- B. Have the client flex the unaffected hip and use the trapeze to help move up in bed.
- C. Raise the head of the bed to no more than 90 degrees when the bed is placed contour.
- D. Place a pillow between the client's knees when initially assisting the client out of bed.
- E. Applies antiembolism stockings that should not be removed for 24 hours postoperatively.
Correct Answer: A,B,D
Rationale: A. A pillow should be used to maintain abduction to prevent dislocation. B. Using the trapeze and flexing the unaffected legs while keeping the affected leg straight help prevent flexion with position changes. The client's hip should not be flexed more than 90 degrees. D. In initial transfers, a pillow is used to remind the client to maintain abduction and prevent internal and external hip rotation.
While teaching the client, what can the nurse explain about the purpose for prescribing this medication?
- A. To reduce emotional depression
- B. To relax skeletal muscles
- C. To promote restful sleep
- D. To relieve inflammation
Correct Answer: B
Rationale: Cyclobenzaprine (Flexeril) is a muscle relaxant used to reduce muscle spasms associated with a herniated disk, alleviating pain and improving mobility. It does not primarily address depression, sleep, or inflammation.
The client with a lower leg amputation has edema, so the NA elevates the client's residual left limb on pillows. What is the most appropriate action by the nurse when observing that the client's leg has been elevated?
- A. Thank the nursing assistant (NA) for being so observant and intervening appropriately to treat the client's edema of the residual limb.
- B. Remove the pillows, raise the foot of the bed, and inform the NA that the limb should not be elevated on pillows because it could cause a flexion contracture.
- C. Inform the NA that this was the correct action at this time in the client's recovery, but once the client's incision heals, the leg should not be elevated.
- D. Report the incident to the surgeon and tell the NA to complete a variance report because the client's leg should not have been elevated.
Correct Answer: B
Rationale: B. The nurse should perform this action. Flexion, abduction, and external rotation of the residual lower limb are avoided to prevent hip contracture.