Nokea
The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first?
- A. The client with a total knee replacement who is complaining of a cold foot.
- B. The client diagnosed with osteoarthritis who is complaining of stiff joints.
- C. The client who needs to receive a scheduled intravenous antibiotic.
- D. The client diagnosed with back pain who is scheduled for a lumbar myelogram.
Correct Answer: A
Rationale: A cold foot post-knee replacement suggests vascular compromise, requiring urgent assessment to prevent tissue damage. Stiff joints, antibiotics, and myelogram prep are lower priority.
You may also like to solve these questions
The nurse knows that elevated findings on which laboratory test typically validate a diagnosis of gout?
- A. Creatinine clearance
- B. Blood urea nitrogen
- C. Serum uric acid
- D. Serum calcium
Correct Answer: C
Rationale: Elevated serum uric acid levels confirm gout, as they reflect the hyperuricemia leading to crystal formation in joints. Other tests are not specific to gout diagnosis.
Which return demonstration indicates that the client has understood the correct way to ambulate with the walker?
- A. The client advances the walker and operative leg while putting most of the weight on the walker's handgrips.
- B. The client advances the walker and operative leg while putting most of the weight on the back legs of the walker.
- C. The client advances the walker and operative leg while putting most of the weight on the toes of the operative leg.
- D. The client advances the walker and operative leg while putting most of the weight on the heel of the nonoperative leg.
Correct Answer: D
Rationale: In a three-point partial weight-bearing gait, the client advances the walker and operative leg together, placing most weight on the nonoperative leg's heel to minimize stress on the operative hip, ensuring stability and safety.
Which diagnostic test result should the nurse monitor when assessing for evidence of metastasis?
- A. Lung scan
- B. Urinalysis
- C. Spinal tap
- D. Blood glucose
Correct Answer: A
Rationale: A lung scan can detect metastasis of a skeletal tumor to the lungs, a common site for bone cancer spread. Urinalysis, spinal tap, and blood glucose are less relevant for metastasis.
Which explanation most accurately explains to the client the primary purpose of the splints?
- A. Splints are used to slow joint deterioration.
- B. Splints are used to improve hand strength.
- C. Splints are used to increase range of motion.
- D. None of the above
Correct Answer: A
Rationale: Splints in rheumatoid arthritis are used to rest joints, reducing inflammation and slowing joint deterioration during acute episodes. They do not primarily strengthen hands or increase motion.
Which statement by the nurse about fiberglass casts is most accurate?
- A. Fiberglass casts are less expensive than plaster
- B. Fiberglass casts are lightweight.
- C. Fiberglass casts are flexible.
- D. Fiberglass casts are less restrictive than plaster casts.
Correct Answer: B
Rationale: Fiberglass casts are lightweight compared to plaster, making them more comfortable for clients. They are not necessarily less expensive, flexible, or less restrictive, as both types immobilize effectively.