Nokea
The nurse is caring for a client who has just had a cast applied. Which statement best describes the expected client outcome relative to the circulatory system for a client with a cast?
- A. There will be no increase in pain in the extremity.
- B. The client will have no circulatory impairment.
- C. The integrity of the cast will be maintained.
- D. The client will report any feelings of skin irritation.
Correct Answer: B
Rationale: The primary circulatory outcome is preventing impairment, such as swelling or color changes. Pain relates to neurological issues, cast integrity is unrelated to circulation, and skin irritation is not a circulatory indicator.
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Which assessment finding warrants immediate action by the nurse when a client is in Buck's traction?
- A. The traction weights are hanging above the floor.
- B. The leg is in line with the pull of the traction.
- C. The right is about is to be the two.
- D. The rope is in the groove of the traction pulley.
Correct Answer: A
Rationale: Traction weights must hang freely to maintain proper pull. If they are above the floor (e.g., resting on something), the traction is ineffective, requiring immediate correction to ensure proper alignment and healing.
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 prevents excessive hip flexion.
A femoral head replacement was performed on an elderly client. Postoperatively, the nurse positions the client with an abductor pillow between the client's legs. What is the primary reason for this?
- A. This position will promote greater comfort.
- B. Abduction promotes greater circulation to the hip joint.
- C. Abduction will prevent the prosthesis from snapping out of the socket.
- D. This position will help to prevent pressure on the sciatic nerve.
Correct Answer: C
Rationale: An abductor pillow maintains abduction, preventing prosthesis dislocation post-femoral head replacement.
The client is admitted to the hospital for a diagnostic workup. The client has vague symptoms of malaise, coughing, chest discomfort, low-grade fever, diffuse rashes, and musculoskeletal aches and pains. A diagnosis of probable lupus erythematosus has been made. The night nurse finds the client crying and saying, 'I would rather die than suffer with this disease for the rest of my life.' Which response by the nurse would be most therapeutic at this time?
- A. Telling the client there are support groups to join after discharge
- B. Offering to stay with the client to discuss concerns and questions
- C. Advising the client to write concerns on paper to discuss with the doctors and nurses tomorrow
- D. Offering the client a back rub and a warm cup of milk
Correct Answer: B
Rationale: Offering to stay and discuss concerns is therapeutic, providing emotional support and addressing the client's fears.
The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client?
- A. The occupational therapist.
- B. The physiatrist.
- C. The recreational therapist.
- D. The home health nurse.
Correct Answer: D
Rationale: A home health nurse monitors recovery, manages complications, and supports mobility post-TKR. OT, physiatrists, and recreational therapists are less critical at discharge.