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The nurse is caring for a client in a hip spica cast. Which intervention should the nurse include in the plan of care?
- A. Assess the client’s popliteal pulses every shift.
- B. Elevate the leg on pillows and apply ice packs.
- C. Teach the client how to ambulate with a tripod walker.
- D. Assess the client for distention and vomiting.
Correct Answer: D
Rationale: Distention and vomiting indicate GI complications (e.g., ileus) in a hip spica cast, requiring assessment. Pulses are accessible, elevation is impractical, and ambulation is limited.
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The client continues to recover following a below-the-knee amputation. What nursing action should the nurse employ to help prevent the most common complication following leg amputation?
- A. Clean the wound with hydrogen peroxide three times a day
- B. Have the client lie prone several times a day
- C. Ask the client to flex and extend the toes on the remaining leg
- D. Encourage the client to completely empty his/her bladder
Correct Answer: B
Rationale: Lying prone prevents hip flexion contractures, the most common complication post-amputation.
The nurse is caring for the client 2 days post-right THR in which the traditional posterior approach was used. Which interventions should the nurse implement?
- A. Checks that an elevated toilet seat is in place and assists the client to the bathroom using a walker
- B. Removes the wedge pillow at the client's request and places pillows to maintain right leg adduction
- C. Reinfuses the 400-mL wound autotransfusion drainage system returns that collected in the past 24 hours
- D. Assists the client to get out of bed on the left side so the client can stand to place and use the urinal
Correct Answer: A
Rationale: A. The client should be able to ambulate with the use of a walker. An elevated toilet seat is used to prevent hip flexion of greater than 90 degrees when the client sits.
The child with an SCI is prescribed baclofen 5 mg tid orally to treat muscle spasticity. How many tablets should the nurse administer for one dose if 20-mg tablets are available?
Correct Answer: 0.25
Rationale: 5 mg divided by 20 mg per tablet equals 0.25 tablets per dose.
The college student consults the clinic nurse for advice on managing lower back pain. Which instructions should the nurse include? Select all that apply.
- A. Continue routine activity within your pain tolerance while paying attention to correct posture.
- B. Temporarily avoid lifting and other activities that increase mechanical stress on your spine.
- C. When sleeping on your side, flex your hips and knees and place a pillow between your knees.
- D. Stay at home for 1 week on bedrest to minimize physical activity and straining your back.
- E. Stand intermittently during classes, and sit with a soft support at the small of your back.
Correct Answer: A,B,C,E
Rationale: A. Remaining active is best. Using good posture will minimize back strain. B. Mechanical stress can increase pain. Prolonged unsupported sitting, heavy lifting, and bending or twisting the back, especially while lifting, should be avoided. C. Using pillows and hip and knee flexion promotes lumbar flexion and back alignment. E. Prolonged sitting should be avoided because fatigue contributes to spasm of the back muscles. Lordosis can be decreased by using a soft support at the small of the back.
The client with rheumatoid arthritis is to receive prednisone 2.5 mg P.D. before meals and at bedtime. What is the primary expected action of the drug?
- A. Maintenance of sodium and potassium balance
- B. Improvement of carbohydrate metabolism
- C. Production of androgen-like effects
- D. Interference with inflammatory reactions
Correct Answer: D
Rationale: Prednisone's primary action in rheumatoid arthritis is to interfere with inflammatory reactions, reducing joint inflammation.