Nokea
The nurse is caring for a client who is bedbound. Which intervention should the nurse implement to reduce this client's risk of developing contractures?
- A. Apply sequential compression devices to the lower extremities
- B. Perform passive range of motion exercises
- C. Obtain a specialty low-air loss mattress
- D. Turn the client every two hours
Correct Answer: B
Rationale: Passive range of motion exercises maintain joint mobility and prevent contractures in bedbound clients. Compression devices prevent clots, mattresses reduce pressure ulcers, and turning aids skin but not primarily joints.
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A nurse is caring for a client who recently had a cast placed on their right lower extremity. Which statement from the client should be of the greatest concern to the nurse?
- A. I've been having pain in my right calf.'
- B. My right leg feels really itchy.'
- C. I have not been keeping my leg elevated while in bed.'
- D. My hands and arms support my body weight while using crutches.'
Correct Answer: A
Rationale: Pain in the calf may indicate compartment syndrome or deep vein thrombosis, both serious complications requiring urgent attention. Itching is common, elevation is helpful but less urgent, and crutch use is expected.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 6 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Orders
2100:
Magnetic resonance imaging of the right foot without contrast
Insert peripheral vascular access device
Laboratory tests: blood culture and sensitivity (C & S), complete blood count (CBC), complete metabolic panel (CMP), lactic acid
vancomycin 1 g, IV, every 12 hours
Wound culture
fentanyl 50 mcg IV, every 5 hours PRN pain
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
Nurses' Notes
2110: Orders received and reviewed. Vital signs: T 103° F (39.4° C), P 92, RR 18, BP 141/87, pulse oximetry reading 98% on room air. Client reports pain '8' on the Numerical Pain Scale.
For each of the statements made by the client, click to specify whether the statement indicates an understanding or requires follow-up of the discharge teaching provided.
- A. I should wash my feet daily with warm water and mild soap, then dry thoroughly, especially between the toes.'
- B. I should inspect my feet bi-weekly for any injuries.'
- C. I should use a corn/callus remover on my feet.'
- D. I should wear compression socks with well-fitting shoes.'
- E. Controlling my blood sugar levels can help reduce my risk of developing foot complications.'
Correct Answer: A: Indicated, B: Follow-up, C: Follow-up, D: Indicated, E: Indicated
Rationale: A: Proper foot hygiene prevents infection. B: Daily, not bi-weekly, inspection is needed with diabetes. C: Corn/callous removers risk skin breakdown. D: Compression socks and good shoes aid circulation. E: Blood sugar control reduces complication risk.
A nurse is caring for a client admitted to the emergency department with suspected rhabdomyolysis. Which of the following findings would the nurse anticipate in a client with this condition?
- A. Elevated creatinine kinase (CK) levels
- B. Decreased serum potassium levels
- C. Hypertension and bradycardia
- D. Clear urine output
Correct Answer: A
Rationale: Rhabdomyolysis causes muscle breakdown, releasing creatinine kinase (CK) into the blood, elevating levels. Potassium levels typically rise, blood pressure and heart rate vary, and urine is dark from myoglobin.
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.
The nurse is caring for a client with a femur fracture. The client reports chest pain, restlessness, and dyspnea. The nurse suspects that the client has developed fat embolism syndrome (FES). The nurse should take which action?
- A. Place the extremity in a dependent position
- B. Obtain a prescription for hypertonic intravenous fluids
- C. Loosen any dressings on the extremity
- D. Notify the physician
Correct Answer: D
Rationale: Chest pain, restlessness, and dyspnea suggest fat embolism syndrome, a medical emergency. Notifying the physician is critical for rapid intervention. Dependent positioning worsens swelling, hypertonic fluids are unrelated, and loosening dressings helps but is secondary.