Nokea
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.
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The client is an elderly man who has had diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation?
- A. Encouraging deep breathing
- B. Asking him if he understands the full effects of the planned surgery
- C. Discussing the effects of diabetes on the vascular system
- D. Having a recovered amputee visit him
Correct Answer: D
Rationale: A visit from a recovered amputee provides peer support, helping the client adjust by seeing a positive outcome.
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.
The nurse gently elevates the client's newly casted arm on a pillow and explains that this is necessary for the first 24 to 48 hours after casting. What is the chief purpose of this action?
- A. It helps a damp cast to dry more evenly.
- B. It reduces the amount of pain medication needed.
- C. Venous return is enhanced, and edema is decreased.
- D. It is more comfortable than keeping the arm dependent.
Correct Answer: C
Rationale: Elevation enhances venous return and reduces edema, the primary reason for this action. It does not directly affect cast drying, pain medication needs, or comfort alone.
Later the client says, 'I know my arm isn't there, but I feel it throbbing.' Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is a common sensation of pain in the amputated limb due to nerve endings firing, accurately describing the client's experience. The other options misattribute the cause.
The nurse is discussing the importance of an exercise program for pain control to a client diagnosed with OA. Which intervention should the nurse include in the teaching?
- A. Wear supportive tennis shoes with white socks when walking.
- B. Carry a complex carbohydrate while exercising.
- C. Alternate walking briskly and jogging when exercising.
- D. Walk at least 30 minutes three (3) times a week.
Correct Answer: D
Rationale: Walking 30 minutes thrice weekly reduces OA pain and stiffness through low-impact exercise. Supportive shoes are helpful but secondary, carbohydrates are irrelevant, and jogging may worsen OA.