Nur 105 - Unit 6
After a client has spinal surgery, it is essential that the nurse: 1.Encourage the client to drink fluids 2.Log-roll the client to the prone position 3.Assess the client's feet for circulation and sensation 4.Observe the client's bowel movements and voiding patterns
2. Log-roll the client to the prone position Alteration in circulation and sensation indicates damage to the spinal cord; if this occurs, the health care provider must be notified immediately. After surgery, the health care provider's prescription should specify if the client is permitted oral fluids. The prone position is contraindicated because it will hyperextend the vertebral column; log-rolling from side to side is preferred. Although observing the client's bowel movements and voiding patterns will be done, it is not the priority.
A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which clinical indicator is unique to a fat embolus? 1. Anxiety 2.Restlessness 3.Pinpoint red spots on the chest 4.Decreased arterial oxygen level
2. Restlessness Fat emboli cause capillary fragility; rupture of capillary walls results in pinpoint red spots (petechiae). Anxiety occurs in both fat embolism and thromboembolism. There often is a feeling of dread or impending doom. Restlessness and confusion due to cerebral hypoxia occur in both fat embolism and thromboembolism. The Po2 may be decreased in both fat embolism and thromboembolism.
To reduce a hip fracture, the client is placed in traction before surgery for an open reduction and internal fixation. Because the client keeps slipping down in bed, increased countertraction is prescribed. How does the nurse increase the countertraction? 1.Elevate the head of the bed. 2.Add more weight to the traction. 3.Use a slight Trendelenburg position. 4.Tie a chest restraint around the client.
3. Use a slight Trendelenburg position Elevating the foot of the bed uses gravity and the client's weight for countertraction. Elevating the head of the bed will not increase countertraction. Adding more weight to the traction will increase traction rather than countertraction. Tying a chest restraint around the client will have no effect on countertraction.
A client with rheumatoid arthritis is scheduled to participate in an exercise program that is established at the extended care facility where the client resides. The nurse evaluates that the client understands the purpose of the program when the client states: 1."I know the exercises are important, so I do them whenever I can." 2."I do my exercises when I go to physical therapy in the morning and afternoon." 3."Because I'm stiff in the morning, I do most of my exercises then, so I'm done for the day." 4."After I eat breakfast, I do one set of exercises slowly, and then I space the rest of them throughout the day."
4. "After I eat breakfast, I do one set of exercises slowly, and then I space the rest of them throughout the day." Spacing activity protects joints from overuse, misuse, and stress, limiting inflammation; it provides a balance between rest and activity. The exercise program should be planned; too much activity can precipitate an exacerbation, and too little may cause contractures. Spaced range of motion should be incorporated into daily living activities, not just twice a day. The actions expressed in the response "Because I'm stiff in the morning, I do most of my exercises then, so I'm done for the day" will cause stress at the joints, which may precipitate an exacerbation.
After an open reduction and internal fixation of a fractured hip, the nurse is helping a client to get out of bed into a chair. What should the nurse do to best accomplish this transfer? 1.Use a transfer board to slide the client from the bed to the chair. 2.Ask the client to put weight equally on both legs and step to the chair. 3.Have several people assist with lifting the client from the bed to the chair. 4.Instruct the client to bear most of the weight on the unaffected leg and pivot to the chair
4. Instruct the client to bear most of the weight on the unaffected leg and pivot to the chair Weight-bearing on the unaffected leg will help maintain muscle strength; weight-bearing on the affected leg may be limited initially by the health care provider's prescription or by the client's inability to tolerate weight-bearing. Using a transfer board to slide the client from the bed to the chair does not involve weight-bearing; weight-bearing helps maintain muscle strength in the unaffected leg and independence and should be encouraged unless contraindicated by a health care provider's prescription. Asking the client to put weight equally on both legs and step to the chair may be contraindicated; weight-bearing on the affected leg without a prescription can disrupt the repair, or the client may not be able to fully bear weight initially because of discomfort. Having several people assist with lifting the client from the bed to the chair does not involve weight-bearing; weight-bearing helps maintain muscle strength in the unaffected leg and independence and should be encouraged unless contraindicated by a health care provider's prescription.
The nurse is making rounds and stops to check a client who has had a total hip arthroplasty. Which of these actions by the unlicensed assistive personnel (UAP) would cause the nurse to intervene? 1.The client's heels are kept off the bed. 2.The UAP elevates the client's affected leg on a pillow. 3.The UAP uses a pillow to keep the client's legs abducted. 4.The client uses a walker when ambulating with the UAP
4. The client uses a walker when ambulating with the UAP Using a pillow to elevate the affected leg would cause flexion of the hip, which is to be avoided. Keeping the heels off the bed is an important measure to prevent skin breakdown. The abduction pillow promotes proper position of the prosthesis and helps to prevent dislocation. Use of a walker is important to assist with ambulation and promote safety.
