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:
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Solution
Answer A is correct. The client’s palms should rest lightly on the handles. The elbows should be flexed no more than 30° but should not be extended, so answer B is incorrect. The client should walk to the middle of the walker, not to the front of the walker, so answer C is incorrect. The client should be taught not to carry the walker, so answer D is incorrect.
A client with a total knee replacement has a CPM applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
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Solution
Answer B is correct. The controller for the continuous passive-motion device should be placed distal to the site to prevent the client from being able to turn off the machine. If the client is allowed to have the control close by, he might be tempted to turn off the machine and stop the passive motion. This treatment is often painful, so the nurse should offer pain medication before the treatment. Answer A is incorrect because the client cannot ambulate during the therapy. Answer C is incorrect because pain is expected and is not a reason to turn off the machine. Answer D is incorrect because the continuous passive-motion machine 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?
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Solution
Answer C is correct. Halo traction will be ordered for the client with a cervical fracture. Russell’s traction is used for bones of the lower extremities, as is Buck’s traction, so answers A and B are incorrect. Cruchfield tongs are used while in the hospital and the client is immobile, so answer D is incorrect.
A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
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Solution
Answer A is correct. 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 illeus. Checking the blood pressure is a treatment for any client but is not specific to a spica cast, so answer B is incorrect. Answers C and D are incorrect because they are not concerns associated with a body cast or spica cast.
The nurse is assigned to care for the client with a Steinmen 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?
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Solution
Answer A is correct. The nurse is performing the pin care correctly when she uses sterile gloves and Q-tips. The nurse can assist her co-worker by opening any packages of sterile dressings that are needed. Answers B, C, and D are incorrect. The nurse should use sterile gloves, not clean gloves, for pin care, a licensed practical nurse can perform pin care, and there is no need to clean the weights.
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?
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Solution
Answer A is correct. 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. This makes answers B, C, and D incorrect.
A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:
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Solution
Answer D is correct. A plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. The cast should be handled with the palms, not the fingertips, so answer A is incorrect. Answer B is incorrect because bivalving a cast is done for compartment syndrome and is not routine. The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client, so answer C is incorrect.
A client with rheumatoid arthritis has a prescription for hydroxychloroquine (Plaquenil). Which instruction should be included in the discharge teaching?
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Solution
Answer D is correct. Plaquenil can cause color blindness, and therefore requires that the client’s vision be evaluated every six months. Answer A is incorrect because there is no need to take the medication with milk. Answers B and C are incorrect because these actions are unnecessary. Answer C is incorrect because there is no need to remain upright for 30 minutes after taking the medication.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?
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Solution
Answer B is correct. The 6-year-old should have a roommate as close to the same age as possible. The client in answer A is 16 and a female. The client in answer C is closest to the client’s age, but the 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed. The 6-year-old with osteomylitis is infected, so answer D is incorrect.
An elderly client with 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
Answer B is correct. Narcan is the antidote for narcotic overdose. If hypoxia occurs, the client should have oxygen administered by mask, not cannula, so answer A is incorrect. There is no data to support administering blood products or cardioresuscitation, so answers C and D are incorrect.