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The nurse is caring for the client who had a surgical repair of a right Dupuytren's contracture. Which intervention should the nurse plan?
- A. Elevate the right lower extremity above the level of the heart
- B. Assist the client with bathing, dressing, grooming, and toileting
- C. Instruct about wearing low-heeled and properly fitting shoes
- D. Frequently rewrap the elastic bandage on the right extremity
Correct Answer: B
Rationale: B. Independent self-care is impaired for a few days after surgery because the hand is bandaged. The nurse should plan that the client receive assistance with personal care and ADLs.
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After the arm cast has been applied, which nursing observation is the best indication that the client may be developing compartment syndrome?
- A. The client's head becomes severe pain.
- B. The client's hand becomes reddened.
- C. The fingers develop muscle spasms.
- D. The radial pulse feels bounding.
Correct Answer: A
Rationale: Severe pain disproportionate to the injury is a hallmark of compartment syndrome, indicating increased pressure within the cast compromising neurovascular status. Redness, spasms, or a bounding pulse are less specific.
The client is about to go to surgery but is still wearing a class ring. Which nursing action is most appropriate regarding care of the client's valuables?
- A. Put the ring in the bedside stand.
- B. Tape the ring to the client's finger.
- C. Give the ring to a security guard.
- D. Take the ring to the hospital safe.
Correct Answer: D
Rationale: Valuables like a ring should be secured in the hospital safe to prevent loss or theft during surgery. Leaving it in the bedside stand is insecure, taping it risks circulation issues, and giving it to a security guard is not standard protocol.
The nurse is preparing to teach the family of an infant with developmental dysplasia of the hip how to apply the Pavlik harness illustrated that has white velcro straps. Place the steps for applying the Pavlik harness in the correct sequence.
- A. Connect the chest halter and leg straps in front.
- B. Position the legs and feet in the stirrups.
- C. Connect the chest halter and leg straps in back.
- D. Position the chest halter at nipple line and fasten with Velcro.
- E. Be sure the hips are flexed and abducted before fastening with Velcro.
Correct Answer: D,B,E,A,C
Rationale: The correct sequence ensures proper positioning and secure application of the Pavlik harness.
The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately?
- A. Localized edema and discoloration occurring hours after the injury.
- B. Generalized weakness and increasing sensitivity to touch.
- C. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain.
- D. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic.
Correct Answer: C
Rationale: Absent pulses and increasing pain suggest compartment syndrome or arterial occlusion, requiring urgent HCP notification. Edema is expected, weakness is nonspecific, and pain relief is positive.
Which description by the nurse most accurately states the purpose of halo-cervical traction?
- A. It restricts neck movement but enables physical activity.
- B. It allows head movement while immobilizing the spine.
- C. It accelerates healing by facilitating physical therapy.
- D. It promotes faster bone repair within a shorter time span.
Correct Answer: A
Rationale: Halo-cervical traction immobilizes the cervical spine to promote healing while allowing some physical activity (e.g., walking), unlike other options that inaccurately describe its function.