Nokea
The nursing student is caring for the client who had a right TKR 1 day ago. Which action by the student requires the nurse to intervene?
- A. Hands the client the control for the continuous passive motion (CPM) machine
- B. Offers the client an analgesic when pain is rated at 3 on a 0 to 10 scale
- C. Repositions the leg to insert an abductor pillow between the client's legs
- D. Places an ice pack wrapped within a towel on the client's operative knee
Correct Answer: C
Rationale: C. Attempting to insert an abductor pillow may cause knee misalignment. An abductor pillow may be used for the client following a THR.
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The nurse is to administer nafcillin 500 mg intravenously to the client with osteomyelitis. A vial of 1 g of powdered nafcillin is to be reconstituted with 3.4 mL of 0.9% NaCl. How many milliliters should the nurse plan to administer?
- A. 1.7 mL
Correct Answer: A
Rationale: Rationale: 500 mg / 1,000 mg = x / 3.4 mL; x = 1.7 mL. The nurse should prepare 1.7 mL nafcillin (Nallpen).
The client is ordered to be in a semi-reclining position following a myelogram. The nurse understands that the primary reason for this is which of the following?
- A. To prevent infection
- B. To prevent spinal headache
- C. To prevent seizures
- D. To promote excretion of dye
Correct Answer: B
Rationale: A semi-reclining position post-myelogram prevents spinal headache by reducing cerebrospinal fluid leakage.
The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively?
- A. Keep an abduction pillow in place between the legs at all times.
- B. Cough and deep breathe at least every four (4) to five (5) hours.
- C. Turn to both sides every two (2) hours to prevent pressure ulcers.
- D. Sit in a high-seated chair for a flexion of less than 90 degrees.
Correct Answer: A
Rationale: An abduction pillow prevents hip dislocation post-THR, a critical complication. Coughing, turning, and chair positioning are important but secondary.
After the arm cast has been applied, which nursing observation is the best indication that the client may be developing compartment syndrome?
- A. The client's head becomes severe pain.
- B. The client's hand becomes reddened.
- C. The fingers develop muscle spasms.
- D. The radial pulse feels bounding.
Correct Answer: A
Rationale: Severe pain disproportionate to the injury is a hallmark of compartment syndrome, indicating increased pressure within the cast compromising neurovascular status. Redness, spasms, or a bounding pulse are less specific.
Which instruction should the nurse include when reinforcing teaching with the parents about safety considerations for a child with a surgically corrected myelomeningocele?
- A. Make sure braces lie smoothly against the child's skin.
- B. Ensure that the child shifts position at least every 3 hours.
- C. Place a blanket between the child and the wheelchair seat.
- D. Check all of the child's skin daily for redness or irritation.
Correct Answer: D
Rationale: Daily skin checks are essential to prevent pressure ulcers and other skin complications in children with myelomeningocele.