MD-2 {2)
A client has had a bone scan done. The nurse determines that the client demonstrates understanding of postprocedure care when the client makes which statement? "Flushing indicates a complication." "I should stay on liquids for a couple of days." "I need to ambulate every couple of hours faithfully for a few days." "I need to drink plenty of water for 1 to 2 days after the procedure."
"I need to drink plenty of water for 1 to 2 days after the procedure." Rationale: No special restrictions are necessary after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. The very small amount of radioactivity from the isotope presents no hazard to the client or staff. The remaining options are unrelated to postprocedure care.
A client who has had spinal fusion and insertion of hardware is extremely concerned with the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to prior employment. The nurse understands that the client's needs could best be addressed by referral to which member of the health care team? The surgeon A social worker The physical therapist The clinical nurse specialist
A social worker Rationale: After spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This professional can provide the most helpful information about resources available to the client. The clinical nurse specialist and the surgeon do not have information related to financial resources. The physical therapist has the best knowledge of techniques for increasing mobility and endurance
The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? The pain level of the client Blood pressure and respiratory rate Capillary refill, sensation, color, and pulse of the left foot The range of motion of the left knee when a continuous passive motion machine is used
Capillary refill, sensation, color, and pulse of the left foot Rationale: The nurse would check capillary refill, sensation, color, and pulse of the affected extremity in a neurovascular assessment. Monitoring the pain level may be a component of the assessment but is not specifically related to neurovascular status. Blood pressure and respiratory rate may also be components of the nursing assessment but are not specific to neurovascular status. Range of motion is related to musculoskeletal status, not neurovascular status.
The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. What should the nurse instruct the client to do? Wear the sling at nighttime. Keep a sling on the arm at all times. Avoid range-of-motion exercises to the affected arm. Lift the shoulder of the casted arm over the head periodically throughout the day.
Lift the shoulder of the casted arm over the head periodically throughout the day. Rationale: A stiff or frozen shoulder can develop as a complication of a cast on an upper extremity. The client should be instructed to lift the shoulder of the casted arm over the head periodically throughout the day to prevent this complication. The client should not keep a sling on the arm at all times or wear the sling at nighttime. Range-of-motion exercises to the casted extremity would assist in preventing this complication.
A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse should explore which item next? Concern about the level of postoperative pain The availability of assistance for the client after discharge Whether the client needs a PRN prescription for an antianxiety agent Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection
Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection Rationale: Clients who receive cadaver bone may worry about contracting human immunodeficiency virus or hepatitis or another infection from the cadaver bone. To ease their fear clients need reassurance and information about the donor screening that is done. The level of pain that will be experienced in the postoperative period and the availability of assistance for the client after discharge should be included as part of the basic preparation of the client for surgery. Administering antianxiety medication is used as a last measure if other reassuring measures are not effective.
The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which would be an abnormal finding? Presence of fasciculations Muscle strength of normal power Symmetrical movements bilaterally Hypertrophy of right upper arm of 1 cm
Presence of fasciculations Rationale: Fasciculations are fine-muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding.
A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? Allows bony healing to begin before surgery and involves pins and screws Provides rigid immobilization of the fracture site and involves pulleys and wheels Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels
Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels Rationale: Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.
A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? Hemorrhage Edema of the residual limb Slight redness of the incision Separation of the wound edges
Separation of the wound edges Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative hemorrhage and edema of the residual limb are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as the incision is dry and intact.
