Nokea
Which response by the nurse would be most accurate?
- A. You may be experiencing referred pain from an adjacent muscle.
- B. You may be experiencing phantom pain from the amputated site.
- C. You may be experiencing psychogenic pain from emotional distress.
- D. You may be experiencing intractable pain that can best be treated with opioids.
Correct Answer: B
Rationale: Phantom pain is common post-amputation, arising from nerve endings.
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A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump?
Correct Answer: 30
Rationale: Concentration: 20,000 units ÷ 500 mL = 40 units/mL. Rate: 1200 units/hr ÷ 40 units/mL = 30 mL/hr.
The nurse documents the admission assessment for the client who is to have a left total hip arthroplasty to treat chronic degenerative joint disease. Which statements indicate that the client uses alternative therapies for CA treatment? Select all that apply.
- A. I take ibuprofen every 4 to 6 hours.'
- B. I wear a copper bracelet all the time.'
- C. I take glucosamine sulfate 1000 mg daily.'
- D. I apply special magnets to the hip joint.'
- E. I sleep on the unaffected hip, turning often.'
Correct Answer: B,C,D
Rationale: B. Wearing a copper bracelet is an alternative therapy used by some with CA for pain control and reduction of joint stiffness. C. Taking glucosamine sulfate is an alternative therapy used by some with CA. Glucosamine is taken to modify cartilage structure, but studies supporting this have been inconclusive. D. Using magnets designed for body application is an alternative therapy used by some with CA for pain control and reduction of joint stiffness.
The nurse is analyzing the serum laboratory report for the client diagnosed with lung cancer that has metastasized to the pelvic bone. Which specific finding should the nurse anticipate?
- A. Elevated calcium
- B. Decreased hemoglobin
- C. Elevated creatinine (SCr)
- D. Elevated creatine kinase (CK)
Correct Answer: A
Rationale: A. Malignant tumors cause hypercalcemia through a variety of mechanisms, one being an increased release of calcium from the bones.
The nurse advises the client on the need for maintenance of the bandage. When should the nurse advise the client with a sprained ankle to rewrap the elastic bandage?
- A. When the toes appear pink
- B. When the ankle feels painful
- C. When the toes look swollen
- D. When the joint feels stiff
Correct Answer: C
Rationale: Swollen toes indicate compromised circulation or inadequate compression, necessitating rewrapping to ensure proper fit and pressure. Pink toes suggest normal circulation, pain may not always indicate bandage issues, and joint stiffness is expected with a sprain but not directly related to bandage maintenance.
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.