Nokea
The nurse is preparing a patient who had an above-the-knee amputation for discharge. Which of the following patient statements indicates that the nurse's discharge teaching has been effective?
- A. I should lie on my abdomen for 30 minutes three or four times a day.
- B. I should elevate my residual limb on a pillow two or three times a day.
- C. I should change the limb sock when it becomes soiled or stretched out.
- D. I should use lotion on the stump to prevent drying and cracking of the skin.
Correct Answer: A
Rationale: The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.
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The nurse is providing health-promotion teaching to a patient whose job involves many hours of word processing. Which of the following actions should the nurse include in the patient teaching plan?
- A. Do stretching and warm-up exercises before starting work.
- B. Use a compression bandage to prevent wrist pain.
- C. Take nonsteroidal anti-inflammatory drugs (NSAIDs) for wrist pain.
- D. Obtain a keyboard pad to support the wrist while word processing.
Correct Answer: D
Rationale: Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling but are not a preventive measure.
The nurse is caring for a patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures who indicates constant severe pain in the leg which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which of the following actions should the nurse take next?
- A. Notify the health care provider.
- B. Assess the incision for redness.
- C. Reposition the left leg on pillows.
- D. Check the patient's blood pressure.
Correct Answer: A
Rationale: The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.
The nurse is caring for a patient in the emergency department with repetitive strain injury to the left elbow as a result of his employment as a checkout clerk in the grocery. Which of the following actions should the nurse include in the plan of care?
- A. Surgical options
- B. Elbow injections
- C. Use a wrist splint
- D. Modifications in arm movement
Correct Answer: D
Rationale: Treatment for a repetitive strain injury includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain, not elbow injuries.
The nurse is counseling a patient about ways to prevent fractures. Which of the following information should the nurse include?
- A. Tack down throw rugs in the home.
- B. Most falls happen outside the home.
- C. Buy shoes that provide good support and are comfortable.
- D. Activities of daily living provide range of motion.
Correct Answer: C
Rationale: Comfortable shoes with good support will help decrease the risk for falls. Throw rugs should be eliminated, not just tacked down. Most falls occur inside the home, and activities of daily living do not necessarily provide sufficient range of motion to prevent fractures.
The nurse is planning discharge teaching for a patient who has had a repair of a fractured mandible. Which of the following information will the nurse include in the teaching plan?
- A. When and how to cut the immobilizing wires
- B. Self-administration of nasogastric tube feedings
- C. The use of sterile technique for dressing changes
- D. The importance of including high-fibre foods in the diet
Correct Answer: A
Rationale: The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fibre foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.