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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.
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The nurse is teaching a new grad about contractures. The nurse knows which statement about contractures secondary to immobility is accurate?
- A. Contractures cannot be prevented because of muscular spasticity.
- B. Contractures cannot be prevented because of muscular tension.
- C. Flexion contractures are the least commonly occurring contracture.
- D. Flexion contractures are the most commonly occurring contracture.
Correct Answer: D
Rationale: Flexion contractures are the most common due to immobility, as muscles shorten in a flexed position. Contractures can be prevented with range of motion and positioning, despite spasticity or tension.
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 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 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.
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.