Nokea
The nurse is assessing the leg of a client in Russell's traction. Which area is it essential to assess?
- A. Pedal area
- B. Femoral area
- C. Popliteal area
- D. Inner aspect of the thigh
Correct Answer: A
Rationale: Assessing the pedal area checks for circulation, sensation, and movement, critical in traction to detect neurovascular compromise.
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The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client?
- A. The client will maintain function of the leg.
- B. The client will ambulate with assistance.
- C. The client will be turned every two (2) hours.
- D. The client will have no infection.
Correct Answer: A
Rationale: Maintaining leg function is the primary goal for fracture recovery. Ambulation, turning, and infection prevention are interventions, not outcomes.
On the basis of the nurse's knowledge of the client's culture and beliefs, which statement regarding the health-seeking behavior is probably most accurate?
- A. Home remedies have been unsuccessful, and the condition threatens the client's self-image.
- B. The power to cure comes from physicians and is passed to nurses.
- C. The client waited for symptoms to resolve spontaneously.
- D. The client sought care due to family encouragement.
Correct Answer: A
Rationale: Hispanic clients may try home remedies first, seeking care when self-image is impacted.
The nurse is assessing the client 3 months following a left shoulder arthroplasty. Which assessment findings should prompt the nurse to consider that the client may have developed osteomyelitis? Select all that apply.
- A. Sudden onset of chills
- B. Temperature 103°F (39.4°C)
- C. Sudden onset of bradycardia
- D. Pulsating shoulder pain that is worsening
- E. Painful, swollen area on the left shoulder
Correct Answer: A,B,D,E
Rationale: A. A sudden onset of chills suggests the infection of osteomyelitis is blood-borne. B. A high fever suggests the infection of osteomyelitis is blood-borne. D. The pulsating shoulder pain is caused from the pressure of the collecting pus. E. The infected area becomes swollen, painful, and extremely tender.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate (Rheumatrex) therapy?
- A. Constipation
- B. Arrhythmia
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores (stomatitis) are a common adverse effect of methotrexate due to its impact on rapidly dividing cells, like those in the oral mucosa. The other symptoms are less commonly associated.
When preparing the client for cast application, which statement by the nurse is most accurate?
- A. The cast will feel tight as it's applied.
- B. Your arm will feel warm as the wet plaster sets.
- C. You can expect a foul odor until the cast is dry.
- D. You may feel itchy while the cast is wet.
Correct Answer: B
Rationale: Wet plaster generates heat as it sets, causing a warm sensation, which is a normal part of the process. Tightness may indicate a problem, odors are not typical, and itching is more common as the cast dries.