Nokea
Which intervention should the nurse include in this client's plan of care for a client recovering from a below-the-knee amputation?
- A. Place pillows between the client's knees.
- B. Encourage range-of-motion exercises.
- C. Administer prophylactic antibiotics.
- D. Implement strict bedrest in a supine position.
Correct Answer: B
Rationale: Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractures and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to reposition, move, and exercise frequently, and therefore should not implement strict bedrest.
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A nurse notes crepitation when performing range-of-motion exercises on a client with a fractured left humerus. Which action should the nurse take next?
- A. Immobilize the client's arm.
- B. Assess the client's distal pulse.
- C. Monitor for signs of infection.
- D. Administer prescribed steroids.
Correct Answer: A
Rationale: A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the client's arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.
A nurse cares for a client in skeletal traction. The nurse notes that the skin around the client's pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next?
- A. Request a prescription to decrease the traction weight.
- B. Apply a warm compress to reduce swelling.
- C. Cleanse the area twice, scrubbing off the crusty areas.
- D. Obtain a prescription to culture the drainage.
Correct Answer: D
Rationale: These clinical manifestations indicate inflammation and possible infection. Obtaining a prescription to culture the drainage is the appropriate action to identify and treat a potential infection. Decreasing traction weight or scrubbing the area could exacerbate the issue, and a warm compress may not address the underlying infection.
A phone triage nurse speaks with a client who has an arm cast. The client states, 'My arm feels really tight and puffy.' How should the nurse respond?
- A. Elevate your arm on two pillows and get ice to apply to the cast.
- B. Continue to take ibuprofen (Motrin) until the swelling subsides.
- C. This is normal. A new cast will often feel a little tight for the first few days.
- D. Please come to the clinic today to have your arm checked by the provider.
Correct Answer: D
Rationale: Puffy fingers and a feeling of tightness from the cast may indicate the development of compartment syndrome. The client should come to the clinic that day to be evaluated by the provider because delay of treatment can cause permanent damage to the extremity. Ice and ibuprofen are acceptable actions, but checking the cast is the priority to ensure client safety. The nurse should not reassure the client that this is normal.
A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)
- A. Edema "? Increased capillary permeability
- B. Pallor "? Increased blood flow to the area
- C. Unequal pulses "? Increased production of lactic acid
- D. Cyanosis "? Anaerobic metabolism
- E. Tingling "? A release of histamine
Correct Answer: A,C,D
Rationale: Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, unequal pulses are caused by increased production of lactic acid, and cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, not increased blood flow, and tingling is caused by increased tissue pressure, not histamine release.
After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture?
- A. Baked fish with orange juice and a vitamin D supplement.
- B. Bacon, lettuce, and tomato sandwich with a vitamin B supplement.
- C. Bacon, lettuce, and tomato sandwich with a vitamin C supplement.
- D. Roast beef with low-fat milk and a vitamin C supplement.
Correct Answer: D
Rationale: The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk provides calcium supplementation, and vitamin C aids in healing. Roast beef provides high protein, making this the best choice. Fish and sandwiches provide less protein.