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The nurse is caring for the client 2 days post-right THR in which the traditional posterior approach was used. Which interventions should the nurse implement?
- A. Checks that an elevated toilet seat is in place and assists the client to the bathroom using a walker
- B. Removes the wedge pillow at the client's request and places pillows to maintain right leg adduction
- C. Reinfuses the 400-mL wound autotransfusion drainage system returns that collected in the past 24 hours
- D. Assists the client to get out of bed on the left side so the client can stand to place and use the urinal
Correct Answer: A
Rationale: A. The client should be able to ambulate with the use of a walker. An elevated toilet seat is used to prevent hip flexion of greater than 90 degrees when the client sits.
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On the basis of the nurse's knowledge of the client's culture and beliefs, which statement regarding the health-seeking behavior is probably most accurate?
- A. Home remedies have been unsuccessful, and the condition threatens the client's self-image.
- B. The power to cure comes from physicians and is passed to nurses.
- C. The client waited for symptoms to resolve spontaneously.
- D. The client sought care due to family encouragement.
Correct Answer: A
Rationale: Hispanic clients may try home remedies first, seeking care when self-image is impacted.
Which is the nurse's best explanation regarding the goal of surgery for an adolescent requiring surgical treatment for scoliosis?
- A. "The surgery will allow you to grow to be taller."
- B. "The surgery will decrease the recurrence of pain."
- C. "The surgery will prevent problems with breathing."
- D. "The surgery will allow your clothes to fit you better."
Correct Answer: C
Rationale: Scoliosis surgery aims to correct spinal deformity and prevent respiratory complications.
The client diagnosed with osteoporosis asks the nurse, 'Why does smoking cigarettes cause my bones to be brittle?' Which response by the nurse is most appropriate?
- A. Smoking causes nutritional deficiencies, which contribute to osteoporosis.'
- B. Tobacco causes an increase in blood supply to the bones, causing osteoporosis.'
- C. Smoking low-tar cigarettes will not cause your bones to become brittle.'
- D. Nicotine impairs the absorption of calcium, causing decreased bone strength.'
Correct Answer: D
Rationale: Nicotine reduces calcium absorption, contributing to bone loss in osteoporosis. Nutritional deficiencies are secondary, blood supply does not increase, and low-tar cigarettes still harm bones.
The client with rheumatoid arthritis is to receive prednisone 2.5 mg P.D. before meals and at bedtime. What is the primary expected action of the drug?
- A. Maintenance of sodium and potassium balance
- B. Improvement of carbohydrate metabolism
- C. Production of androgen-like effects
- D. Interference with inflammatory reactions
Correct Answer: D
Rationale: Prednisone's primary action in rheumatoid arthritis is to interfere with inflammatory reactions, reducing joint inflammation.
The nurse is reviewing the serum laboratory results of the client with DM prior to surgical removal of pins used to stabilize a compound ankle fracture. Based on the results, which action should the nurse take?
- A. Notify the surgeon because the white blood cell count is elevated.
- B. Notify the anesthesiologist because multiple lab values are abnormal.
- C. Give potassium chloride 10 mEq in 100 mL NaCl per agency protocol.
- D. Continue to prepare the client for the scheduled pin removal surgery.
Correct Answer: A
Rationale: A. The elevated WBC indicates that the client may have an infection, which increases the risk of developing osteomyelitis. DM and a compound fracture also increase the client's risk for osteomyelitis.