Nokea
The nurse is planning an educational session related to foot problems at a local senior's club. Which of the following information should the nurse include in the session related to why the older adult is prone to developing foot problems? (Select all that apply.)
- A. Poor circulation
- B. Inactivity
- C. Decreased lower extremity sensation
- D. Poor foot hygiene
- E. Atherosclerosis
Correct Answer: A,C,E
Rationale: The older adult is prone to developing foot problems because of poor circulation, atherosclerosis, and decreased sensation in the lower extremities. Inactivity and foot hygiene are personal choices and are not age-related changes.
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The nurse is caring for a patient who has had a surgical reduction of an open fracture of the left tibia. Which of the following assessment findings is most important to report to the health care provider?
- A. Left leg muscle spasms
- B. Serious wound drainage
- C. Left leg pain with movement
- D. Temperature 38.6°C (101.5°F)
Correct Answer: D
Rationale: An elevated temperature is suggestive of possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.
The nurse is assessing a patient in the foot clinic who has severe heel pain. Which of the following foot disorders should the nurse assess for?
- A. Hallux rigidus
- B. Morton's neuroma
- C. Pes cavus
- D. Plantar fasciitis
Correct Answer: D
Rationale: Complaints of severe heel pain will alert the nurse to assess for plantar bursitis, plantar fasciitis, or bone spur in adult. Hallux rigidus, pes cavus, and Morton's neuroma do not have the symptom of severe heel pain.
The nurse is caring for a patient who underwent a laminectomy and discectomy for a herniated intervertebral disc. Following the surgery, which of the following actions should the nurse implement when positioning the patient on their side?
- A. Instruct the patient to move their legs before turning the rest of the body.
- B. Have the patient turn by grasping the side rails and pulling the shoulders over.
- C. Place a pillow between the patient's legs and turn the entire body as a unit.
- D. Turn the patient's head and shoulders first, followed by the hips, legs, and feet.
Correct Answer: C
Rationale: The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.
The nurse is caring for a patient who has acute osteomyelitis and is receiving tobramycin 80 mg IV twice daily. Which of the following actions should the nurse take before administering the gentamicin?
- A. Ask the patient about any nausea.
- B. Obtain the patient's oral temperature.
- C. Change the prescribed wet-to-dry dressing.
- D. Review the patient's blood urea nitrogen (BUN) and creatinine levels.
Correct Answer: D
Rationale: Gentamicin is nephrotoxic and can cause renal failure. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common adverse effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.
The nurse is caring for a patient following a laminectomy with a spinal fusion who reports numbness and tingling of the right lower leg. Which of the following actions should the nurse do first?
- A. Report the patient's symptoms to the surgeon.
- B. Check the vital signs for indications of hemorrhage.
- C. Turn the patient to the side to relieve pressure on the right leg.
- D. Document the findings and reassess the patient in two hours.
Correct Answer: A
Rationale: Numbness and tingling should be immediately reported to the surgeon rather than documented and rechecked in two hours. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness.