Nokea
The nurse writes a concept of 'impaired mobility' for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply.
- A. Request a physical therapy referral.
- B. Administer enoxaparin (Lovenox) subcutaneously.
- C. Utilize a gait belt when ambulating the client.
- D. Assess the client’s pain levels on a 1-to-10 scale.
- E. Provide a high-carbohydrate, high-fat, high-sodium diet.
Correct Answer: A,B,C,D
Rationale: PT referral, enoxaparin, gait belt, and pain assessment promote mobility and prevent complications in hip fracture. High-carb/fat/sodium diet is inappropriate.
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The nurse is assessing the client immediately following a C5-C6 anterior cervical discectomy. Which potential problem should be the nurse's priority?
- A. Altered breathing pattern
- B. Impaired tissue perfusion
- C. Altered mobility
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Retractors used during surgery can injure the recurrent laryngeal nerve, resulting in the inability to cough effectively to clear secretions. Edema and bleeding can also compromise the airway and compress the spinal cord.
The nurse advises the client on the need for maintenance of the bandage. When should the nurse advise the client with a sprained ankle to rewrap the elastic bandage?
- A. When the toes appear pink
- B. When the ankle feels painful
- C. When the toes look swollen
- D. When the joint feels stiff
Correct Answer: C
Rationale: Swollen toes indicate compromised circulation or inadequate compression, necessitating rewrapping to ensure proper fit and pressure. Pink toes suggest normal circulation, pain may not always indicate bandage issues, and joint stiffness is expected with a sprain but not directly related to bandage maintenance.
When the nurse observes the client walking, which assessment finding indicates the need for more instruction regarding the use of the cane?
- A. The tip of the cane is covered with a rubber cap.
- B. The client wears athletic shoes with nonskid soles.
- C. The client uses the cane on the painful side.
- D. The client looks straight ahead when walking.
Correct Answer: C
Rationale: The cane should be used on the unaffected side to support the painful hip, distributing weight appropriately. Using it on the painful side reduces its effectiveness, requiring further instruction.
The client has returned to the nursing unit following a right below-the-knee amputation. How should the nurse position the client?
- A. Supine with head turned to the side
- B. With shock blocks placed under the foot of the bed
- C. Semi-sitting position with knees bent
- D. Left lateral with pillows between the knees
Correct Answer: C
Rationale: A semi-sitting position promotes comfort, reduces edema, and facilitates breathing post-amputation.
A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?
Correct Answer: 30
Rationale: Concentration: 20,000 units ÷ 500 mL = 40 units/mL. Rate: 1200 units/hr ÷ 40 units/mL = 30 mL/hr.