Nokea
The nurse is developing a care plan for a client following a lumbar laminectomy. The nurse should plan to
- A. Log roll the client.
- B. Apply a cervical collar.
- C. Place an overhead trapeze on the bed.
- D. Keep the client in high-Fowler's position while in bed.
Correct Answer: A
Rationale: Log rolling maintains spinal alignment and prevents strain after a lumbar laminectomy. A cervical collar is for neck injuries, a trapeze aids mobility but isn't primary, and high-Fowler's position may stress the surgical site.
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The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 6 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Orders
2100:
Magnetic resonance imaging of the right foot without contrast
Insert peripheral vascular access device
Laboratory tests: blood culture and sensitivity (C & S), complete blood count (CBC), complete metabolic panel (CMP), lactic acid
vancomycin 1 g, IV, every 12 hours
Wound culture
fentanyl 50 mcg IV, every 5 hours PRN pain
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
Nurses' Notes
2110: Orders received and reviewed. Vital signs: T 103° F (39.4° C), P 92, RR 18, BP 141/87, pulse oximetry reading 98% on room air. Client reports pain '8' on the Numerical Pain Scale.
For each of the statements made by the client, click to specify whether the statement indicates an understanding or requires follow-up of the discharge teaching provided.
- A. I should wash my feet daily with warm water and mild soap, then dry thoroughly, especially between the toes.'
- B. I should inspect my feet bi-weekly for any injuries.'
- C. I should use a corn/callus remover on my feet.'
- D. I should wear compression socks with well-fitting shoes.'
- E. Controlling my blood sugar levels can help reduce my risk of developing foot complications.'
Correct Answer: A: Indicated, B: Follow-up, C: Follow-up, D: Indicated, E: Indicated
Rationale: A: Proper foot hygiene prevents infection. B: Daily, not bi-weekly, inspection is needed with diabetes. C: Corn/callous removers risk skin breakdown. D: Compression socks and good shoes aid circulation. E: Blood sugar control reduces complication risk.
The nurse is caring for a client with a newly applied plaster cast. The nurse should
- A. Use a small object like a pencil or ruler to itch the leg if it becomes uncomfortable.
- B. Expedite drying by using a hot blow dryer on the cast.
- C. Let the cast hang below the heart to promote blood flow.
- D. Handle the cast with the palms of the hands.
Correct Answer: D
Rationale: Handling a wet plaster cast with the palms prevents denting, which could cause pressure points. Scratching inside risks skin damage, hot dryers can burn, and a dependent position increases swelling.
The nurse performs a focused assessment on a casted patient experiencing increased pain in the affected limb. The nurse notes pallor and swelling distal to the cast area. The patient reports increased pain upon passively moving the extremity. Which of the following fracture-related complications should the nurse be concerned about?
- A. Fat embolism
- B. Infection
- C. Pulmonary embolism
- D. Compartment syndrome
Correct Answer: D
Rationale: Pallor, swelling, and increased pain with passive movement are classic signs of compartment syndrome, a serious complication from pressure buildup in a casted limb. Fat and pulmonary embolisms involve systemic symptoms, and infection typically includes fever.
The nurse educates a client about the application of a plaster cast to a fractured radius. Which of the following statements by the client would require follow-up?
- A. If my arm feels itchy, I can use a hair dryer on the cool setting for relief.'
- B. I can reduce my arm's swelling by elevating it with a pillow.'
- C. I should be okay to shower with my cast.'
- D. It will be normal for me to feel heat after the cast is applied.'
Correct Answer: C
Rationale: Showering with a plaster cast risks wetting it, leading to breakdown or infection, requiring follow-up. Cool air for itching, elevation for swelling, and initial heat from cast setting are appropriate.
The nurse is caring for a client who is bedbound. Which intervention should the nurse implement to reduce this client's risk of developing contractures?
- A. Apply sequential compression devices to the lower extremities
- B. Perform passive range of motion exercises
- C. Obtain a specialty low-air loss mattress
- D. Turn the client every two hours
Correct Answer: B
Rationale: Passive range of motion exercises maintain joint mobility and prevent contractures in bedbound clients. Compression devices prevent clots, mattresses reduce pressure ulcers, and turning aids skin but not primarily joints.