Nokea
The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take?
- A. Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg)
- B. Turn the client using a foam wedge every two hours
- C. Ensure that a client's heels are supported with a pillow
- D. Elevate the foot of the bed to provide counter traction
Correct Answer: D
Rationale: Elevating the foot of the bed provides counter traction to maintain alignment in Buck traction. Excessive weight risks injury, turning disrupts traction, and heel support is good but not the priority.
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The nurse is caring for a client being admitted to the medical-surgical unit with an acute flare of gout. After performing medication reconciliation, which medication does the nurse suspect could have triggered the acute gout flare? See the exhibit.
- A. hydrochlorothiazide
- B. temazepam
- C. rosuvastatin
- D. escitalopram
Correct Answer: A
Rationale: Hydrochlorothiazide, a thiazide diuretic, can increase serum uric acid levels by reducing renal excretion, potentially triggering an acute gout flare. Temazepam, rosuvastatin, and escitalopram do not significantly affect uric acid levels or gout.
The nurse is preparing to give alendronate to the client with osteoporosis. The nurse should explain to the client that the expected outcome of this medication is primarily to
- A. decrease bone inflammation
- B. increase synovial fluid in the joint space
- C. inhibit bone resorption
- D. increase serum calcium levels
Correct Answer: C
Rationale: Alendronate, a bisphosphonate, inhibits osteoclast activity, thereby reducing bone resorption and increasing bone density in osteoporosis. It does not primarily reduce inflammation, increase synovial fluid, or directly increase serum calcium levels, which may actually decrease due to reduced bone breakdown.
The nurse is planning a staff development conference regarding contractures. Which of the following information should the nurse include? Select all that apply.
- A. Range-of-motion exercises of the extremities help prevent contractures.
- B. Splinting the extremities may increase the risk of contractures.
- C. Too many pillows under the head may cause a neck flexion contracture.
- D. Using multiple staff members to reposition a client may prevent a contracture.
- E. Contractures after a hip arthroplasty can be prevented with an abduction pillow.
Correct Answer: A, C, E
Rationale: Range-of-motion exercises maintain joint flexibility and help prevent contractures. Too many pillows under the head can cause the neck to remain flexed, increasing the risk of a flexion contracture. An abduction pillow keeps the legs properly aligned and prevents adduction contractures after hip surgery.
The following scenario applies to the next 1 items
Item 1 of 1
History and Physical
17-year-old male arrives at the emergency department following playing baseball. He slid into a base, felt a ‘pop’, and had pain in his right ankle. The client reports pain of 7 out of 10 in his right ankle, which is described as throbbing. Right pedal pulse was 2+, and the sensation was intact. The client had a limited and painful range of motion in his ankle. Significant swelling and bruising in the ankle were observed.
The client does not have a medical or surgical history. He takes no medications.
Diagnostic Results
X-Ray: bimalleolar fracture of the right ankle
Orders
Crutches
Non-weight bearing status
Apply a splint to the ankle
Acetaminophen-Oxycodone 5/325 mg PO
While teaching the client how to use crutches, the nurse should instruct the client to ambulate using the
- A. Two-point gait
- B. Three-point gait
- C. Four-point gait
- D. Ankle having to be splinted.
- E. Non-weight bearing status.
- F. Prescribed pain medication.
Correct Answer: B
Rationale: A three-point gait is appropriate for non-weight bearing status, as with a splinted bimalleolar fracture, allowing the client to keep weight off the injured ankle using crutches and the unaffected leg.
The following scenario applies to the next 1 items
The nurse cares for a client who sustained a femur fracture twelve hours ago
Item 1 of 1
Nurses’ Notes
Client reports shortness of breath and stated, ‘something is not right.’ The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air. Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.
The client is demonstrating signs and symptoms of
- A. Pulmonary embolism
- B. Myocardial infarction
- C. Fat embolism syndrome
- D. Compartment syndrome
Correct Answer: C
Rationale: Fat embolism syndrome is likely after a femur fracture, with symptoms like shortness of breath, bilateral crackles, chest pain, and petechiae on the torso. Pulmonary embolism and myocardial infarction are less directly tied to fractures, and compartment syndrome affects the limb.