Nokea
Which assessment finding is the best indication that the client is experiencing secondary complications from the fractured ribs?
- A. Irregular pulse rate
- B. The client's affected leg is shorter than her unaffected leg.
- C. The client's affected leg is shorter than her unaffected leg.
- D. The client's affected leg is executed leg is externally rotated.
- E. The client prefers to sit rather than lie flat.
Correct Answer: E
Rationale: Fractured ribs can cause complications like pneumothorax or hemothorax, leading to difficulty breathing when lying flat. The client's preference to sit upright suggests respiratory distress, a secondary complication. Leg findings are unrelated to rib fractures, and irregular pulse is less specific.
You may also like to solve these questions
The nurse identifies the concept of impaired functional ability for a client diagnosed with rheumatoid arthritis. Which intervention should the nurse implement?
- A. Teach the client to apply antiembolism (TED) hose.
- B. Administer the nonsteroidal medication before the morning meal.
- C. Encourage the client to perform low-impact exercises daily.
- D. Refer the client to occupational therapy for gait training.
Correct Answer: C
Rationale: Low-impact exercises maintain joint function in RA, addressing impaired ability. TED hose are for DVT, NSAIDs are for pain, and OT is for specific tasks, not gait.
Which interventions should be included in the discharge teaching for a client who had a total hip replacement? Select all that apply.
- A. Discuss the client’s weight-bearing limits.
- B. Request the client demonstrate use of assistive devices.
- C. Explain the importance of increasing activity gradually.
- D. Instruct the client not to take medication prior to ambulating.
- E. Tell the client to ambulate with open-toed house shoes.
Correct Answer: A,B,C
Rationale: Weight-bearing limits, assistive device use, and gradual activity prevent complications post-THR. Pain medication aids ambulation, and open-toed shoes are unsafe.
The nurse is working with an unlicensed assistive personnel (UAP). Which action by the UAP warrants immediate intervention?
- A. The UAP feeds a client two (2) days postoperative cervical laminectomy a regular diet.
- B. The UAP calls for help when turning to the side a client who is post-lumbar laminectomy.
- C. The UAP is helping the client who weighs 300 pounds and is diagnosed with back pain to the chair.
- D. The UAP places the call light within reach of the client who had a disk fusion.
Correct Answer: A
Rationale: A regular diet post-cervical laminectomy risks aspiration if swallowing is impaired; this requires immediate intervention. Calling for help, assisting a heavy client, and placing the call light are appropriate.
Which statement by the nurse about fiberglass casts is most accurate?
- A. Fiberglass casts are less expensive than plaster
- B. Fiberglass casts are lightweight.
- C. Fiberglass casts are flexible.
- D. Fiberglass casts are less restrictive than plaster casts.
Correct Answer: B
Rationale: Fiberglass casts are lightweight compared to plaster, making them more comfortable for clients. They are not necessarily less expensive, flexible, or less restrictive, as both types immobilize effectively.
When the nurse examines the client, which body part is usually affected by gout?
- A. Great toe
- B. Index finger
- C. Sacrococcygeal vertebrae
- D. Temporomandibular joint
Correct Answer: A
Rationale: The great toe is commonly affected in gout due to uric acid crystal deposition.