Nokea
The nurse is caring for the client who has had a total hip replacement. Which data indicate the surgical treatment is effective?
- A. The client states the pain is at a '3' on a 1-to-10 scale.
- B. The client has a limited ability to ambulate.
- C. The client's left leg is shorter than the right leg.
- D. The client ambulates to the bathroom.
Correct Answer: D
Rationale: Ambulating to the bathroom indicates effective THR, restoring mobility. Mild pain is expected, limited ambulation is negative, and leg length discrepancy is a complication.
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Which most immediate treatment by the HCP should the nurse anticipate for a child with a dislocated kneecap?
- A. Open surgical intervention to repair the kneecap
- B. Arthroscopy to surgically repair the torn cartilage
- C. Realignment of the kneecap by sliding it back into position
- D. Application of a cast to the affected leg until the kneecap heals
Correct Answer: C
Rationale: Immediate treatment for a dislocated kneecap involves manual realignment to restore position.
The client just underwent a left THR. After a family member assists the client with repositioning in bed, the client states hearing a 'pop' and has increased pain at the surgical site. Which is the most appropriate initial action by the nurse?
- A. Check the position of the left lower extremity.
- B. Elevate the head of the client's bed.
- C. Adjust the pillow used for abduction.
- D. Administer the prescribed pain medication.
Correct Answer: A
Rationale: A. The nurse's initial action should be to check the extremity's position. Improper movement and repositioning can cause prosthesis dislocation; an audible pop and increased pain are signs of possible dislocation.
The nurse is caring for an elderly client diagnosed with a herniated nucleus pulposus of L4-5. Which scientific rationale explains the incidence of a ruptured disk in the elderly?
- A. The client did not use good body mechanics when lifting an object.
- B. There is an increased blood supply to the back as the body ages.
- C. Older clients develop atherosclerotic joint disease as a result of fat deposits.
- D. Clients develop intervertebral disk degeneration as they age.
Correct Answer: D
Rationale: Intervertebral disk degeneration with aging reduces disk hydration and elasticity, increasing rupture risk. Poor body mechanics is a risk but not the primary cause, blood supply decreases, and atherosclerosis affects joints differently.
After assessing the client's cast, what action should the nurse take next?
- A. Document the finding in the medical record.
- B. Call the physician and report the finding.
- C. Check the nurse, then record the nurse.
- D. Apply an ice bag over the drainage area.
Correct Answer: B
Rationale: Bloody drainage seeping through a cast suggests potential complications like infection or tissue damage, requiring immediate physician notification for evaluation. Documentation and ice application are secondary, and the third option is unclear.
The client is in Russell's traction. Which statement best describes how Russell's traction works?
- A. The legs are suspended vertically with the hip flexed at 90 degrees and knees extended.
- B. A straight pull on the affected leg is assured.
- C. A belt is applied just above and surrounding the iliac crests. The belt is then attached to a pulley system.
- D. Vertical traction is used at the knee while, at the same time, a horizontal force is exerted on the tibia and fibula.
Correct Answer: D
Rationale: Russell's traction uses vertical traction at the knee and horizontal force on the tibia and fibula to align fractures, unlike the other descriptions.