Nokea
The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify?
- A. Risk for ineffective coping related to the inability to perform ADLs.
- B. Risk for compartment syndrome-related injured muscle tissue.
- C. Risk for infection related to exposed bone and tissue.
- D. Risk for complications related to compromised neurovascular status.
Correct Answer: B
Rationale: Compartment syndrome is a critical risk in closed fractures due to swelling, threatening limb viability. Coping, infection (more for open fractures), and general complications are secondary.
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The emergency department nurse is caring for a client with a compound fracture of the right ulna. Which interventions should the nurse implement? List in order of priority.
- A. Apply a sterile, normal saline-soaked gauze to the arm.
- B. Send the client to radiology for an x-ray of the arm.
- C. Assess the fingers of the client’s right hand.
- D. Stabilize the arm at the wrist and the elbow.
- E. Administer a tetanus toxoid injection.
Correct Answer: C,A,D,B,E
Rationale: Priority: 1) Assess fingers (neurovascular status); 2) Cover wound with sterile gauze (prevent infection); 3) Stabilize arm (reduce damage); 4) X-ray (confirm fracture); 5) Tetanus (prevent infection).
The nurse is caring for the client after a right TKR. To prevent circulatory complications, the nurse should ensure that the client is performing which action?
- A. Flexing both feet and exercising uninvolved joints every hour while awake
- B. Using the continuous passive motion device (CPM) every 2 hours for 30 minutes
- C. Being assisted up to a chair as soon as the effects of anesthesia have worn off
- D. Using the trapeze to lift off the bed and then rotating each leg intermittently
Correct Answer: A
Rationale: A. Dorsiflexion of the foot promotes muscle contraction, which compresses veins. This reduces venous stasis and risk of thrombus formation. It should be performed every hour while awake.
Which client symptom indicates that the nurse should discontinue the medication and notify the physician even if the client's pain is unrelieved?
- A. Vomiting
- B. Dizziness
- C. Drowsiness
- D. Headache
Correct Answer: A
Rationale: Vomiting is a sign of colchicine toxicity, requiring immediate discontinuation and physician notification, as it can precede serious complications like bone marrow suppression. Other symptoms are less urgent.
The nurse is caring for a client in a hip spica cast. Which intervention should the nurse include in the plan of care?
- A. Assess the client’s popliteal pulses every shift.
- B. Elevate the leg on pillows and apply ice packs.
- C. Teach the client how to ambulate with a tripod walker.
- D. Assess the client for distention and vomiting.
Correct Answer: D
Rationale: Distention and vomiting indicate GI complications (e.g., ileus) in a hip spica cast, requiring assessment. Pulses are accessible, elevation is impractical, and ambulation is limited.
When planning the client's discharge, the nurse must help the client obtain which essential piece of equipment for home care?
- A. A wheelchair
- B. A hospital bed
- C. A raised toilet seat
- D. A mechanical lift
Correct Answer: C
Rationale: A raised toilet seat prevents excessive hip flexion, reducing dislocation risk.