Nokea
When the nurse observes the client walking, which assessment finding indicates the need for more instruction regarding the use of the cane?
- A. The tip of the cane is covered with a rubber cap.
- B. The client wears athletic shoes with nonskid soles.
- C. The client uses the cane on the painful side.
- D. The client looks straight ahead when walking.
Correct Answer: C
Rationale: The cane should be used on the unaffected side to support the painful hip, distributing weight appropriately. Using it on the painful side reduces its effectiveness, requiring further instruction.
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The physician orders prednisone for a client with rheumatoid arthritis for painful wrists and joints. Which instruction is it essential for the nurse to give the client?
- A. Take the pills with milk or food.'
- B. Be sure to take the medication between meals.'
- C. Stop the pills at once if your face begins to get puffy.'
- D. Your urine may turn pinkish while taking this.'
Correct Answer: A
Rationale: Taking prednisone with food or milk reduces gastrointestinal irritation, a key instruction for safe administration.
To prevent skin breakdown while the client is in Russell's traction, the nurse must frequently inspect the skin in which area?
- A. Over the ischial spines
- B. In the popliteal space
- C. Near the iliac crests
- D. At the zygomatic arch
Correct Answer: B
Rationale: Russell's traction involves a sling under the knee, placing pressure on the popliteal space, which is prone to skin breakdown due to prolonged contact and immobility. Frequent inspection here prevents pressure ulcers.
The client has a fractured right ankle that has just been casted. The nurse is instructing the client in crutch walking techniques. Which method is most appropriate?
- A. Move the right crutch, then the left foot, then the left crutch, and finally the right foot.
- B. Balance weight on the left foot and move right foot and both crutches forward, then bear weight on both crutches and move the left foot forward.
- C. Move the right crutch and left foot forward together; then move the left crutch and right foot.
- D. Move the right crutch and right foot together; then move the left crutch and the left foot.
Correct Answer: A
Rationale: The correct crutch walking technique (three-point gait) involves moving the right crutch, then the left foot, followed by the left crutch, and finally the right foot, protecting the fractured ankle.
The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention?
- A. The client’s hemoglobin is 8.1 g/dL.
- B. The client’s white blood cell count is 9,000/mm3.
- C. The client’s creatinine level is 0.8 mg/dL.
- D. The client’s potassium level is 4.2 mEq/L.
Correct Answer: A
Rationale: Hemoglobin of 8.1 g/dL indicates significant blood loss, requiring urgent intervention post-shoulder replacement. Other values are normal.
What is the purpose of the continuous passive motion (CPM) machine that the nurse should explain while teaching the client?
- A. A CPM machine is used to strengthen the leg muscles.
- B. A CPM machine is used to relieve foot swelling.
- C. A CPM machine is used to reduce surgical pain.
- D. A CPM machine is used to restore joint function.
Correct Answer: D
Rationale: CPM promotes joint mobility and prevents stiffness post-arthroplasty.