Nokea
While teaching the client, what can the nurse explain about the purpose of stump bandaging?
- A. It lengthens and tones the muscles.
- B. It maintains joint flexibility.
- C. It shapes the stump for prosthesis use.
- D. It absorbs blood and drainage.
Correct Answer: C
Rationale: Stump bandaging shapes the residual limb into a conical form, facilitating prosthetic fitting and reducing swelling. It does not primarily tone muscles, maintain flexibility, or absorb drainage.
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The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)?
- A. Allow the client to stay in bed until the pain becomes bearable.
- B. Tell the UAP to give the client a bed bath this morning.
- C. Try to encourage the client to get up and go to the shower.
- D. Notify the family the client is refusing to be bathed.
Correct Answer: C
Rationale: Encouraging the client to shower promotes mobility, which reduces OA stiffness, while addressing pain. Bed rest worsens stiffness, bed baths enable immobility, and family notification is unnecessary.
Until a translator is available, which nursing action is best when teaching the client who speaks English as a second language about body mechanics?
- A. Speak slowly while looking at the client.
- B. Write the instructions on paper.
- C. See the client and the patient.
- D. Have the client watch a video.
Correct Answer: A
Rationale: Speaking slowly while maintaining eye contact enhances comprehension for a non-native speaker, using nonverbal cues to reinforce verbal instructions until a translator is available.
What equipment is best for preventing external rotation of the operative leg when caring for a client with a total hip replacement?
- A. A footboard
- B. A trochanter roll
- C. A turning sheet
- D. A foam mattress
Correct Answer: B
Rationale: A trochanter roll placed along the hip prevents external rotation of the operative leg, maintaining proper alignment post-hip replacement. The other options do not specifically address rotation.
Which laboratory test value, if elevated, is the best diagnostic indicator of rheumatoid arthritis?
- A. Erythrocyte sedimentation rate (ESR)
- B. Partial thromboplastin time (PTT)
- C. Partial thromboplastin time (PTT)
- D. Blood urea nitrogen (BUN)
Correct Answer: A
Rationale: An elevated ESR indicates inflammation, a hallmark of rheumatoid arthritis, making it a key diagnostic marker. PTT and BUN are unrelated to rheumatoid arthritis diagnosis.
The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report?
- A. The 84-year-old female with a fractured right femoral neck in Buck’s traction.
- B. The 64-year-old female with a left total knee replacement who has confusion.
- C. The 88-year-old male post-right total hip replacement with an abduction pillow.
- D. The 50-year-old postop client with a continuous passive motion (CPM) device.
Correct Answer: B
Rationale: Confusion post-TKR may indicate neurological or metabolic complications, requiring urgent assessment. Fractures, THR, and CPM use are stable.