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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 skin
- 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: Flexion degree, cycles, and usage time measure CPM effectiveness.
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The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA?
- A. I take medication every two (2) hours for my pain.'
- B. I use a heating pad when I go to bed at night.'
- C. I wear a copper bracelet to help with my OA.'
- D. I always wear my ankle splints when I sleep.'
Correct Answer: C
Rationale: Copper bracelets are an alternative therapy for OA, believed to reduce symptoms. Pain medication and heating pads are conventional, and splints are for support, not alternative.
The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse?
- A. Capillary refill time is less than three (3) seconds.
- B. Pain is not relieved by the patient-controlled analgesia.
- C. Left fingers are edematous and the left hand is purple.
- D. Warm and dry skin on left fingers distal to the elastic bandage.
Correct Answer: C
Rationale: Edema and purple discoloration indicate neurovascular compromise, requiring immediate intervention. Normal refill, unrelieved pain, and warm skin are less urgent.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen?
- A. Do you have any stomach pain or dark stools?
- B. Are you experiencing headaches or dizziness?
- C. Do you notice any swelling in your legs?
- D. Are you having trouble sleeping at night?
Correct Answer: A
Rationale: NSAIDs like ibuprofen commonly cause gastrointestinal adverse effects, such as stomach pain or dark stools (indicating bleeding). These are more specific than headaches, swelling, or sleep issues.
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.
The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit?
- A. Severe bone deformity.
- B. Joint stiffness.
- C. Waddling gait.
- D. Swan-neck fingers.
Correct Answer: B
Rationale: Joint stiffness, especially in the morning, is a hallmark of OA due to cartilage loss. Severe deformity and swan-neck fingers are more typical of rheumatoid arthritis, and waddling gait is nonspecific.