Nokea
Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching?
- A. I need to eat a high-protein diet to ensure healing.'
- B. I need to wiggle my fingers every hour to increase circulation.'
- C. I need to take my pain medication before my pain is too bad.'
- D. I need to keep this immobilizer on when lying down only.'
Correct Answer: D
Rationale: Immobilizers must be worn continuously to stabilize a fractured ulna, not just when lying down. High-protein diet, finger movement, and proactive pain management are correct.
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The nurse is caring for clients on an orthopedic floor. Which client should be assessed first?
- A. The client diagnosed with back pain who is complaining of a '4' on a 1-to-10 scale.
- B. The client who has undergone a myelogram who is complaining of a slight headache.
- C. The client two (2) days post-disk fusion who has T 100.4, P 96, R 24, and BP 138/78.
- D. The client diagnosed with back pain who is being discharged and whose ride is here.
Correct Answer: C
Rationale: Fever, tachycardia, and tachypnea post-disk fusion suggest infection or complications, requiring urgent assessment. Mild pain, headache, and discharge are lower priority.
The nurse would be correct to request a consultation with a dietitian if the client chooses a meal that includes which food?
- A. Nuts
- B. Milk
- C. Eggs
- D. Liver
Correct Answer: D
Rationale: Liver is high in purines, which increase uric acid levels, worsening gout. Nuts, milk, and eggs are low-purine foods, suitable for a gout diet, necessitating a dietitian consultation for education.
What is the goal of therapy for a child newly diagnosed with scoliosis as explained by the nurse?
- A. Limit or stop progression of the curvature of the spine.
- B. Prepare the child for surgical correction at a later date.
- C. Minimize the complications of prolonged immobilization.
- D. Develop a pain management plan to minimize complications.
Correct Answer: A
Rationale: The primary goal of scoliosis treatment is to halt or limit the progression of spinal curvature.
The client just underwent a left THR. After a family member assists the client with repositioning in bed, the client states hearing a 'pop' and has increased pain at the surgical site. Which is the most appropriate initial action by the nurse?
- A. Check the position of the left lower extremity.
- B. Elevate the head of the client's bed.
- C. Adjust the pillow used for abduction.
- D. Administer the prescribed pain medication.
Correct Answer: A
Rationale: A. The nurse's initial action should be to check the extremity's position. Improper movement and repositioning can cause prosthesis dislocation; an audible pop and increased pain are signs of possible dislocation.
Which intervention should the nurse implement for a client with a fractured hip in Buck’s traction?
- A. Assess the insertion sites for signs and symptoms of infection.
- B. Monitor for drainage or odor from under the plaster covering the pins.
- C. Check the condition of the skin beneath the Velcro boot frequently.
- D. Take weights off for one (1) hour every eight (8) hours and as needed.
Correct Answer: C
Rationale: Checking skin under the Velcro boot prevents irritation or breakdown in Buck’s traction. Insertion sites and plaster are for skeletal traction, and weights must remain constant.