Nokea
The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP order should the nurse question?
- A. Maintain heparin to achieve a therapeutic level.
- B. Initiate and monitor intravenous fluids.
- C. Keep the O2 saturation higher than 93%
- D. Administer an intravenous loop diuretic.
Correct Answer: D
Rationale: Loop diuretics are inappropriate for fat embolism syndrome, as they may worsen hypovolemia. Heparin, fluids, and oxygen saturation are standard treatments.
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The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA?
- A. I take medication every two (2) hours for my pain.'
- B. I use a heating pad when I go to bed at night.'
- C. I wear a copper bracelet to help with my OA.'
- D. I always wear my ankle splints when I sleep.'
Correct Answer: C
Rationale: Copper bracelets are an alternative therapy for OA, believed to reduce symptoms. Pain medication and heating pads are conventional, and splints are for support, not alternative.
Which activity is best to begin implementing immediately after the client's surgery?
- A. Standing at the side of the bed
- B. Balancing between parallel bars
- C. Lifting oneself with the trapeze
- D. Transferring from the bed to a chair
Correct Answer: C
Rationale: Lifting with a trapeze strengthens upper body muscles safely immediately post-surgery, preparing for crutch use without stressing the stump. Other activities are more advanced.
The nurse is discharging a client who had a total hip replacement. Which statement indicates further teaching is needed?
- A. I should not cross my legs because my hip may come out of the socket.'
- B. I will call my HCP if I have a sudden increase in pain.'
- C. I will sit on a chair with arms and a firm seat.'
- D. After three (3) weeks, I don’t have to worry about infection.'
Correct Answer: D
Rationale: Infection risk persists beyond 3 weeks post-THR; this statement requires correction. Avoiding leg crossing, reporting pain, and proper seating are correct.
Which assessment finding most likely indicates that a client has osteoporosis?
- A. Swollen joints
- B. Discomfort when sitting
- C. Spinal deformity
- D. Diminished energy level
Correct Answer: C
Rationale: Spinal deformity, such as kyphosis, is a common sign of osteoporosis due to vertebral compression fractures from reduced bone density. Swollen joints, discomfort, or low energy are less specific.
The client diagnosed with cervical disk degeneration has undergone a laminectomy. Which interventions should the nurse implement?
- A. Position the client prone with the knees slightly elevated.
- B. Assess the client for difficulty speaking or breathing.
- C. Measure the drainage in the Jackson Pratt bulb every day.
- D. Encourage the client to postpone the use of narcotic medications.
Correct Answer: B
Rationale: Cervical laminectomy risks airway or neurological complications; assessing speech and breathing is critical. Prone positioning is inappropriate, JP drainage is routine, and delaying narcotics is unsafe.