Nokea
Which is the best method to assess circulation in the casted extremity?
- A. Ask the client to wiggle the fingers.
- B. Feel the cast to determine if it is unusually hot or cold.
- C. Depress the client's nail beds, and document the client's knee on the center to return.
- D. See if there is enough room to insert a finger between the cast and the extremity.
Correct Answer: C
Rationale: Depressing the nail beds to assess capillary refill (color return within 2-3 seconds) is the most reliable method to evaluate circulation in a casted extremity, indicating adequate blood flow. Wiggling fingers assesses motor function, not circulation directly, and the other options are less specific.
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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 27-year-old client has a right above-the-elbow amputation secondary to a boating accident. Which statement to the rehabilitation nurse indicates the client has accepted the amputation?
- A. I am going to sue the guy who hit my boat.'
- B. The therapist is going to help me get retrained for another job.'
- C. I decided not to get a prosthesis. I don't think I need it.'
- D. My wife is so worried about me and I wish she weren't.'
Correct Answer: B
Rationale: Planning job retraining indicates acceptance and adaptation to amputation. Lawsuits, prosthesis refusal, and concern for others suggest denial or unresolved grief.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Do you have any stomach pain or black stools?
- B. Are you experiencing any joint swelling?
- C. Have you noticed any changes in your vision?
- D. Are you feeling more tired than usual?
Correct Answer: A
Rationale: Stomach pain or black stools indicate gastrointestinal bleeding, a serious NSAID side effect.
The client is prescribed Fosamax, a bisphosphonate. Which information should the nurse teach?
- A. Take this medication with a full glass of water.
- B. Take with breakfast to prevent gastrointestinal upset.
- C. Use sunscreen to prevent sensitivity to sunlight.
- D. This medication increases calcium reabsorption.
Correct Answer: A
Rationale: Fosamax is taken with water to prevent esophageal irritation. Food reduces absorption, photosensitivity is not a side effect, and it inhibits bone resorption, not calcium reabsorption.
The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client?
- A. The client will maintain vital signs within normal limits.
- B. The client will have a decrease in muscle spasms in the affected leg.
- C. The client will have no signs or symptoms of infection.
- D. The client will be able to ambulate down to the nurse’s station.
Correct Answer: D
Rationale: Ambulation to the nurse’s station is a long-term goal post-ORIF, indicating restored mobility. Vital signs, spasms, and infection are short-term or secondary.