Nokea
The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively?
- A. Keep an abduction pillow in place between the legs at all times.
- B. Cough and deep breathe at least every four (4) to five (5) hours.
- C. Turn to both sides every two (2) hours to prevent pressure ulcers.
- D. Sit in a high-seated chair for a flexion of less than 90 degrees.
Correct Answer: A
Rationale: An abduction pillow prevents hip dislocation post-THR, a critical complication. Coughing, turning, and chair positioning are important but secondary.
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The nurse working on a medical-surgical floor feels a pulling in the back when lifting a client up in the bed. Which should be the first action taken by the nurse?
- A. Continue working until the shift is over and then try to sleep on a heating pad.
- B. Go immediately to the emergency department for treatment and muscle relaxants.
- C. Inform the charge nurse and nurse manager on duty and document the occurrence.
- D. See a private health-care provider on the nurse's off time but charge the hospital.
Correct Answer: C
Rationale: Reporting and documenting the injury ensures workplace safety protocols and workers’ compensation processes are followed. Continuing work risks further injury, ED is premature, and private care is secondary.
Which statements made by a parent indicate that appropriate care is being provided for a 4-year-old with spastic-type CP?
- A. "I perform range of motion (ROM) exercises every 4 hours to help prevent contractures."
- B. "I give my child a therapeutic massage after the stretching exercises to help manage pain."
- C. "I minimize the calories I provide with meals because my child is more prone to obesity."
- D. "I have my child wear a helmet during the day because of chronic tonic-clonic seizures."
- E. "Using utensils with large, padded handles makes it easier for my child to feed himself."
Correct Answer: A,B,D,E
Rationale: ROM exercises, therapeutic massage, helmet use for seizures, and adaptive utensils indicate appropriate care for spastic CP.
The client is scheduled for a computed tomography (CT) scan. Which question is most important for the nurse to ask before the procedure?
- A. On a scale of 1 to 10, how do you rate your pain?'
- B. Do you feel uncomfortable in enclosed spaces?'
- C. Are you allergic to seafood or iodine?'
- D. Have you signed a permit for this procedure?'
Correct Answer: C
Rationale: Iodine/seafood allergies are critical to assess before CT with contrast to prevent anaphylaxis. Claustrophobia, pain, and consent are secondary.
The client with rheumatoid arthritis has been taking 15 to 20 extra-strength aspirin a day. Which additional statement that the client makes would be of greatest concern to the nurse?
- A. I sometimes have ringing in my ears.'
- B. I have a rash under my arms.'
- C. My fingers are swollen sometimes.'
- D. I don't have very much energy.'
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of aspirin toxicity, a serious concern requiring immediate attention.
What is the purpose of the continuous passive motion (CPM) machine that the nurse should explain while teaching the client?
- A. A CPM machine is used to strengthen the leg muscles.
- B. A CPM machine is used to relieve foot swelling.
- C. A CPM machine is used to reduce surgical pain.
- D. A CPM machine is used to restore joint function.
Correct Answer: D
Rationale: The CPM machine gently flexes and extends the knee post-arthroplasty to restore joint function and prevent stiffness, not primarily to strengthen muscles, reduce swelling, or relieve pain.