Nokea
The physician orders that the client with a hip prosthesis may be out of bed to sit in a chair. How should the nurse position the chair to facilitate transferring the client to the side?
- A. At the end of the bed
- B. Perpendicular to the bed
- C. Parallel with the bed
- D. Against a side wall
Correct Answer: C
Rationale: Positioning the chair parallel to the bed allows the client to transfer safely to the nonoperative side, maintaining hip alignment and minimizing the risk of dislocation during the transfer.
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When the nurse examines the client, which body part is usually affected by gout?
- A. Great toe
- B. Index finger
- C. Sacrococcygeal vertebrae
- D. Temporomandibular joint
Correct Answer: A
Rationale: Gout typically affects the great toe (first metatarsophalangeal joint) due to uric acid crystal deposition, causing acute pain and swelling. Other areas are less commonly involved.
Which assessment finding most likely indicates that a client has osteoporosis?
- A. Swollen joints
- B. Discomfort when sitting
- C. Spinal deformity
- D. Diminished energy level
Correct Answer: C
Rationale: Spinal deformity, like kyphosis, is a common sign of osteoporosis.
Which nursing action is appropriate while the client is being transported?
- A. The nurse leaves the traction as is.
- B. The nurse removes the weights during the transport.
- C. The nurse rests the weights on the end of the bed.
- D. The nurse takes the client's leg out of the traction.
Correct Answer: B
Rationale: Removing the weights during transport prevents unintended movement or injury while maintaining the leg's position. Leaving traction as is or resting weights risks disrupting alignment, and removing the leg negates traction benefits.
The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client?
- A. The client will maintain vital signs within normal limits.
- B. The client will have a decrease in muscle spasms in the affected leg.
- C. The client will have no signs or symptoms of infection.
- D. The client will be able to ambulate down to the nurse’s station.
Correct Answer: D
Rationale: Ambulation to the nurse’s station is a long-term goal post-ORIF, indicating restored mobility. Vital signs, spasms, and infection are short-term or secondary.
The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
- A. Adjust the patient-controlled analgesia (PCA) machine for a lower dose.
- B. Ensure the weights of the Buck's traction are off the floor and hang freely.
- C. Raise the head of the bed to 45 degrees and the foot to 15 degrees.
- D. Turn the client on the affected leg using pillows to support the other leg.
Correct Answer: B
Rationale: Proper Buck’s traction alignment (weights off floor) reduces pain from misalignment. Adjusting PCA, bed positioning, or turning may worsen pain or are inappropriate.