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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.
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The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement?
- A. Monitor the client’s serum aPTT.
- B. Encourage oral and intravenous fluids.
- C. Do not eat foods high in vitamin K.
- D. Administer in the anterolateral upper abdomen.
Correct Answer: D
Rationale: Lovenox is administered in the anterolateral abdomen for optimal absorption. aPTT is for unfractionated heparin, fluids are unrelated, and vitamin K affects warfarin.
The school nurse is completing spinal screenings. Which data require a referral to an HCP?
- A. Bilateral arm lengthening while bending over at the waist.
- B. A deformity which resolves when the head is raised.
- C. Equal spacing of the arms and body at the waist.
- D. A right arm lower than the left while bending over at the waist.
Correct Answer: D
Rationale: Asymmetrical arm positioning (right lower than left) suggests scoliosis, requiring HCP referral. Symmetrical arms, resolving deformities, and equal spacing are normal.
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.
Which statement made by the family member indicates the need for further teaching?
- A. The hand should be elevated higher than the elbow.
- B. The knot should be tied at the back of the neck.
- C. The elbow should be flexed within the sling.
- D. The sling is used to elevate and support the arm.
Correct Answer: B
Rationale: Tying the knot at the back of the neck may cause discomfort or pressure on the cervical spine. The knot should be tied to the side to avoid this. The other statements correctly describe the proper use of a triangular sling for shoulder immobilization.
The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement?
- A. Refer the client to physical therapy at home.
- B. Refer the client to an assistive living facility.
- C. Refer the client to a workforce commission for job training.
- D. Refer the client to the dietitian.
Correct Answer: A
Rationale: Home PT restores hand/forearm function post-crushing injury. Assisted living, job training, and dietitian referrals are premature or unrelated.