AH PREP U Ch. 40

The nurse is caring for a client who lives alone and had total knee replacement. An appropriate nursing care diagnosis for the client would be: A. Risk for ineffective therapeutic regimen management B. Risk for avascular necrosis of the joint C. Situational low self-esteem D. Disturbed body image

A. Risk for ineffective therapeutic regimen management The client without adequate support and resources is at risk for ineffective therapeutic regimen management.

Which is an inaccurate principle of traction? A. The client must be in good alignment in the center of the bed. B. The weights are not removed unless intermittent treatment is prescribed. C. Skeletal traction is interrupted to turn and reposition the client. D. The weights must hang freely.

A. Skeletal traction is interrupted to turn and reposition the client. Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.

A nurse is caring for a client after stabilization of a radial fracture. Which actions by the nurse would be appropriate for the client following arm casting? Select all that apply. A. Elevate the arm on a plastic-covered pillow B. Handle the cast with the palms of the hand C. Petal and smooth the edges of the cast D. Circulate room air w/ portable fan E. Protect the cast by covering with a sheet.

B. Handle the cast with the palms of the hand D. Circulate room air w/ portable fan

The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for? A. An open reduction B. A total hip replacement C. A fasciotomy D. A total knee replacement

C. A fasciotomy A treatment option for compartment syndrome is fasciotomy.

A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client? A. Apply warm compresses B. Administering prescribed analgesics C. Changing the client's position within prescribed limits D. Assisting with ROM and isometric exercises.

C. Changing the client's position within prescribed limits. Changing the position of a client within prescribed limits helps relieve pressure on bony areas and promotes comfort. Analgesics help to relive pain but may not help relieve pressure on bony areas.

A client has undergone an external fixation. Which actions would be the priority for this client? A. Monitoring the client's urine output B. Planning the client's diet C. Maintaining pin care D. Monitoring the client's blood pressure

C. Maintaining pin care Pin care is a priority for a client with external fixation, because pin sites are entry points for infection. The nurse should also monitor redness, drainage, and tenderness at the site.

Which is not a guideline for avoiding hip dislocation after replacement surgery? A. Keep knees apart at all times B. Never cross the legs when seated C. The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes. D. Put a pillow between the legs when sleeping.

C. The hip may be flexed to put on clothing such as pants, stocking, socks, or shoes. Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.

The nurse is preparing a client to have his cast cut off after having it for 6 weeks to treat a fractured tibia. What should the nurse inform the client prior to having the cast be removed? A. The leg will look moist and will have small bumps that will go away in a few days. B. The leg will look as it did prior to the cast being applied. C. The skin may be covered with a yellowish crust that will shed in a few days. D. The leg strength is enforced by the wearing of the cast.

C. The skin may be covered with a yellowish crust that will shed in a few days. Once the cast is off, the skin appears mottled and may be covered with a yellowish crust composed of accumulated body oil and dead skin. The client usually sheds this residue in a few days.

A patient arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the patient to describe the pain? A. Sore and aching B. A dull, deep, boring ache C. Similar to "muscle cramps" D. Sharp and piercing

D. Sharp and piercing

Which intervention would the nurse implement with the client in a plaster cast? Select all that apply. A. Position casted extremity firmly on a hard surface while drying. B. Trim, reshape, and smooth edges of cast C. Protect wet cast by covering it with a sheet D. Notify HCP if client reports warmth of cast E. Handle wet cast w/ palms of hands

E. Handle wet cast w/ palms of hands B. Trim, reshape and smooth edges of cast Changing the position of a client within prescribed limits helps relieve pressure on bony areas and promotes comfort. Analgesics help to relive pain but may not help relieve pressure on bony areas.