Nokea
The nurse is assigned to care for a client who is 2 days postoperative after an above-the-knee amputation of the right leg. The nurse plans to implement which measure to prevent hip contractures?
- A. Maintain the client in a supine position.
- B. Maintain a high-Fowler’s position when the client is in bed.
- C. Elevate the stump on a pillow.
- D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Correct Answer: D
Rationale: Correct Answer: D. Position the client on the abdomen for 20 to 30 minutes twice a day.
Rationale: Positioning the client on the abdomen helps prevent hip contractures by stretching the hip flexors and maintaining hip extension. This position also helps to prevent hip adduction contractures, which can occur due to prolonged positioning on the back. By alternating positions, the client's hip joint is kept in a more functional and extended position, reducing the risk of contractures.
Summary of other choices:
A: Maintaining the client in a supine position does not actively prevent hip contractures and may even contribute to hip flexion contractures.
B: Maintaining a high-Fowler's position when the client is in bed does not address hip extension and may lead to hip flexion contractures.
C: Elevating the stump on a pillow is important for stump care but does not specifically target prevention of hip contractures.
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The emergency service team brings a homeless client found lying in an alley to the emergency department. An assessment is performed, and the client is suspected of having frostbite of the hands. Which finding would the nurse expect to note in this condition?
- A. Red skin with edema in the nail beds.
- B. Black fingertips surrounded by an erythematous rash.
- C. A white appearance to the skin that is insensitive to touch.
- D. A pink edematous hand.
Correct Answer: C
Rationale: The correct answer is C: A white appearance to the skin that is insensitive to touch. Frostbite initially presents with a white or pale appearance due to vasoconstriction, followed by numbness or insensitivity to touch. This occurs as a result of decreased blood flow to the affected area. As frostbite progresses, the skin may turn blue or purplish due to tissue damage. Red skin with edema in the nail beds (Choice A) is more indicative of inflammation or infection rather than frostbite. Black fingertips surrounded by an erythematous rash (Choice B) may suggest gangrene, a severe complication of untreated frostbite. A pink edematous hand (Choice D) is not characteristic of frostbite, as it typically presents with a white or bluish discoloration.
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
- A. The ability to comply with anticoagulant therapy for life.
- B. The likelihood of the client experiencing body image problems.
- C. The physical demands of the client’s lifestyle.
- D. The ability to participate in a cardiac rehabilitation program.
Correct Answer: A
Rationale: The correct answer is A: The ability to comply with anticoagulant therapy for life. This is essential because mechanical valve replacement requires lifelong anticoagulant therapy to prevent clot formation. Noncompliance can lead to serious complications such as thromboembolism or valve failure. Assessing the client's understanding, willingness, and ability to adhere to this therapy is crucial for successful outcomes.
Other options are incorrect because:
B: Body image problems are important but not essential before surgery.
C: Physical demands of lifestyle are relevant but not crucial for valve replacement.
D: Participation in cardiac rehab is beneficial post-surgery but not essential before.
Overall, the ability to comply with anticoagulant therapy is the most critical factor to assess preoperatively.
A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
- A. Airway obstruction.
- B. Pneumonia.
- C. Pneumothorax.
- D. Fat embolism.
Correct Answer: D
Rationale: The correct answer is D: Fat embolism. Fat embolism can occur in clients with long bone fractures, like a femoral head fracture. Fat emboli can travel to the lungs leading to respiratory distress, shortness of breath, and dyspnea. This is a potential complication that can occur within the first 24-48 hours post-injury. Fat embolism is characterized by respiratory symptoms and can lead to hypoxia and respiratory failure.
Other choices are incorrect because:
A: Airway obstruction typically presents with choking or difficulty swallowing, not specifically with shortness of breath and dyspnea.
B: Pneumonia would typically present with fever, productive cough, and chest pain, not sudden-onset shortness of breath.
C: Pneumothorax presents with sudden chest pain and shortness of breath due to air in the pleural space, not directly related to a femoral head fracture.
Overall, the key to this question is
A nurse is caring for a client who has poison ivy and is prescribed diphenhydramine. Which of the following instructions should the nurse give regarding the adverse effect of dry mouth associated with diphenhydramine?
- A. Administer the medication with food.
- B. Chew on sugarless gum or suck on hard candies.
- C. Place a humidifier at your bedside every evening.
- D. Discontinue the medication and notify your provider.
Correct Answer: B
Rationale: The correct answer is B: Chew on sugarless gum or suck on hard candies. Diphenhydramine commonly causes dry mouth as a side effect due to its anticholinergic properties. Chewing on sugarless gum or sucking on hard candies stimulates saliva production, helping to alleviate dry mouth. Administering the medication with food (choice A) is not directly related to treating dry mouth. Placing a humidifier at the bedside (choice C) may help with dry throat but not specifically dry mouth caused by diphenhydramine. Discontinuing the medication (choice D) without consulting the provider is not recommended as it may lead to worsening symptoms or potential withdrawal effects.
A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
- A. I have no appetite.
- B. The pain hurts so much it is making me nauseous.
- C. When I position myself on my right side, it makes the pain worse.
- D. The pain seems to be gone now.
Correct Answer: D
Rationale: The correct answer is D because sudden relief of pain in appendicitis could indicate a ruptured appendix, which is a surgical emergency requiring immediate intervention. This is because when the appendix ruptures, the pain initially decreases due to the release of pressure in the appendix, but the situation can quickly escalate to a life-threatening condition like peritonitis. Choices A, B, and C all indicate ongoing symptoms of appendicitis that would warrant further assessment and intervention.