When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
-
Solution
Elevate the client’s hips.
The client with a prolapsed cord should be treated by elevating the hips and covering the cord with a moist, sterile saline gauze. The nurse should use her fingers to push up on the presenting part until a cesarean section can be performed.
Options A, B, and D: The nurse should not attempt to replace the cord, turn the client on the side, or cover with a dry gauze.
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
-
Solution
Palms rest lightly on the handles
The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended.
Option B: A 0° is not a relaxed angle for the elbows and will not facilitate correct walker use.
Option C: The client should walk to the middle of the walker, not to the front of the walker.
Option D: The client should be taught not to carry the walker because this would not provide stability.
A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates an understanding of the CPM machine?
-
Solution
“The CPM machine controls should be positioned distal to the site.”
The controller for the continuous-passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg.
Option A: The client is in the bed during CPM therapy.
Option C: The client will experience pain with the treatment.
Option D: Use of the CPM does not alleviate the need for physical therapy.
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
-
Solution
Halo traction
Halo traction will be ordered for the client with a cervical fracture.
Options A and B: Russell’s traction is used for bones of the lower extremities, as is Buck’s traction.
Option D: Crutchfield tongs are used while in the hospital and the client is immobile.
A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
-
Solution
Check the bowel sounds
A body cast or spica cast extends from the upper abdomen to the knees or below. Bowel sounds should be checked to ensure that the client is not experiencing a paralytic ileus.
Options B, C, and D: Checking the blood pressure is a treatment for any client, offering pain medication is not called for, and checking for swelling isn’t specific to the stem.
The nurse is assigned to care for the client with a Steinmann pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
-
Solution
Assisting the LPN with opening sterile packages and peroxide
The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips.
Options B, C, and D: A licensed practical nurse can perform pin care, there is no need to clean the weights, and the nurse can help with opening the packages but it isn’t required.
The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
-
Solution
“It will be alright for your friends to autograph the cast.”
There is no reason that the client’s friends should not be allowed to autograph the cast; it will not harm the cast in any way, so answers B, C, and D are incorrect.
A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates an understanding of a plaster-of-Paris cast? The nurse:
-
Solution
Allows 24 hours before bearing weight
A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours.
Option A: The cast should be handled with the palms, not the fingertips.
Option B: Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast.
Option C: The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying.
A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
-
Solution
Report chest pain.
Cox II inhibitors have been associated with heart attacks and strokes. Any changes in cardiac status or signs of a stroke should be reported immediately, along with any changes in bowel or bladder habits because bleeding has been linked to use of Cox II inhibitors.
Options A, C, and D: The client does not have to take the medication with milk, remain upright, or allow 6 weeks for optimal effect.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?
-
Solution
12-year-old male with a fractured femur
The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match.
Option A: The client is too old and is female.
Option C: The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed
Option D: The 6-year-old with osteomyelitis is infectious.