Nokea
The nurse should plan to include information about which common practice that can increase the risk for developmental dysplasia of the hip (DDH)?
- A. Carrying a child in a backpack
- B. Carrying a child in a frontpack
- C. Swaddling of a child
- D. Extended time in a car seat
Correct Answer: C
Rationale: Tight swaddling can restrict hip movement and increase the risk of DDH.
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When preparing the client for cast application, which statement by the nurse is most accurate?
- A. The cast will feel tight as it's applied.
- B. Your arm will feel warm as the wet plaster sets.
- C. You can expect a foul odor until the cast is dry.
- D. You may feel itchy while the cast is wet.
Correct Answer: B
Rationale: Wet plaster generates heat as it sets, causing a warm sensation, which is a normal part of the process. Tightness may indicate a problem, odors are not typical, and itching is more common as the cast dries.
While the client is waiting for the ankle to be X-rayed, which nursing measure is most helpful for relieving the soft-tissue swelling?
- A. Place a heating pad on the ankle.
- B. Apply ice to the ankle.
- C. Exercise the client's foot.
- D. Immobilize the client's foot.
Correct Answer: B
Rationale: Applying ice is the most effective initial measure to reduce soft-tissue swelling by causing vasoconstriction, which decreases blood flow and fluid accumulation in the injured area. Heat may increase swelling, exercise could exacerbate the injury, and immobilization alone does not address swelling as directly.
The client has been in a body cast for the past 2 days to treat numerous broken vertebrae from a fall. The client is reporting dyspnea, vomiting, epigastric pain, and abdominal distention. Which action demonstrates the nurse's best clinical judgment?
- A. Immediately notify the health care provider.
- B. Initiate oxygen at 2 liters per nasal cannula.
- C. Place ice packs around the outside of the cast.
- D. Administer ondansetron prescribed q6h prn.
Correct Answer: A
Rationale: A. The nurse should immediately notify the HCP. A window in the abdominal portion of the cast or bivalving is needed to relieve the pressure.
If the client is typical of others with a herniated disk, the nurse would expect the client to report which additional symptom?
- A. Pain radiating into the buttocks and leg
- B. Tenderness over one or both iliac crests
- C. Diminished sensation in one or both knees
- D. Brief periods when the toes feel quite cold
Correct Answer: A
Rationale: A herniated lumbar disk commonly causes sciatica, with pain radiating into the buttocks and leg due to nerve root compression. Other symptoms are less typical or specific.
The nurse is caring for the client 2 days post-right THR in which the traditional posterior approach was used. Which interventions should the nurse implement?
- A. Checks that an elevated toilet seat is in place and assists the client to the bathroom using a walker
- B. Removes the wedge pillow at the client's request and places pillows to maintain right leg adduction
- C. Reinfuses the 400-mL wound autotransfusion drainage system returns that collected in the past 24 hours
- D. Assists the client to get out of bed on the left side so the client can stand to place and use the urinal
Correct Answer: A
Rationale: A. The client should be able to ambulate with the use of a walker. An elevated toilet seat is used to prevent hip flexion of greater than 90 degrees when the client sits.