Nokea
Which nursing intervention is most appropriate for preventing a pathological fracture?
- A. Encouraging a high fluid intake
- B. Providing a nutritional diet
- C. Supporting the limb during movement
- D. Relieving pressure on bony prominences
Correct Answer: C
Rationale: Supporting the limb during movement minimizes stress on the necrotic bone, reducing the risk of a pathological fracture in osteomyelitis. Fluid, diet, and pressure relief are less directly preventive.
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Which substances should the nurse advise the client to avoid?
- A. Aspirin and fiber-containing laxatives
- B. Tobacco products and carbonated beverages
- C. Orange juice and caffeinated drinks
- D. Calcium-enriched dairy products
Correct Answer: B
Rationale: Tobacco and carbonated beverages reduce bone density, worsening osteoporosis.
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 prevents external rotation, maintaining hip alignment.
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.
Which return demonstration indicates that the client has understood the correct way to ambulate with the walker?
- A. The client advances the walker and operative leg while putting most of the weight on the walker's handgrips.
- B. The client advances the walker and operative leg while putting most of the weight on the back legs of the walker.
- C. The client advances the walker and operative leg while putting most of the weight on the toes of the operative leg.
- D. The client advances the walker and operative leg while putting most of the weight on the heel of the nonoperative leg.
Correct Answer: D
Rationale: In a three-point partial weight-bearing gait, the client advances the walker and operative leg together, placing most weight on the nonoperative leg's heel to minimize stress on the operative hip, ensuring stability and safety.
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.