Nokea
The nurse is caring for a client two days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to:
- A. Stabilize the knee joint during ambulation
- B. Promote knee flexion
- C. Reduce post-surgical swelling
- D. Prevent blood clots
Correct Answer: B
Rationale: The primary purpose of a CPM device is to promote knee flexion and range of motion post-surgery, aiding recovery. It doesn't stabilize during ambulation, primarily reduce swelling, or prevent clots.
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The nurse is caring for assigned clients. The nurse should recognize that the client at greatest risk for compartment syndrome is the client who has which of the following?
- A. A left tibial fracture that was recently placed in a cast
- B. Swelling in the ankles and is wearing compression stockings
- C. Chronic osteomyelitis of the right femur
- D. Skin traction following a left hip fracture
Correct Answer: A
Rationale: A recent tibial fracture in a cast increases compartment syndrome risk due to swelling and pressure within a confined space. Ankle swelling, chronic osteomyelitis, and skin traction pose lower or different risks.
A nurse is taking care of a client that is status-post hand arthroplasty. When creating the care plan, which of the following nursing interventions should be avoided to prevent complications?
- A. Encourage the client to perform finger and wrist exercises ten times per hour, using a full range of flexion and extension.
- B. Place the client's personal items within reach of the client's non-operative arm.
- C. Place the client's operative arm on a pillow to rest and keep it elevated.
- D. Encourage the client to use the non-operative arm as much as possible.
Correct Answer: A
Rationale: Excessive full range of motion exercises shortly after hand arthroplasty can strain the surgical site, risking damage or delayed healing. Elevation, using the non-operative arm, and placing items within reach are appropriate.
The following scenario applies to the next 1 items
The nurse in a urgent care facility cares for a 46-year-old male
Item 1 of 1
Triage Note
1400: 46-year-old man reports right ankle pain that started one hour ago while playing soccer with his children. He states that he was getting ready to kick the ball and lost his footing on wet grass. Focused assessment: swelling over the lateral malleolus down to the area of the fourth and fifth metatarsals is present, and pedal pulses are 2+ bilaterally. Pain is endorsed with movement, and the range of motion of the right ankle is very limited. No gross deformity of the ankle was observed. Pain is rated 9 on a scale of 0 (no pain) to 10 (severe pain). T 97.5° F (36.4° C), P 98, RR 18, BP 144/90, pulse oximetry reading 96% on room air. The client reports allergies to erythromycin with an unknown reaction. Medical history included a myocardial infarction 8 months ago, irritable bowel syndrome, and plaque psoriasis. Current medications include clopidogrel and atenolol.
Physician Orders
• Discharge home with an orthopedic referral
• Ketorolac 15 mg intramuscular (IM) x 1 dose
• Apply ace wrap to the right ankle
• Home prescription: Ketorolac 10 mg by mouth twice a day PRN pain for three days
• Home prescription: Oxycodone 5 mg by mouth twice a day PRN pain for three days
• Home prescription: Docusate 50 mg by mouth once a day for three days
• Home prescription: Crutches, no weight bearing to the right lower extremity until seen by orthopedics
Diagnostics
Right Ankle X-Ray
No obvious fracture is seen. Bones show normal alignment and architecture. Joint spaces and articular margins are intact. Soft tissue swelling noted.
The nurse implements the physician's orders. Complete the sentences below by choosing from the list of options. The nurse reviews the prescriptions and should question the prescribed……….. with the physician based on the client's medical history of…….The nurse is gathering the prescribed crutches and plans on teaching the client to ambulate using the……..The nurse should instruct the client that the crutches should be………To promote comfort and to reduce swelling, the nurse should instruct the client to apply…………..compresses to the ankle for no greater than………..
- A. Ketorolac
- B. Recent myocardial infarction.
- C. Three point gait.
- D. 6 inches (15 cm) in front of their feet while standing.
- E. Cold
- F. 20 minutes at a time.
Correct Answer: A, B,C,D,E,F
Rationale: A, B: Ketorolac, an NSAID, increases bleeding risk, concerning with a recent myocardial infarction and clopidogrel use. Other options relate to crutch use and swelling management, which are appropriate.
The PACU nurse is caring for a patient who is presenting with agitation following knee replacement surgery. What action should the nurse take first?
- A. Notify the anesthesiologist of the adverse reaction.
- B. Assess the patient's respiratory function.
- C. Obtain an order for additional sedation to keep the patient safe during agitation.
- D. Administer a benzodiazepine antagonist.
Correct Answer: B
Rationale: Assessing respiratory function is the priority, as agitation post-surgery may signal hypoxia, a life-threatening issue. Notifying the anesthesiologist, sedation, and reversal agents are secondary after ruling out airway or breathing problems.
The nurse is developing a plan of care for a patient who has a halo vest immobilizer (halo brace) following a cervical spine fracture. Which of the following should the nurse include in the patient's plan of care?
- A. Pin care every shift
- B. Neck flexion and extension exercises
- C. Taping the wrench to the vest
- D. Report loosening of the pins
- E. Use straws when providing liquids
Correct Answer: A, D, E
Rationale: Pin care prevents infection, reporting loose pins ensures stability, and straws aid safe drinking. Neck exercises are contraindicated as they risk spinal injury, and taping the wrench is standard but not always required unless specified.