Nokea
The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client?
- A. The client will maintain function of the leg.
- B. The client will ambulate with assistance.
- C. The client will be turned every two (2) hours.
- D. The client will have no infection.
Correct Answer: A
Rationale: Maintaining leg function is the primary goal for fracture recovery. Ambulation, turning, and infection prevention are interventions, not outcomes.
You may also like to solve these questions
Which assessment findings should the nurse associate with the development of hydrocephalus in a 7-year-old child?
- A. Headache
- B. Vomiting
- C. Angioedema
- D. Personality change
- E. Increased head circumference
Correct Answer: A,B,D
Rationale: Headache, vomiting, and personality changes are common symptoms of hydrocephalus due to increased intracranial pressure.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate (Rheumatrex) therapy?
- A. Constipation
- B. Arrhythmia
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores (stomatitis) are a common adverse effect of methotrexate due to its impact on rapidly dividing cells, like those in the oral mucosa. The other symptoms are less commonly associated.
The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client?
- A. Have you made any special arrangements for your amputated limb?'
- B. What types of food would you like to eat while you're in the hospital?'
- C. Would you like a rabbi to visit you while you are in the recovery room?'
- D. Will you start checking your other foot at least once a day for cuts?'
Correct Answer: A
Rationale: Jewish cultural practices may require special handling of amputated limbs (e.g., burial); this question respects beliefs. Food, rabbi visits, and foot checks are secondary.
The nurse is assessing the client 3 months following a left shoulder arthroplasty. Which assessment findings should prompt the nurse to consider that the client may have developed osteomyelitis? Select all that apply.
- A. Sudden onset of chills
- B. Temperature 103°F (39.4°C)
- C. Sudden onset of bradycardia
- D. Pulsating shoulder pain that is worsening
- E. Painful, swollen area on the left shoulder
Correct Answer: A,B,D,E
Rationale: A. A sudden onset of chills suggests the infection of osteomyelitis is blood-borne. B. A high fever suggests the infection of osteomyelitis is blood-borne. D. The pulsating shoulder pain is caused from the pressure of the collecting pus. E. The infected area becomes swollen, painful, and extremely tender.
What should the nurse do after noting serosanguineous drainage on the cast of a child with myelodysplasia post-TEV repair?
- A. Cut a window where the drainage is seeping through the cast.
- B. Petal the cast to minimize skin irritation and decrease leakage.
- C. Measure the area of drainage on the cast and document this.
- D. Telephone the surgeon to report the serosanguineous drainage.
Correct Answer: C
Rationale: Measuring and documenting the drainage allows monitoring without compromising the cast's integrity.