Nokea
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll prevents external rotation, maintaining hip alignment.
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Which statement indicates that the client understands the restrictions to be followed?
- A. I should avoid pointing my toes.
- B. I shouldn't cross my legs.
- C. I shouldn't lie flat in bed.
- D. I shouldn't stand upright.
Correct Answer: B
Rationale: Avoiding crossing legs prevents adduction of the hip, which could lead to dislocation after total hip replacement. The other restrictions are less critical or inaccurate.
The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first?
- A. The client with a total knee replacement who is complaining of a cold foot.
- B. The client diagnosed with osteoarthritis who is complaining of stiff joints.
- C. The client who needs to receive a scheduled intravenous antibiotic.
- D. The client diagnosed with back pain who is scheduled for a lumbar myelogram.
Correct Answer: A
Rationale: A cold foot post-knee replacement suggests vascular compromise, requiring urgent assessment to prevent tissue damage. Stiff joints, antibiotics, and myelogram prep are lower priority.
The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement?
- A. Monitor the client’s serum aPTT.
- B. Encourage oral and intravenous fluids.
- C. Do not eat foods high in vitamin K.
- D. Administer in the anterolateral upper abdomen.
Correct Answer: D
Rationale: Lovenox is administered in the anterolateral abdomen for optimal absorption. aPTT is for unfractionated heparin, fluids are unrelated, and vitamin K affects warfarin.
Which statement made by the family member indicates the need for further teaching?
- A. The hand should be elevated higher than the elbow.
- B. The knot should be tied at the back of the neck.
- C. The elbow should be flexed within the sling.
- D. The sling is used to elevate and support the arm.
Correct Answer: B
Rationale: Tying the knot at the back of the neck may cause discomfort or pressure on the cervical spine. The knot should be tied to the side to avoid this. The other statements correctly describe the proper use of a triangular sling for shoulder immobilization.
The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first?
- A. Wrap the left hand with towels and apply pressure.
- B. Instruct the friend to hold his hand above his head.
- C. Apply pressure to the radial artery of the left hand.
- D. Go into the friend's house and call 911.
Correct Answer: A
Rationale: Applying pressure with towels controls bleeding, the priority in traumatic amputation. Elevation is secondary, radial pressure is less effective, and calling 911 delays hemorrhage control.