Nokea
Which evidence is the best indication that the client who had a knee arthroplasty is recovering according to expected outcomes and no longer needs the continuous passive motion (CPM) machine?
- A. The client has minimal pain when ambulating.
- B. The client can flex the operative knee 90 degrees.
- C. The client can tolerate full weight bearing.
- D. The edges of the client's surgical wound are approximated.
Correct Answer: B
Rationale: 90-degree knee flexion indicates restored joint function, a key recovery milestone.
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The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement?
- A. Adjust the patient-controlled analgesia (PCA) machine for a lower dose.
- B. Ensure the weights of the Buck's traction are off the floor and hang freely.
- C. Raise the head of the bed to 45 degrees and the foot to 15 degrees.
- D. Turn the client on the affected leg using pillows to support the other leg.
Correct Answer: B
Rationale: Proper Buck’s traction alignment (weights off floor) reduces pain from misalignment. Adjusting PCA, bed positioning, or turning may worsen pain or are inappropriate.
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll placed along the hip prevents external rotation of the operative leg, maintaining proper alignment post-hip replacement. The other options do not specifically address rotation.
The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)?
- A. Allow the client to stay in bed until the pain becomes bearable.
- B. Tell the UAP to give the client a bed bath this morning.
- C. Try to encourage the client to get up and go to the shower.
- D. Notify the family the client is refusing to be bathed.
Correct Answer: C
Rationale: Encouraging the client to shower promotes mobility, which reduces OA stiffness, while addressing pain. Bed rest worsens stiffness, bed baths enable immobility, and family notification is unnecessary.
Which diagnostic test result should the nurse monitor when assessing for evidence of metastasis?
- A. Lung scan
- B. Urinalysis
- C. Spinal tap
- D. Blood glucose
Correct Answer: A
Rationale: A lung scan detects metastasis, as skeletal tumors often spread to the lungs.
The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests should the nurse expect the health-care provider to order to R/O osteoarthritis?
- A. Full-body magnetic resonance imaging scan.
- B. Serum studies for synovial fluid amount.
- C. X-ray of the affected joints.
- D. Serum erythrocyte sedimentation rate (ESR).
Correct Answer: C
Rationale: X-rays reveal OA characteristic joint space narrowing and osteophytes. MRI is excessive, synovial fluid studies are not routine, and ESR is for inflammatory conditions, not OA.