Nokea
The nurse is caring for a client following a knee arthroscopy procedure. Which of the following assessments should be the priority?
- A. Wound and skin integrity
- B. Mobility assessment
- C. Skin and vascular assessment
- D. Circulation and sensation
Correct Answer: D
Rationale: Circulation and sensation are the priority post-arthroscopy to detect neurovascular compromise, such as nerve damage or impaired blood flow, which can be urgent. Wound, mobility, and skin are important but secondary.
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The nurse is caring for a client six hours postoperative following a below-knee amputation (BKA). Which of the following assessment findings requires follow-up?
- A. Restlessness
- B. Blood pressure of 140/78 mmHg
- C. Pulse rate of 89 bpm
- D. Hypoactive bowel sounds in all four quadrants
Correct Answer: A
Rationale: Restlessness can be a sign of pain, anxiety, or hypoxia, all of which require follow-up in a postoperative client. The blood pressure and pulse rate are within normal limits, and hypoactive bowel sounds are expected shortly after surgery due to anesthesia and reduced gastrointestinal motility.
While reviewing a client's medical record who has fallen twice in the past month, which medications should the nurse recommend be discontinued to lower the client's risk for future falls?
- A. Fluoxetine
- B. Temazepam
- C. Bupropion
- D. Ferrous sulfate
- E. Hydrocodone-acetaminophen
- F. Hydroxyzine
- G. Docusate
Correct Answer: B, E, F
Rationale: Temazepam (sedative), hydrocodone-acetaminophen (opioid), and hydroxyzine (sedating antihistamine) increase fall risk via drowsiness or dizziness. Fluoxetine, bupropion, ferrous sulfate, and docusate have lower fall risk.
The nurse is caring for a client who is bedbound. Which intervention should the nurse implement to reduce this client's risk of developing contractures?
- A. Apply sequential compression devices to the lower extremities
- B. Perform passive range of motion exercises
- C. Obtain a specialty low-air loss mattress
- D. Turn the client every two hours
Correct Answer: B
Rationale: Passive range of motion exercises maintain joint mobility and prevent contractures in bedbound clients. Compression devices prevent clots, mattresses reduce pressure ulcers, and turning aids skin but not primarily joints.
The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up?
- A. If my arm feels itchy, I can use a hair dryer on the cool setting for relief.'
- B. I can reduce my arm's swelling by elevating it with a pillow.'
- C. I should be okay to shower with my cast.'
- D. It will be normal for me to feel heat after the cast is applied.'
Correct Answer: C
Rationale: Showering with a plaster cast risks wetting it, leading to breakdown or infection, requiring follow-up. Cool air for itching, elevation for swelling, and initial heat from cast setting are appropriate.
The nurse has received a prescription for an oral bisphosphonate for a client with osteoporosis. Which finding in the client's medical history would contraindicate the administration of this medication?
- A. diabetes mellitus
- B. hypercalcemia
- C. lactose intolerance
- D. Roux-en-Y gastric bypass
Correct Answer: D
Rationale: Roux-en-Y gastric bypass alters gastrointestinal absorption, reducing the efficacy of oral bisphosphonates and increasing the risk of esophageal or gastric irritation. Diabetes mellitus, hypercalcemia, and lactose intolerance are not absolute contraindications, though hypercalcemia requires monitoring.