An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
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Solution
Have narcan (naloxone) available
Narcan is the antidote for narcotic overdose.
Option A: If hypoxia occurs, the client should have oxygen administered by mask, not cannula.
Options C and D: There is no data to support the administration of blood products or cardiac resuscitation.
A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?
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Solution
High-seat commode
The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee.
Option B: The recliner is good because it prevents 90° flexion but not daily activities.
Option C: A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management.
Option D: An abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis.
The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
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Solution
The client’s parents are skilled stained-glass artists.
Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads.
Option A: Traveling out of the country does not increase the risk of plumbism.
Option C: The house was built after the lead was removed with the paint.
Option D: Having several siblings is unrelated to the stem.
The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor?
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Solution
The client’s hematocrit is 26%.
The client with a total knee replacement should be assessed for anemia. A hematocrit of 26% is extremely low and might require a blood transfusion.
Options A: Bleeding of 2cm on the dressing is not extreme. Circle and date and time the bleeding and monitor for changes in the client’s status.
Option B: A low-grade temperature is not unusual after surgery. Ensure that the client is well hydrated, and recheck the temperature in 1 hour. If the temperature is above 100.6°F (38.1°C), report this finding to the doctor. Tylenol will probably be ordered.
Option D: Voiding after surgery is also not uncommon and no need for concern.
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates an understanding of the nurse’s teaching?
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Solution
“I must flush the tube with water after feedings and clamp the tube.”
The client’s family member should be taught to flush the tube after each feeding and clamp the tube.
Options B and C: The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client.
Option D: Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing.
The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
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Solution
Serum collection (Davol) drain
Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging.
Option B: The client’s pain should be assessed, but this is not life-threatening.
Options C and D: When the client is in less danger, the nutritional status should be assessed and an immobilizer is not used.
A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
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Solution
Utilizes a Steinman pin
Balanced skeletal traction uses pins and screws. A Steinman pin goes through large bones and is used to stabilize large bones such as the femur.
Option B: Only the affected leg is in traction.
Option C: Kirschner wires are used to stabilize small bones such as fingers and toes.
Option D: Buck’s traction is not used for fractured hips.
A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
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Solution
The buttocks are 15° off the bed.
The infant’s hips should be off the bed approximately 15° in Bryant’s traction.
Option A is incorrect because this does not indicate that the traction is working correctly, nor does C.
Option D is incorrect because Bryant’s traction is a skin traction, not a skeletal traction.
The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
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Solution
Hormonal disturbances
After menopause, women lack hormones necessary to absorb and utilize calcium.
Options A and C: Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes.
Option D: Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely related to osteoporosis.
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
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Solution
Disalignment
The client with a hip fracture will most likely have misalignment.
Options A, C, and D: All fractures cause pain, and coolness of the extremities and absence of pulses are indicative of compartment syndrome or peripheral vascular disease.