Nokea
Which of the following would the nurse identify as the highest priority when documenting the postoperative circulation status of the recently casted extremity?
- A. Adequate neurovascular functioning
- B. Minimal pain on movement
- C. Vital signs within normal limits
- D. No drainage noted on the cast
Correct Answer: A
Rationale: Adequate neurovascular functioning (circulation, sensation, and movement) is the highest priority to ensure no complications like compartment syndrome or vascular compromise, which can lead to tissue damage. Pain, vital signs, and drainage are secondary.
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When planning the client's postoperative care, which is the least desirable position in which the nurse can place the client?
- A. Lying supine
- B. Sitting in a chair
- C. Lying on the side
- D. Standing to shower
Correct Answer: D
Rationale: Standing to shower is least desirable post-below-the-knee amputation due to the risk of falls and weight-bearing on the stump, which could disrupt healing. Other positions are safer.
When the nurse observes the client walking, which assessment finding indicates the need for more instruction regarding the use of the cane?
- A. The tip of the cane is covered with a rubber cap.
- B. The client wears athletic shoes with nonskid soles.
- C. The client uses the cane on the painful side.
- D. The client looks straight ahead when walking.
Correct Answer: C
Rationale: The cane should be used on the unaffected side to support the painful hip, distributing weight appropriately. Using it on the painful side reduces its effectiveness, requiring further instruction.
Which intervention for bladder emptying should the nurse plan to implement for a 14-year-old with a neurogenic bladder from an SCI with a lower motor neuron lesion?
- A. Intermittent catheterization
- B. Insertion of a retention catheter
- C. Insertion of a suprapubic catheter
- D. Giving an anticholinergic medication
Correct Answer: A
Rationale: Intermittent catheterizationelevation is preferred for neurogenic bladder due to lower motor neuron lesions to prevent urinary retention.
In which conditions might the nurse assess for the presence of papilledema?
- A. Eczema
- B. Craniosynostosis
- C. Shaken baby syndrome
- D. Hydrocephalus
- E. Chest trauma
Correct Answer: B,C,D
Rationale: Papilledema, indicating increased intracranial pressure, can be associated with craniosynostosis, shaken baby syndrome, and hydrocephalus.
The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
- A. Help the client with a two (2)-day postop amputation put on the prosthesis.
- B. Request the UAP double-check a unit of blood to be hung.
- C. Change the surgical dressing on the client with a Syme's amputation.
- D. Ask the UAP to take the client to the physical therapy department.
Correct Answer: D
Rationale: Transporting a client to PT is within UAP scope. Prosthesis application, blood verification, and dressing changes require nursing judgment.