The client with a joint replacement is scheduled to receive Lovenox (enoxaparin). Which lab value should be reported to the doctor?
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Solution
Answer B is correct. A PTT of 300 is extremely prolonged and can indicate bleeding. Answers A, C, and D are incorrect because there is no need to report a PT of 20, a Protime of 30 seconds, or an INR of 3 because these are within normal findings.
A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with prevention of dislocation of the prosthesis?
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Solution
Answer A is correct. An abduction pillow will help to prevent adduction of the hip joint. The client should be taught to avoid crossing the legs. Answer B is incorrect because the client should not flex the hip more than 90°; the straight chair would potentiate the flexion of the hip more than 90°. Answer C is incorrect because the client should use a walker, not crutches, to ambulate. Answer D is incorrect because a hard mattress is best, not a soft one.
The nurse is caring for the client with a 5-year-old diagnosed with plumbism. Which information in the health history is most likely related to the development of plumbism?
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Solution
Answer B is correct. Plumbism is lead poisoning. If the parents have stained glass as a hobby, there is a danger that the lead used to adhere stained glass can drop in the work area where the child can consume the lead beads. Other factors associated with the consumption of lead are eating from pottery made in Central America or Mexico that is unfired. In answer A, there is no data to suggest that the child is drinking from pottery bought in Central America. Answer C is incorrect because the child in this situation lives in a house built in 1990. Lead was taken out of paint in 1976. Answer D is unrelated to plumbism.
The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor?
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Solution
Answer C is correct. The client with a total knee replacement should be assessed for anemia. A hemaglobin of 6g/dL is extremely low and might require a blood transfusion (the normal is 14–18g/dL). Bleeding on the dressing of 2cm is not extreme, so answer A is incorrect. Circle the bleeding, write the date and time on the dressing, and chart the finding. If the drainage continues to enlarge, notify the doctor. A low-grade temperature is not unusual after surgery, so answer B is incorrect. Recheck the temperature in 1 hour. If the temperature rises above 101°F, report this finding to the doctor. Tylenol will probably be ordered. Voiding after surgery is not uncommon and is not a sign of immediate danger, so answer D is incorrect. Ensure that the client is well hydrated and monitored.
Which statement made by the family member caring for the client with a percutaneous gastrotomy tube indicates understanding of the nurse’s teaching?
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Solution
Answer A is correct. The client’s family member should be taught to flush the tube after each feeding and clamp the tube. The placement should be checked before feedings, so answer B is incorrect. Indigestion can occur with the PEG tube just as it can occur with any client, so there is no need to call the doctor, as suggested in answer C. Medications can be ordered for this, but it is not a reason for alarm. A percutaneous endoscopy gastrotomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing, so answer D is incorrect.
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 client for:
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Solution
Answer A is correct. Bleeding is a common complication of orthopedic surgery. The blood-collection device should be checked frequently to ensure that the client is not hemorrhaging. Answer B is incorrect because the client’s pain should be assessed, but this is not life-threatening. Answer C is incorrect because the nutritional status should be assessed later. An immobilizer is not used, so answer D is incorrect.
A client with a fractured hip has been placed in traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
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Solution
Answer A is correct. 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. Answer B is incorrect because only the affected leg is in traction. Kirschner wires are used to stabilize small bones, such as fingers and toes, so answer C is incorrect. Answer D is incorrect because this type of 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
Answer B is correct. The infant’s hips should be off the bed approximately 15° in Bryant’s traction. Answers A and C are incorrect because they do not indicate that the traction is working correctly. Answer D is incorrect because Bryant’s traction is skin traction, not skeletal traction.
The nurse knows that the 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
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Solution
Answer B is correct. After menopause, women lack hormones necessary to absorb and utilize calcium. Doing weight-bearing exercises and taking calcium supplements can help prevent osteoporosis, but these are not the most likely causes, so answers A and C are incorrect. Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely to cause osteoporosis, so answer D is incorrect.
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
Answer B is correct. The client with a hip fracture will most likely have disalignment. Answer A is incorrect because all fractures experience pain. Coolness of the extremity and the absence of pulses are indicative of compartment syndrome or peripheral vascular disease, not a fractured hip, so answers C and D are incorrect.