Nokea
Which of the following might interfere with the effectiveness of Russell's traction?
- A. The rope is strung tautly from pulley to pulley.
- B. The trapeze is hanging above the client's chest.
- C. The rope is knotted at the location of a pulley.
- D. The weight is about 24'' (61 cm) from the floor.
Correct Answer: C
Rationale: A knotted rope at the pulley disrupts smooth movement, reducing traction effectiveness by altering the pull. Taut ropes, a properly placed trapeze, and weights hanging freely are correct for effective traction.
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Which priority intervention should the day surgery nurse implement for a client who has had right knee arthroscopy?
- A. Encourage the client to perform range-of-motion exercises.
- B. Monitor the amount and color of the urine.
- C. Check the client’s pulses distally and assess the toes.
- D. Monitor the client’s vital signs.
Correct Answer: C
Rationale: Checking distal pulses and toes assesses for neurovascular compromise, a priority post-arthroscopy. ROM, urine, and vitals are secondary.
The nurse is admitting a female client who is complaining of severe back pain radiating down the left leg whenever she tries to ambulate. The concepts of impaired mobility and comfort are implemented on the care map. Which nursing interventions should the nurse implement?
- A. Assist the client when ambulating to the bathroom and administer medications based on the pain scale.
- B. Place the client on strict bedrest and have the client use a regular bedpan for elimination of urine and feces.
- C. Ambulate the client in the hallway at least four (4) times per day and discourage the use of pharmacological pain relief.
- D. Request the health-care provider (HCP) to assist the client in ambulating in the hallway so the HCP can observe the client’s pain.
Correct Answer: A
Rationale: Assisting with ambulation and pain medication addresses mobility and comfort in sciatica. Strict bedrest hinders recovery, excessive ambulation without pain control is unsafe, and HCP observation is unnecessary.
The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP order should the nurse question?
- A. Maintain heparin to achieve a therapeutic level.
- B. Initiate and monitor intravenous fluids.
- C. Keep the O2 saturation higher than 93%
- D. Administer an intravenous loop diuretic.
Correct Answer: D
Rationale: Loop diuretics are inappropriate for fat embolism syndrome, as they may worsen hypovolemia. Heparin, fluids, and oxygen saturation are standard treatments.
The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement?
- A. Assess the client's surgical dressing every two (2) hours.
- B. Do not allow the client to see the residual limb.
- C. Keep a large tourniquet at the client's bedside.
- D. Perform passive range-of-motion exercises to the right leg.
Correct Answer: A
Rationale: Frequent dressing assessment detects bleeding, a critical post-BKA risk. Hiding the limb is inappropriate, tourniquets are for emergencies, and ROM is premature in recovery.
Which assessment finding most likely indicates that a client has osteoporosis?
- A. Swollen joints
- B. Discomfort when sitting
- C. Spinal deformity
- D. Diminished energy level
Correct Answer: C
Rationale: Spinal deformity, such as kyphosis, is a common sign of osteoporosis due to vertebral compression fractures from reduced bone density. Swollen joints, discomfort, or low energy are less specific.