Nokea
The nurse is caring for a client who sustained a fractured tibia and fibula and has a cast applied to the extremity. Which of the following findings would indicate the client has developed compartment syndrome?
- A. The development of petechiae over the chest
- B. A new onset of dyspnea and chest pain
- C. Severe pain that is unrelieved by an opioid analgesic
- D. Localized bone pain with a fever
Correct Answer: C
Rationale: Severe, unrelieved pain is a hallmark of compartment syndrome, caused by increased pressure within a muscle compartment compromising circulation and nerve function. Petechiae and dyspnea suggest fat embolism, and bone pain with fever may indicate infection.
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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 41-year-old female in the outpatient clinic
Item 1 of 1
• Progress Note
1300:
• Client presenting for the initial dose of etanercept following the diagnosis of rheumatoid arthritis.
• The client reported joint pain in the hands not improving with acetaminophen.
• Will prescribe better pain control and follow up in six weeks.
• Physician Orders
• Etanercept 50 mg SubQ every week
• Naproxen 500 mg PO Daily, as needed for pain
The nurse prepares to administer the prescribed etanercept.Complete the sentences below by selecting the appropriate option:The nurse should instruct the client that the prescribed etanercept
--------------------------Prior to the first dose, the nurse should ensure the client has had a----------------------After administering the medication, the nurse should----------------------
- A. raises the blood glucose
- B. increases the risk for infection
- C. causes weight gain.
- D. fasting blood glucose
- E. negative purified protein derivative (PPD) test
- F. baseline lipid panel.
- G. assess for an injection site reaction.
Correct Answer: B,E,G
Rationale: Etanercept is a tumor necrosis factor (TNF) blocking agent used to treat autoimmune disorders such as psoriasis or rheumatoid arthritis (RA). This medication increases the client's risk of infection, requiring baseline testing for TB, such as a PPD. If the client has latent TB, it may be activated again. Etanercept does not cause weight gain or raise blood glucose. This would be true if the client were prescribed a corticosteroid which may be used in exacerbations of RA. A lipid panel has no relevance to etanercept. Etanercept is administered subcutaneously at a 45 to a 90-degree angle. This medication is not administered in the deltoid; this would be appropriate for an intramuscular injection. Aspiration for subcutaneous injections is unnecessary as piercing a blood vessel is rare. The most common adverse effect of this medication is injection site reaction (redness, pain, discomfort). The area should not be rubbed or massaged as it could worsen the injection site reaction.
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.
The nurse has received a prescription for an oral bisphosphonate for a client with osteoporosis. Which finding in the client's medical history would contraindicate the administration of this medication?
- A. diabetes mellitus
- B. hypercalcemia
- C. lactose intolerance
- D. Roux-en-Y gastric bypass
Correct Answer: D
Rationale: Roux-en-Y gastric bypass alters gastrointestinal absorption, reducing the efficacy of oral bisphosphonates and increasing the risk of esophageal or gastric irritation. Diabetes mellitus, hypercalcemia, and lactose intolerance are not absolute contraindications, though hypercalcemia requires monitoring.
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.