Nokea
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.
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The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first?
- A. Wrap the left hand with towels and apply pressure.
- B. Instruct the friend to hold his hand above his head.
- C. Apply pressure to the radial artery of the left hand.
- D. Go into the friend's house and call 911.
Correct Answer: A
Rationale: Applying pressure with towels controls bleeding, the priority in traumatic amputation. Elevation is secondary, radial pressure is less effective, and calling 911 delays hemorrhage control.
The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement?
- A. Refer the client to physical therapy at home.
- B. Refer the client to an assistive living facility.
- C. Refer the client to a workforce commission for job training.
- D. Refer the client to the dietitian.
Correct Answer: A
Rationale: Home PT restores hand/forearm function post-crushing injury. Assisted living, job training, and dietitian referrals are premature or unrelated.
Which statement by the nurse about fiberglass casts is most accurate?
- A. Fiberglass casts are less expensive than plaster
- B. Fiberglass casts are lightweight.
- C. Fiberglass casts are flexible.
- D. Fiberglass casts are less restrictive than plaster casts.
Correct Answer: B
Rationale: Fiberglass casts are lightweight compared to plaster, making them more comfortable for clients. They are not necessarily less expensive, flexible, or less restrictive, as both types immobilize effectively.
Which statement made by the family member indicates the need for further teaching?
- A. The hand should be elevated higher than the elbow.
- B. The knot should be tied at the back of the neck.
- C. The elbow should be flexed within the sling.
- D. The sling is used to elevate and support the arm.
Correct Answer: B
Rationale: Tying the knot at the back of the neck may cause discomfort or pressure on the cervical spine. The knot should be tied to the side to avoid this. The other statements correctly describe the proper use of a triangular sling for shoulder immobilization.
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.