Nokea
The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first?
- A. Notify the client's surgeon immediately.
- B. Assess the client's blood pressure and pulse.
- C. Reinforce the dressing with additional dressing.
- D. Check the client's last hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: Reinforcing the dressing controls bleeding, the priority in hemorrhage. Notifying the surgeon, assessing vitals, and checking labs are secondary.
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Which statement reflects the most widely recognized theory for the use of transcutaneous electric nerve stimulation (TENS)?
- A. The sensation created by the TENS unit blocks the brain's perception of pain impulses.
- B. The sensation created by the TENS unit travels to the nerve root of the injury.
- C. The sensation created by the TENS unit destroys the brain's pain center.
- D. The sensation created by the TENS unit weakens nociceptor sensory nerves.
Correct Answer: A
Rationale: The gate control theory posits that TENS blocks pain impulses by stimulating non-pain sensory nerves, reducing the brain's perception of pain from the injured area.
The nurse notes during an annual health screening for the 78-year-old client that the client is 1.5 inches shorter than at last year's visit. Which initial screening might the nurse best anticipate for this client?
- A. Bone mineral density (BMD) test
- B. An x-ray of both hips and spine
- C. A bone scan of the hips and spine
- D. A physical check for scoliosis
Correct Answer: A
Rationale: A. BMD testing will best determine if the loss of height is due to osteoporosis, a common finding with aging.
The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement?
- A. Monitor the continuous passive motion machine.
- B. Apply thigh-high TED hose bilaterally.
- C. Place the abductor pillow between the legs.
- D. Encourage the family to perform ADLs for the client.
Correct Answer: A
Rationale: Monitoring the CPM machine ensures proper knee flexion/extension post-TKR. TED hose are standard, abductor pillows are for THR, and family ADL performance hinders independence.
Which instruction should the nurse include when reinforcing teaching with the parents about safety considerations for a child with a surgically corrected myelomeningocele?
- A. Make sure braces lie smoothly against the child's skin.
- B. Ensure that the child shifts position at least every 3 hours.
- C. Place a blanket between the child and the wheelchair seat.
- D. Check all of the child's skin daily for redness or irritation.
Correct Answer: D
Rationale: Daily skin checks are essential to prevent pressure ulcers and other skin complications in children with myelomeningocele.
The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis?
- A. X-ray of the femur.
- B. Serum alkaline phosphatase.
- C. Dual-energy x-ray absorptiometry (DEXA).
- D. Serum bone Gla-protein test.
Correct Answer: C
Rationale: DEXA is the gold standard for osteoporosis diagnosis, measuring bone mineral density. X-rays detect fractures, alkaline phosphatase is nonspecific, and bone Gla-protein is not diagnostic.