Nokea
When the nurse is documenting the client's progress while using a continuous passive motion (CPM) machine, which assessment data are essential to include?
- A. Degree of flexion, number of cycles, and condition of the incision
- B. Degree of flexion, number of cycles, and amount of time the client used the machine
- C. Degree of flexion, number of cycles, and characteristics of drainage from the wound
- D. Degree of flexion, number of cycles, and presence and quality of arterial pulses
Correct Answer: B
Rationale: Documenting the degree of flexion, number of cycles, and time used on the CPM machine tracks progress in restoring joint function. Incision condition, drainage, or pulses are monitored separately.
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A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply.
- A. The client requests pain medication to sleep.
- B. The client has eupnea and normal sinus rhythm.
- C. The client has petechiae over the neck and chest.
- D. The client has a high arterial oxygen level.
- E. The client has yellow globules floating in the urine.
Correct Answer: C,E
Rationale: Petechiae and yellow globules suggest fat embolism syndrome, requiring immediate intervention. Pain medication, normal breathing, and high oxygen are not urgent.
The nurse supervises a nursing assistant who is applying the client's antiembolism stockings. What is the correct technique for applying these stockings?
- A. The nursing assistant applies the stockings before getting the client out of bed.
- B. The nursing assistant applies the stockings just before helping the client do leg exercises.
- C. The nursing assistant applies the stockings after nursing that the client's legs are cool.
- D. The nursing assistant applies the stockings at night before the client's bedtime.
Correct Answer: A
Rationale: Applying antiembolism stockings before the client gets out of bed ensures compression is in place during upright positions when venous pooling is most likely. Applying them later or based on leg temperature is less effective.
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.
The nurse, caring for the client who had bilateral THRs 2 days ago, determines that the client will need a referral to manage exercises and stairs when at home. The nurse should plan to initiate a referral with which interdisciplinary team member?
- A. Occupational therapist
- B. Social worker
- C. Physical therapist
- D. Health care provider
Correct Answer: C
Rationale: C. The physical therapist is the team member with expertise to assist in exercises and ambulating with assistive devices.
The client with a cervical neck injury as a result of a motor-vehicle accident is complaining of unrelieved pain after administration of a narcotic analgesic. Which alternative method of pain control is an independent nursing action?
- A. Medicate the client with a muscle relaxant.
- B. Heat alternating with ice applied by a physical therapist.
- C. Watch television or listen to music.
- D. Discuss surgical options with the health-care provider.
Correct Answer: C
Rationale: Distraction via TV or music is an independent nursing action to manage pain. Muscle relaxants require a prescription, heat/ice involves PT, and surgical discussions are physician-driven.