Nokea
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.
You may also like to solve these questions
The nurse is caring for a client two days post-op total knee replacement with a continuous passive motion (CPM) device at the bedside. The nurse would recognize that the primary purpose of this machine is to:
- A. Stabilize the knee joint during ambulation
- B. Promote knee flexion
- C. Reduce post-surgical swelling
- D. Prevent blood clots
Correct Answer: B
Rationale: The primary purpose of a CPM device is to promote knee flexion and range of motion post-surgery, aiding recovery. It doesn't stabilize during ambulation, primarily reduce swelling, or prevent clots.
While caring for a patient who has recently suffered from a fracture, the nurse sees that the patient's injured extremity will be placed in traction. Which of the following actions should the nurse refrain from performing?
- A. Keeping the pulley system tightened so that they may not move freely
- B. Check the ropes for fraying or breaks
- C. Keep the weights above the floor
- D. Ensure proper body alignment
Correct Answer: A
Rationale: Tightening the pulley system to prevent free movement can disrupt traction's purpose of maintaining alignment and pull. Checking ropes, keeping weights off the floor, and ensuring alignment are all appropriate.
A client with a history of statin use presents to the clinic with complaints of muscle weakness and pain. The nurse suspects myopathy. Which of the following laboratory tests should the nurse prioritize to evaluate for muscle damage?
- A. Electrocardiogram (ECG)
- B. Liver function tests (LFTs)
- C. Creatine kinase (CK)
- D. Complete blood count (CBC)
Correct Answer: C
Rationale: Creatine kinase (CK) levels rise with muscle damage, common in statin-induced myopathy. ECG is for cardiac issues, LFTs monitor liver, and CBC is not specific to muscle damage.
The nurse is discharging a client following knee arthroplasty. Which of the following information should the nurse include in discharge teaching?
- A. After this procedure, you will use a wheelchair to get around.'
- B. You will need to resume your prescribed anticoagulants.'
- C. Placing a pillow under your knee will help with the pain.'
- D. You may ice the site for one hour at a time.'
Correct Answer: B
Rationale: Resuming prescribed anticoagulants is crucial to prevent deep vein thrombosis after knee arthroplasty. A wheelchair may not be necessary, pillows under the knee can cause flexion contractures, and icing for one hour at a time risks skin damage; 15-20 minutes is safer.
The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 2 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.
Which three (3) findings in the history and physical suggest that the client's condition is worsening?
- A. Chills
- B. Sensation in feet
- C. Fever
- D. Erythema
- E. General malaise
Correct Answer: A, C, E
Rationale: Chills, fever, and general malaise indicate systemic infection or worsening, possibly osteomyelitis, especially with a history of untreated cellulitis. Sensation loss is chronic, and erythema is an earlier sign not necessarily worsening.