Nokea
The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report?
- A. The 84-year-old female with a fractured right femoral neck in Buck’s traction.
- B. The 64-year-old female with a left total knee replacement who has confusion.
- C. The 88-year-old male post-right total hip replacement with an abduction pillow.
- D. The 50-year-old postop client with a continuous passive motion (CPM) device.
Correct Answer: B
Rationale: Confusion post-TKR may indicate neurological or metabolic complications, requiring urgent assessment. Fractures, THR, and CPM use are stable.
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The female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 minutes every day. Which response is most appropriate by the nurse?
- A. Praise the client for committing to do this activity.
- B. Explain to the client walking 30 minutes a day is a better activity.
- C. Encourage the client to swim every other day instead of daily.
- D. Discuss with the client how sedentary activities help prevent osteoporosis.
Correct Answer: B
Rationale: Walking, a weight-bearing exercise, better promotes bone density than swimming for osteoporosis. Daily swimming is less effective, sedentary activities worsen osteoporosis, and praise ignores efficacy.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Do you have any stomach pain or black stools?
- B. Are you experiencing any joint swelling?
- C. Have you noticed any changes in your vision?
- D. Are you feeling more tired than usual?
Correct Answer: A
Rationale: Stomach pain or black stools indicate gastrointestinal bleeding, a serious NSAID side effect.
Which laboratory test value, if elevated, is the best diagnostic indicator of rheumatoid arthritis?
- A. Erythrocyte sedimentation rate (ESR)
- B. Partial thromboplastin time (PTT)
- C. Partial thromboplastin time (PTT)
- D. Blood urea nitrogen (BUN)
Correct Answer: A
Rationale: An elevated ESR indicates inflammation, a hallmark of rheumatoid arthritis, making it a key diagnostic marker. PTT and BUN are unrelated to rheumatoid arthritis diagnosis.
Which evidence is the best indication that the client who had a knee arthroplasty is recovering according to expected outcomes and no longer needs the continuous passive motion (CPM) machine?
- A. The client has minimal pain when ambulating.
- B. The client can flex the operative knee 90 degrees.
- C. The client can tolerate full weight bearing.
- D. The edges of the client's surgical wound are approximated.
Correct Answer: B
Rationale: 90-degree knee flexion indicates restored joint function, a key recovery milestone.
Which diagnostic test result should the nurse monitor when assessing for evidence of metastasis?
- A. Lung scan
- B. Urinalysis
- C. Spinal tap
- D. Blood glucose
Correct Answer: A
Rationale: A lung scan detects metastasis, as skeletal tumors often spread to the lungs.