Nokea
The nurse is teaching a client with low back pain. Which of the following statements, if made by the client, would require follow-up?
- A. I am planning to stop smoking cigarettes.'
- B. I should sleep on my stomach.'
- C. I have decided to purchase a firm mattress.'
- D. I will bend my knees when lifting objects.'
Correct Answer: B
Rationale: Sleeping on the stomach can strain the lower back, requiring follow-up teaching. Quitting smoking, a firm mattress, and bending knees when lifting are all beneficial for back health.
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The nurse is caring for an 88-year-old client who is fifteen minutes post-operative following total hip arthroplasty. It would be a priority to assess which of the following?
- A. Range of motion
- B. Urinary output
- C. Vital signs
- D. Incision
Correct Answer: C
Rationale: Vital signs are the priority post-op to detect instability, bleeding, or shock, especially in an elderly client. Range of motion, urinary output, and incision are important but secondary in the immediate 15-minute period.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 4 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
The nurse plans care for this client. For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client.
- A. Warm compress to the client's right foot
- B. Serum complete blood count (CBC)
- C. Serum blood cultures
- D. Administration of prescribed pain medication
- E. Magnetic Resonance Imaging (MRI)
- F. Intravenous fluids: Dextrose 5% in water (D5W)
Correct Answer: A: Not Indicated, B: Indicated, C: Indicated, D: Indicated, E: Indicated, F: Indicated
Rationale: A: Warm compresses may worsen inflammation and infection. B: CBC monitors infection and inflammation. C: Blood cultures identify systemic infection. D: Pain medication addresses severe pain. E: MRI confirms osteomyelitis. F: IV fluids support hydration and antibiotic delivery.
The nurse teaches a client about their newly applied halo fixator device with a vest. Which of the following statements should the nurse make?
- A. You should ride a bicycle instead of driving a car.'
- B. Report any fever or drainage at the pin sites.'
- C. Always keep the wrench taped to the front of the vest.'
- D. When getting out of bed, roll to your side and push on the mattress.'
- E. Wear a cotton t-shirt under the vest to absorb any moisture.'
Correct Answer: B, C, E
Rationale: Report fever or drainage for infection, keep the wrench taped for emergency adjustments, and wear a cotton t-shirt for comfort. Bicycling risks falls, and rolling to the side is safe but not the only method.
The following scenario applies to the next 1 items
The nurse cares for a client who sustained a femur fracture twelve hours ago
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Nurses’ Notes
Client reports shortness of breath and stated, ‘something is not right.’ The client was assessed to have a respiratory rate of 25/min and oxygen saturation of 90% while on room air. Lung sounds had bilateral crackles throughout, and respirations were labored. Chest pain was reported that worsened with breathing. An emergent 12-lead electrocardiogram was obtained, and it was observed that the client had reddish-purple spots on their torso. A rapid response was called.
The client is demonstrating signs and symptoms of
- A. Pulmonary embolism
- B. Myocardial infarction
- C. Fat embolism syndrome
- D. Compartment syndrome
Correct Answer: C
Rationale: Fat embolism syndrome is likely after a femur fracture, with symptoms like shortness of breath, bilateral crackles, chest pain, and petechiae on the torso. Pulmonary embolism and myocardial infarction are less directly tied to fractures, and compartment syndrome affects the limb.
The nurse is teaching a client with osteomalacia regarding ways to strengthen their bones. Which statement by the client would necessitate further teaching by the nurse?
- A. I've started to walk more frequently under the sun.'
- B. I don't like dairy products so I've stopped eating them.'
- C. I've enrolled myself in an exercise program for seniors at the community center.'
- D. I've been taking Vitamin D supplements lately.'
Correct Answer: B
Rationale: Avoiding dairy removes a key calcium source, critical for bone strength in osteomalacia. Sun exposure, exercise, and vitamin D supplements all support bone health.