Nokea
The nurse knows that a client who sustains multiple fractures of long bones is at risk for developing fat embolism syndrome. Which findings suggest that the client is developing this complication? Select all that apply.
- A. Bradycardia
- B. Petechiae
- C. Dyspnea
- D. Mental status changes
- E. Hypertension
- F. Hematuria
Correct Answer: B,C,D
Rationale: Fat embolism syndrome typically presents with petechiae (small red spots from fat emboli in the skin), dyspnea (from pulmonary involvement), and mental status changes (from cerebral hypoxia). Bradycardia, hypertension, and hematuria are not characteristic.
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Postoperatively, which intervention should be completed before turning the client onto the nonoperative side?
- A. Placing pillows between the client's legs
- B. Having the client point the toes downward
- C. Having the client's knee on the side
- D. Elevating the head of the client's bed
Correct Answer: A
Rationale: Placing pillows between the legs before turning prevents adduction of the operative hip, reducing the risk of dislocation in a client with a hip prosthesis. The other actions do not directly address hip stability.
The nurse is admitting a female client who is complaining of severe back pain radiating down the left leg whenever she tries to ambulate. The concepts of impaired mobility and comfort are implemented on the care map. Which nursing interventions should the nurse implement?
- A. Assist the client when ambulating to the bathroom and administer medications based on the pain scale.
- B. Place the client on strict bedrest and have the client use a regular bedpan for elimination of urine and feces.
- C. Ambulate the client in the hallway at least four (4) times per day and discourage the use of pharmacological pain relief.
- D. Request the health-care provider (HCP) to assist the client in ambulating in the hallway so the HCP can observe the client’s pain.
Correct Answer: A
Rationale: Assisting with ambulation and pain medication addresses mobility and comfort in sciatica. Strict bedrest hinders recovery, excessive ambulation without pain control is unsafe, and HCP observation is unnecessary.
Which activity is best to begin implementing immediately after the client's surgery?
- A. Standing at the side of the bed
- B. Balancing between parallel bars
- C. Lifting oneself with the trapeze
- D. Transferring from the bed to a chair
Correct Answer: C
Rationale: Lifting with a trapeze strengthens upper body muscles safely immediately post-surgery, preparing for crutch use without stressing the stump. Other activities are more advanced.
The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse?
- A. Capillary refill time is less than three (3) seconds.
- B. Pain is not relieved by the patient-controlled analgesia.
- C. Left fingers are edematous and the left hand is purple.
- D. Warm and dry skin on left fingers distal to the elastic bandage.
Correct Answer: C
Rationale: Edema and purple discoloration indicate neurovascular compromise, requiring immediate intervention. Normal refill, unrelieved pain, and warm skin are less urgent.
Which of the following might interfere with the effectiveness of Russell's traction?
- A. The rope is strung tautly from pulley to pulley.
- B. The trapeze is hanging above the client's chest.
- C. The rope is knotted at the location of a pulley.
- D. The weight is about 24'' (61 cm) from the floor.
Correct Answer: C
Rationale: A knotted rope at the pulley disrupts smooth movement, reducing traction effectiveness by altering the pull. Taut ropes, a properly placed trapeze, and weights hanging freely are correct for effective traction.