Nokea
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.
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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.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen?
- A. Do you have any stomach pain or dark stools?
- B. Are you experiencing headaches or dizziness?
- C. Do you notice any swelling in your legs?
- D. Are you having trouble sleeping at night?
Correct Answer: A
Rationale: NSAIDs like ibuprofen commonly cause gastrointestinal adverse effects, such as stomach pain or dark stools (indicating bleeding). These are more specific than headaches, swelling, or sleep issues.
Which evidence is the best indication that the client who had a knee arthroplasty is recovering according to expected outcomes and no longer needs the continuous passive motion (CPM) machine?
- A. The client has minimal pain when ambulating.
- B. The client can flex the operative knee 90 degrees.
- C. The client can be given to the operation of the client's surgical wound is approximated.
- D. None of the above
Correct Answer: B
Rationale: Achieving 90-degree knee flexion is a key milestone post-knee arthroplasty, indicating sufficient joint mobility to discontinue the CPM machine. Pain and wound healing are important but less specific to CPM use.
The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse?
- A. Capillary refill time is less than three (3) seconds.
- B. Pain is not relieved by the patient-controlled analgesia.
- C. Left fingers are edematous and the left hand is purple.
- D. Warm and dry skin on left fingers distal to the elastic bandage.
Correct Answer: C
Rationale: Edema and purple discoloration indicate neurovascular compromise, requiring immediate intervention. Normal refill, unrelieved pain, and warm skin are less urgent.
Before turning the client postoperatively, which nursing instruction is especially important to prevent postoperative complications?
- A. Hold your breath as you are turning.
- B. Move your lower body first, then your chest.
- C. As you hold onto the trapeze, lift your hips off the bed.
- D. Let me roll you as if you were a log.
Correct Answer: D
Rationale: Log-rolling maintains spinal alignment during turning post-laminectomy, preventing strain on the surgical site and reducing complications like nerve damage or incision dehiscence.