Nokea
The nurse is caring for a client on bed rest for a week following a right hip fracture. Which of the following findings, if noted in the client, would indicate signs of complications due to immobility?
- A. An area of the client's sacrum is unable to be blanched
- B. The skin and the sclerae are yellow
- C. Crackles in the bases of the client's lungs
- D. Swelling and tenderness in the left calf
- E. The client is using the bedpan to void
Correct Answer: A, C, D
Rationale: Non-blanchable sacral skin indicates pressure injury, crackles suggest pneumonia or fluid from immobility, and calf swelling/tenderness may signal deep vein thrombosis. Jaundice and bedpan use are not directly immobility-related.
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The nurse is caring for a client reporting phantom limb pain after a below-the-knee amputation. The client is experiencing what type of pain?
- A. Perceived pain
- B. Somatic pain
- C. Neuropathic pain
- D. Nociceptive pain
Correct Answer: C
Rationale: Phantom limb pain is neuropathic, resulting from nerve damage or dysfunction after amputation, causing pain in the absent limb. Perceived pain is vague, somatic is from tissues, and nociceptive is from actual injury.
The nurse reviews the client's clinical data. Which action should the nurse take based on the clinical data?
- A. Administer the prescribed ketorolac
- B. Remove the heating pad from the client's lower back
- C. Contact the physician to question the prescription of ketorolac
- D. Reposition the client to the side of the bed and have them twist from side to side
- E. Remove and discard the prescribed fentanyl patch because of its lack of efficacy
Correct Answer: B
Rationale: Removing the heating pad is appropriate, as heat can worsen inflammation or strain in low back pain. Ketorolac may be suitable, twisting risks harm, and fentanyl efficacy needs more data before removal.
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.
While caring for a patient who has recently suffered from a fracture, the nurse sees that the patient's injured extremity will be placed in traction. Which of the following actions should the nurse refrain from performing?
- A. Keeping the pulley system tightened so that they may not move freely
- B. Check the ropes for fraying or breaks
- C. Keep the weights above the floor
- D. Ensure proper body alignment
Correct Answer: A
Rationale: Tightening the pulley system to prevent free movement can disrupt traction's purpose of maintaining alignment and pull. Checking ropes, keeping weights off the floor, and ensuring alignment are all appropriate.
The nurse is teaching a client scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. Which of the following information should the nurse include?
- A. Do not eat or drink 6-8 hours prior to your test.'
- B. You will feel flushing as you receive the intravenous contrast.'
- C. The scan takes several hours to complete.'
- D. Please remove all metallic objects before this exam.'
Correct Answer: D
Rationale: Removing metallic objects prevents interference with the DEXA scan, which measures bone density. Fasting and contrast are not required, and the scan typically takes 10-30 minutes.