Nokea
The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement?
- A. Assess the client's surgical dressing every two (2) hours.
- B. Do not allow the client to see the residual limb.
- C. Keep a large tourniquet at the client's bedside.
- D. Perform passive range-of-motion exercises to the right leg.
Correct Answer: A
Rationale: Frequent dressing assessment detects bleeding, a critical post-BKA risk. Hiding the limb is inappropriate, tourniquets are for emergencies, and ROM is premature in recovery.
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Which intervention is an example of a secondary nursing intervention when discussing osteoporosis?
- A. Obtain a bone density evaluation test.
- B. Perform non-weight-bearing exercises regularly.
- C. Increase the intake of dietary calcium.
- D. Refer clients to a smoking cessation program.
Correct Answer: A
Rationale: Bone density testing (e.g., DEXA) is secondary prevention, detecting osteoporosis early. Calcium intake and smoking cessation are primary, and non-weight-bearing exercises are less effective.
The nurse is caring for an 80-year-old client admitted with a fractured right femoral neck who is oriented x3. Which intervention should the nurse implement first?
- A. Check for a positive Homans' sign.
- B. Encourage the client to take deep breaths and cough.
- C. Determine the client's normal orientation status.
- D. Monitor the client's Buck's traction.
Correct Answer: C
Rationale: Confirming baseline orientation ensures accurate neurological assessment in an elderly fracture patient. Homans’ sign, breathing exercises, and traction monitoring follow.
Before turning the client postoperatively, which nursing instruction is especially important to prevent postoperative complications?
- A. Hold your breath as you are turning.
- B. Move your lower body first, then your chest.
- C. As you hold onto the trapeze, lift your hips off the bed.
- D. Let me roll you as if you were a log.
Correct Answer: D
Rationale: Log-rolling maintains spinal alignment during turning post-laminectomy, preventing strain on the surgical site and reducing complications like nerve damage or incision dehiscence.
Which activity is best to begin implementing immediately after the client's surgery?
- A. Standing at the side of the bed
- B. Balancing between parallel bars
- C. Lifting oneself with the trapeze
- D. Transferring from the bed to a chair
Correct Answer: C
Rationale: Lifting with a trapeze strengthens upper body muscles safely immediately post-surgery, preparing for crutch use without stressing the stump. Other activities are more advanced.
Which of the following might interfere with the effectiveness of Russell's traction?
- A. The rope is strung tautly from pulley to pulley.
- B. The trapeze is hanging above the client's chest.
- C. The rope is knotted at the location of a pulley.
- D. The weight is about 24'' (61 cm) from the floor.
Correct Answer: C
Rationale: A knotted rope at the pulley disrupts smooth movement, reducing traction effectiveness by altering the pull. Taut ropes, a properly placed trapeze, and weights hanging freely are correct for effective traction.