Nokea
The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon?
- A. A total of 100 mL of red drainage in the autotransfusion drainage system.
- B. Pain relief after using the patient-controlled analgesia (PCA) pump.
- C. Cool toes, distal pulses palpable, and pale nailbeds bilaterally.
- D. Urinary output of 60 mL of clear yellow urine in three (3) hours.
Correct Answer: C
Rationale: Cool toes and pale nailbeds suggest vascular compromise, requiring surgeon notification. Expected drainage, pain relief, and low urine output are less urgent.
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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.
The nurse is assessing the leg of a client in Russell's traction. Which area is it essential to assess?
- A. Pedal area
- B. Femoral area
- C. Popliteal area
- D. Inner aspect of the thigh
Correct Answer: A
Rationale: Assessing the pedal area checks for circulation, sensation, and movement, critical in traction to detect neurovascular compromise.
The client has been in a body cast for the past 2 days to treat numerous broken vertebrae from a fall. The client is reporting dyspnea, vomiting, epigastric pain, and abdominal distention. Which action demonstrates the nurse's best clinical judgment?
- A. Immediately notify the health care provider.
- B. Initiate oxygen at 2 liters per nasal cannula.
- C. Place ice packs around the outside of the cast.
- D. Administer ondansetron prescribed q6h prn.
Correct Answer: A
Rationale: A. The nurse should immediately notify the HCP. A window in the abdominal portion of the cast or bivalving is needed to relieve the pressure.
If the client is typical of others with a herniated disk, the nurse would expect the client to report which additional symptom?
- A. Pain radiating into the buttocks and leg
- B. Tenderness over one or both iliac crests
- C. Diminished sensation in one or both knees
- D. Brief periods when the toes feel quite cold
Correct Answer: A
Rationale: A herniated lumbar disk commonly causes sciatica, with pain radiating into the buttocks and leg due to nerve root compression. Other symptoms are less typical or specific.
Which client goal is most appropriate for a client diagnosed with OA?
- A. Perform passive range-of-motion exercises.
- B. Maintain optimal functional ability.
- C. Client will walk three (3) miles every day.
- D. Client will join a health club.
Correct Answer: B
Rationale: Maintaining optimal function aligns with OA management, promoting mobility and independence. Passive ROM is inappropriate, 3 miles daily is unrealistic, and joining a health club is nonspecific.