Nokea
The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention?
- A. The client’s hemoglobin is 8.1 g/dL.
- B. The client’s white blood cell count is 9,000/mm3.
- C. The client’s creatinine level is 0.8 mg/dL.
- D. The client’s potassium level is 4.2 mEq/L.
Correct Answer: A
Rationale: Hemoglobin of 8.1 g/dL indicates significant blood loss, requiring urgent intervention post-shoulder replacement. Other values are normal.
You may also like to solve these questions
What is the purpose of the continuous passive motion (CPM) machine that the nurse should explain while teaching the client?
- A. A CPM machine is used to strengthen the leg muscles.
- B. A CPM machine is used to relieve foot swelling.
- C. A CPM machine is used to reduce surgical pain.
- D. A CPM machine is used to restore joint function.
Correct Answer: D
Rationale: CPM promotes joint mobility and prevents stiffness post-arthroplasty.
What interventions should the nurse implement for a child who sustained a twisting injury of the right arm?
- A. Elevate the arm and apply ice at the site of the child's injury.
- B. Wrap the child's arm with an elastic bandage.
- C. Telephone the child's parent to discuss the injury.
- D. Call the health care provider identified by the child.
- E. Make arrangements to obtain an x-ray of the child's arm.
- F. Meet with the student who caused the child's injury.
Correct Answer: A,B,C
Rationale: Elevation, ice, and wrapping reduce swelling; contacting the parent ensures proper follow-up.
Which of the following would the nurse identify as the highest priority when documenting the postoperative circulation status of the recently casted extremity?
- A. Adequate neurovascular functioning
- B. Minimal pain on movement
- C. Vital signs within normal limits
- D. No drainage noted on the cast
Correct Answer: A
Rationale: Adequate neurovascular functioning (circulation, sensation, and movement) is the highest priority to ensure no complications like compartment syndrome or vascular compromise, which can lead to tissue damage. Pain, vital signs, and drainage are secondary.
In which conditions might the nurse assess for the presence of papilledema?
- A. Eczema
- B. Craniosynostosis
- C. Shaken baby syndrome
- D. Hydrocephalus
- E. Chest trauma
Correct Answer: B,C,D
Rationale: Papilledema, indicating increased intracranial pressure, can be associated with craniosynostosis, shaken baby syndrome, and hydrocephalus.
The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
- A. Help the client with a two (2)-day postop amputation put on the prosthesis.
- B. Request the UAP double-check a unit of blood to be hung.
- C. Change the surgical dressing on the client with a Syme's amputation.
- D. Ask the UAP to take the client to the physical therapy department.
Correct Answer: D
Rationale: Transporting a client to PT is within UAP scope. Prosthesis application, blood verification, and dressing changes require nursing judgment.