Nokea
The nurse is caring for a client prior to surgery to repair a broken right hip. Which nursing care measure is essential?
- A. Get the client out of bed twice a day to maintain mobility
- B. Use pillows to maintain the right hip in a state of abduction
- C. Elevate the foot of the bed to 25 degrees
- D. Feed the client to conserve her energy
Correct Answer: B
Rationale: Maintaining abduction with pillows prevents dislocation and aligns the hip pre-surgery.
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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.
Which area of health teaching is essential to include in the discharge instructions for a client who has undergone a total hip replacement?
- A. Modifying ways of donning clothing
- B. Using special equipment for bathing
- C. Taking vigorous daily walks
- D. Receiving a daily stool softener
Correct Answer: A
Rationale: Modifying clothing application (e.g., avoiding bending or crossing legs) prevents hip dislocation, making it essential for discharge teaching. Vigorous walks are contraindicated, and the other options are less critical.
The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify?
- A. Risk for ineffective coping related to the inability to perform ADLs.
- B. Risk for compartment syndrome-related injured muscle tissue.
- C. Risk for infection related to exposed bone and tissue.
- D. Risk for complications related to compromised neurovascular status.
Correct Answer: B
Rationale: Compartment syndrome is a critical risk in closed fractures due to swelling, threatening limb viability. Coping, infection (more for open fractures), and general complications are secondary.
Which neural tube defect is the nurse describing when stating that the vertebral arch fails to close and the spinal cord and meninges stay within the vertebral canal?
- A. Meningocele
- B. Spina bifida occulta
- C. Spina bifida cystica
- D. Myelomeningocele
Correct Answer: B
Rationale: Spina bifida occulta involves a failure of the vertebral arch to close, with the spinal cord and meninges remaining within the vertebral canal.
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.