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Which technique is the best strategy for assessing circulation in the leg in Buck's traction?
- A. Observe whether the client can wiggle or move the toes.
- B. Palpate for pulsation of the dorsalis pedis artery.
- C. Take the client's blood pressure with a thigh cuff positioned on the affected leg.
- D. Determine whether the client can feel sharp and dull sensations.
Correct Answer: B
Rationale: Palpating the dorsalis pedis pulse directly assesses arterial circulation in the leg, providing the most accurate indication of blood flow. Toe movement and sensation are less specific, and blood pressure measurement is not relevant.
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The client is an elderly man who has had diabetes and peripheral vascular disease for several years. He now has had a right below-the-knee amputation. Which preoperative nursing action will do the most to help the client adjust to having an amputation?
- A. Encouraging deep breathing
- B. Asking him if he understands the full effects of the planned surgery
- C. Discussing the effects of diabetes on the vascular system
- D. Having a recovered amputee visit him
Correct Answer: D
Rationale: A visit from a recovered amputee provides peer support, helping the client adjust by seeing a positive outcome.
The client is admitted to the ED after a sports injury. The client verbalizes extreme shoulder pain, and the nurse sees that the client's right arm is shorter than the left. What should the nurse do initially? Select all that apply.
- A. Lift the right arm to support it with a pillow.
- B. Apply a covered ice pack to the left shoulder.
- C. Prepare the client for immediate surgical repair.
- D. Check the pulses and sensation of the right arm.
- E. Prepare to administer an analgesic as prescribed
- F. Inspect the left shoulder for swelling and bruising.
Correct Answer: D,E
Rationale: D. Assessment of pulses and sensation is important because compression of nerves and blood vessels can occur with shoulder dislocation. A shortened arm on the right indicates that the right shoulder is affected. E. The client is in severe pain and requires pain control.
The client with rheumatoid arthritis has been taking 15 to 20 extra-strength aspirin a day. Which additional statement that the client makes would be of greatest concern to the nurse?
- A. I sometimes have ringing in my ears.'
- B. I have a rash under my arms.'
- C. My fingers are swollen sometimes.'
- D. I don't have very much energy.'
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of aspirin toxicity, a serious concern requiring immediate attention.
Which nursing instruction is most beneficial to minimize stress on the client's painful joints?
- A. Maintain a normal weight.
- B. Apply a topical analgesic cream.
- C. Take a calcium supplement.
- D. Become more physically active.
Correct Answer: A
Rationale: Maintaining a normal weight reduces mechanical stress on weight-bearing joints like the hip, alleviating pain and slowing osteoarthritis progression. The other options are less impactful for joint stress.
The client has an external fixator for reduction of a tibia fracture. The nurse is evaluating the client's effectiveness in ambulating with crutches. Place an X on each of the three areas where the client should be bearing weight When crutch walking.
- A. The client should be bearing weight on the hand grips when bringing legs forward. When moving crutches, the weight should be borne on the unaffected leg.
Correct Answer: image
Rationale: The client should be bearing weight on the hand grips when bringing legs forward and on the unaffected leg when moving crutches to ensure proper crutch-walking technique and stability.