Nokea
Which assessment finding is the best indication that the client in halo traction is developing a serious complication?
- A. The client experiences orthostatic hypotension.
- B. The client needs assistance with shaving.
- C. The client cannot open the mouth widely.
- D. The client complains about irritation under the axillae.
Correct Answer: C
Rationale: Inability to open the mouth widely may indicate cranial nerve compression or device misalignment, a serious complication requiring immediate attention. The other findings are less urgent or unrelated.
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The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP order should the nurse question?
- A. Maintain heparin to achieve a therapeutic level.
- B. Initiate and monitor intravenous fluids.
- C. Keep the O2 saturation higher than 93%
- D. Administer an intravenous loop diuretic.
Correct Answer: D
Rationale: Loop diuretics are inappropriate for fat embolism syndrome, as they may worsen hypovolemia. Heparin, fluids, and oxygen saturation are standard treatments.
When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying prone
- D. Standing to shower
Correct Answer: C
Rationale: Prone positioning stresses the stump and impairs healing.
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.
When the nurse assesses the client, which finding is the best indication that the shoulder has been dislocated?
- A. The client is experiencing intense pain.
- B. The client is receiving intense pain.
- C. The client is hesitant to move the arm.
- D. The affected arm is longer than the other.
Correct Answer: D
Rationale: A dislocated shoulder often results in the affected arm appearing longer due to the humeral head being displaced from the glenoid fossa, altering the arm's alignment. Pain and hesitancy to move are common but less specific, and 'receiving intense pain' is a typographical error.
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.