Nokea
The nurse is caring for a client in skeletal traction. When performing pin care, which action by the nurse is most important?
- A. Clean the site, working toward the pin.
- B. Use an applicator only once.
- C. Gently remove crusts around pin sites.
- D. Apply an antimicrobial ointment.
Correct Answer: B
Rationale: When performing pin care, the nurse should use at least one applicator per pin and not use an applicator more than once, cleaning the site from the pin outward. Crusts around pin sites should be gently removed, but that is less important than not re-using applicators. Ointment is avoided unless it is specifically ordered.
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A client is scheduled for a total left knee arthroplasty in 2 weeks. When would the best time for postoperative nursing management to begin?
- A. Before surgery
- B. When the client is taken to the postanesthesia care unit
- C. After the client returns to the room after surgery and receives pain medication
- D. Twenty-four hours after the procedure
Correct Answer: A
Rationale: Ideally, postoperative nursing management begins before surgery with demonstrations of deep-breathing and coughing exercises and descriptions and demonstrations of the incentive spirometer. Even if the client will have postoperative physical therapy, the nurse explains and helps the client practice active and isometric leg exercises. The nurse also describes other devices that may be used after surgery, such as intravenous infusions of fluid and blood, oxygen, a wound drain, elastic stockings, or roller bandages. It also is necessary to include a discussion of the possible use of traction or the CPM machine. The other options offered do not allow adequate time for instruction.
The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?
- A. Scrubbing the drainage from around the pin site
- B. Obtaining a culture
- C. Applying iodine-based solution
- D. Apply ointment to the pin site.
Correct Answer: B
Rationale: A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.
A client has just undergone a leg amputation. What will the nurse closely monitor the client for during the immediate postoperative period?
- A. Neuroma
- B. Hematoma
- C. Chronic osteomyelitis
- D. Unexplainable burning pain (causalgia)
Correct Answer: B
Rationale: Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period. Sleeplessness, nausea, and vomiting may occur but are adverse reactions, not complications. Chronic osteomyelitis and causalgia are potential complications that are likely to arise in the late postoperative period. A neuroma occurs when the cut ends of the nerves become entangled in the healing scar. This would occur later in the postoperative course.
The nurse is caring for a client who sustained rib fractures in an automobile accident. What symptoms does the nurse recognize as a complication of rib fractures and should immediately be reported to the physician?
- A. Blood pressure of 140/90 mm Hg
- B. Crackles in the lung bases
- C. SUBJECT: Client complains of pain in the affected rib area when taking a deep breath
- D. Heart rate of 94 beats/minute
Correct Answer: B
Rationale: Crackles in the lung bases can be an indicator that the client has developed pneumonia from shallow respirations. The blood pressure is high but may be due to pain. It is expected that the client will have pain in the rib area when taking deep breaths. A heart rate of 94 beats/minute is within normal range.
The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client's lungs and, when moving the gown, observes petechial hemorrhages on the skin of the chest. What is the first action by the nurse?
- A. Call the physician to inform them of the findings.
- B. Administer pain medication.
- C. Request an antihistamine for the allergic reaction.
- D. Increase the intravenous fluids for hemorrhage.
Correct Answer: A
Rationale: The findings of the nurse indicate that the client may have a fat embolus, and the physician should be informed immediately. Administration of pain medication is not indicated at this time. The rash is not indicative of an allergic reaction. There is no indication that the rash is related to hemorrhage, and there is no need to increase the IV fluids.