Nokea
The nurse is caring for a client six hours postoperative following a below-knee amputation (BKA). Which of the following assessment findings requires follow-up?
- A. Restlessness
- B. Blood pressure of 140/78 mmHg
- C. Pulse rate of 89 bpm
- D. Hypoactive bowel sounds in all four quadrants
Correct Answer: A
Rationale: Restlessness can be a sign of pain, anxiety, or hypoxia, all of which require follow-up in a postoperative client. The blood pressure and pulse rate are within normal limits, and hypoactive bowel sounds are expected shortly after surgery due to anesthesia and reduced gastrointestinal motility.
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The nurse reviews newly prescribed medications from the primary healthcare provider (PHCP). The nurse understands that the prescribed etanercept is intended to treat which condition?
- A. Osteoarthritis
- B. Diabetes mellitus
- C. Infective endocarditis (IE)
- D. Rheumatoid arthritis
Correct Answer: D
Rationale: Etanercept is a tumor necrosis factor (TNF) inhibitor used to treat autoimmune conditions like rheumatoid arthritis by reducing inflammation and joint damage. Osteoarthritis is not autoimmune, diabetes mellitus affects glucose metabolism, and infective endocarditis is a bacterial infection, none of which are treated with etanercept.
The nurse is assessing a client who reports left knee pain after playing baseball. The nurse should initially
- A. Feel the knee for warmth.
- B. Inspect the knee for any swelling.
- C. Palpate for crepitus in the knee.
- D. Have the client perform active range of motion in the knee.
Correct Answer: B
Rationale: Initial assessment starts with inspection for swelling, a visible sign of injury or inflammation post-activity. Warmth, crepitus, and range of motion are assessed next but are not the first step.
The nurse is caring for a client who has a fiberglass cast that has just been applied to their left arm due to a humerus fracture. Three hours later, the client complains of numbness in his fingers, and says his fingers 'have become pale.' What is the nurse's most appropriate action?
- A. Reassure the client that this is just a normal occurrence after having a cast.
- B. Ask the client to clench his fist frequently.
- C. Remove the cast immediately.
- D. Notify the primary healthcare provider (PHCP).
Correct Answer: D
Rationale: Numbness and pallor in the fingers are signs of potential compartment syndrome or impaired circulation, which are serious complications. The most appropriate action is to notify the primary healthcare provider immediately for further evaluation and intervention. Reassuring the client or asking them to clench their fist does not address the urgency, and removing the cast is not within the nurse's scope without a provider's order.
The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make?
- A. You should ride a bicycle instead of driving a car.'
- B. Report any fever or drainage at the pin sites.'
- C. Always keep the wrench taped to the front of the vest.'
- D. When getting out of bed, roll to your side and push on the mattress.'
- E. Wear a cotton t-shirt under the vest to absorb any moisture.'
Correct Answer: B, C, E
Rationale: Report fever or drainage for infection, keep the wrench taped for emergency adjustments, and wear a cotton t-shirt for comfort. Bicycling risks falls, and rolling to the side is safe but not the only method.
The nurse is caring for a client with a newly applied plaster cast. The nurse should
- A. Use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable.
- B. Expedite drying by using a hot blow dryer on the cast.
- C. Let the cast hang below the heart to promote blood flow.
- D. Handle the cast with the palms of the hands.
Correct Answer: D
Rationale: Handling a wet plaster cast with the palms prevents denting, which could cause pressure points. Scratching inside risks skin damage, hot dryers can burn, and a dependent position increases swelling.