Nokea
The nurse is caring for the client following a knee arthroscopy. What information should the nurse teach? Select all that apply.
- A. Elevate the involved extremity on pillows for 24 to 48 hours.
- B. Apply an ice pack continually to the involved joint for 24 hours.
- C. Report severe joint pain immediately to the health care provider.
- D. Resume usual activities to minimize joint stiffness and swelling.
- E. Treat pain with a mild analgesic such as acetaminophen.
Correct Answer: A,C,E
Rationale: A. Elevation will help to decrease edema. C. Severe joint pain may indicate a possible complication and should be reported immediately. E. Usually a mild analgesic such as acetaminophen (Tylenol) is sufficient for pain control following a diagnostic arthroscopy.
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Which risk factor found in the client's medical record does the nurse identify as most significant for sustaining a hip fracture?
- A. The client is postmenopausal.
- B. The client is somewhat obese.
- C. The client has type 2 diabetes.
- D. The client is lactose intolerant.
Correct Answer: A
Rationale: Postmenopausal status is the most significant risk factor for hip fractures due to estrogen loss, which accelerates bone density reduction, increasing fracture risk. Obesity, diabetes, and lactose intolerance are less directly related.
The HCP prescribes cyclobenzaprine 30 mg orally tid for the client hospitalized with acute cervical neck pain. The pharmacy supplied 10-mg tablets. Which action by the nurse is best?
- A. Administer three 10-mg tablets with food
- B. Call the HCP to question the dose prescribed
- C. Observe for drowsiness after administration
- D. Also give prn prescribed morphine sulfate IV
Correct Answer: B
Rationale: B. The nurse should call the HCP to question the dose. If carried out as prescribed, the client would receive a total daily dose of 90 mg of cyclobenzaprine (Flexeril). The total daily dose should not exceed 60 mg.
The nurse knows that elderly women have a high incidence of hip fracture for which reason?
- A. Decreased progesterone secretion
- B. Decreased mobility due to arthritic conditions
- C. Increased calcium absorption
- D. Osteoporosis in the skeletal structure
Correct Answer: D
Rationale: Osteoporosis, common in elderly women, weakens bones, increasing hip fracture risk.
Which material added by the nurse is best for covering the tips of the pin to prevent injuries while the client is in skeletal leg.
- A. Gauze squares
- B. Cotton balls
- C. Cork blocks
- D. Rubber tubes
Correct Answer: C
Rationale: Cork blocks securely cover pin tips, preventing injury to the client or staff while maintaining stability. Gauze and cotton are less durable, and rubber tubes may not fit securely.
Which interventions are appropriate for an adolescent experiencing a seizure?
- A. A tongue blade inserted into the adolescent's mouth during a seizure can cause injury.
- B. Padding protects the adolescent's limbs from injury against the hard side rails during a seizure.
- C. Airway obstruction can occur during or after the seizure. An oropharyngeal airway should be available but should not be inserted during the seizure. If the seizure has commenced, nothing should be forced into the adolescent's mouth.
- D. The etiology is unknown. Only if an airborne or droplet infectious disease were suspected as the cause would droplet precautions be considered.
- E. Suctioning equipment may be needed to clear secretions after the seizure.
Correct Answer: B,C,E
Rationale: Padding protects limbs from injury, an oropharyngeal airway should be available but not inserted during a seizure, and suctioning equipment may be needed post-seizure to clear secretions.