NCLEX- RN Practice Exam 12

EXPLANATION

✔Correct answer:

"The CPM machine promotes joint mobility and prevents stiffness."  The Continuous Passive Motion (CPM) machine is commonly used after joint surgeries, such as a total knee replacement, to enhance recovery by promoting joint mobility and preventing stiffness. By gently and passively moving the knee joint through a controlled range of motion, the CPM machine helps maintain flexibility, improves circulation, and reduces the risk of scar tissue formation. These benefits are crucial in the immediate postoperative period to aid recovery and prepare the joint for subsequent physical therapy and active exercises.

The CPM machine works to maintain joint movement without requiring active muscle contraction from the client. It is an adjunct to physical therapy, helping to prepare the knee joint for more intensive rehabilitation and improving functional outcomes.

Think of the CPM machine as a "helper" that keeps a door (the knee joint) swinging gently back and forth to prevent it from getting stuck (stiffness) while the hinges (the joint tissues) heal properly.

Nurses play an important role in ensuring the correct and safe use of the CPM machine to optimize the client’s recovery. Key interventions include:

• Educating the client on the purpose and expected outcomes of CPM therapy.
• Setting the machine to the prescribed range of motion and speed, as ordered by the healthcare provider.
• Monitoring for pain, discomfort, or signs of complications, such as swelling or redness at the surgical site.
• Ensuring proper alignment of the leg in the machine to prevent strain or injury.
• Documenting the client’s tolerance to therapy and communicating any concerns to the provider promptly.

✘Incorrect answer options:

"The CPM machine is used to strengthen the muscles around the knee joint." While the CPM machine is beneficial for maintaining joint mobility and preventing stiffness, it does not strengthen muscles. Muscle strengthening requires active participation in physical therapy exercises, which are not the function of a CPM machine.

"This device will prevent all swelling in the knee after surgery." Swelling is a natural part of the inflammatory process following surgery and cannot be entirely prevented by the CPM machine. While the CPM machine may help reduce swelling by promoting circulation, additional measures such as elevation, ice therapy, and compression are also necessary to manage postoperative edema.

"This device will allow you to walk without assistance sooner." The CPM machine is not designed to directly impact ambulation. While it supports joint recovery by maintaining mobility, regaining the ability to walk without assistance depends on a combination of physical therapy, muscle strengthening, and overall healing.

EXPLANATION

✔Correct answers:

• Muscle twitching and spasms.
• Tingling around the mouth and fingers.
• Positive Trousseau’s sign.

A positive Chvostek's sign is a clinical indicator of hypocalcemia (low calcium levels in the blood). It involves facial muscle twitching in response to tapping over the facial nerve in front of the ear. This sign occurs due to increased neuromuscular excitability caused by hypocalcemia. Hypocalcemia also causes other symptoms, including muscle twitching and spasms (tetany), tingling (paresthesia) around the mouth and extremities, and a positive Trousseau’s sign, which is another classic sign of hypocalcemia. These findings are consistent with increased neuromuscular irritability due to insufficient calcium levels.

1. Muscle Twitching and Spasms (Tetany): Hypocalcemia increases the excitability of nerves and muscles, causing involuntary contractions or spasms, particularly in the hands, feet, and face.
2. Tingling Around the Mouth and Fingers: Paresthesia, or tingling sensations, is a hallmark symptom of hypocalcemia and reflects the effect of low calcium on peripheral nerves.
3. Positive Trousseau’s Sign: This sign is elicited by inflating a blood pressure cuff on the arm above systolic pressure for 2–3 minutes, leading to carpal spasm (flexion of the wrist and fingers). Like Chvostek’s sign, it indicates neuromuscular hyperexcitability caused by hypocalcemia.

Think of calcium as a “brake” for your nerves and muscles. When calcium levels drop, the “brake” doesn’t work properly, causing the nerves and muscles to fire excessively (twitching, spasms, and tingling).

Clients with hypocalcemia require close monitoring and supportive care to address symptoms and prevent complications:

• Monitor for signs of tetany (e.g., muscle twitching, cramps, or spasms) and neuromuscular irritability (e.g., Chvostek’s and Trousseau’s signs).
• Encourage a diet high in calcium and vitamin D to support calcium absorption (e.g., dairy products, leafy greens, fortified foods).
• Administer calcium supplements or IV calcium gluconate as prescribed, particularly in severe cases.
• Monitor cardiac function closely, as hypocalcemia can cause arrhythmias or prolonged QT intervals.
• Educate the client on recognizing early symptoms of hypocalcemia and seeking prompt medical attention.

✘Incorrect answer options:

Hypoactive deep tendon reflexes. This is incorrect because hypocalcemia causes hyperactive, not hypoactive, deep tendon reflexes due to increased neuromuscular excitability.

Hypertension and tachycardia. Hypocalcemia does not typically cause hypertension or tachycardia. In fact, it may lead to hypotension and bradycardia in severe cases due to its effects on cardiac muscle contractility and vascular tone.

Brittle nails and dry hair. While brittle nails and dry hair may be associated with chronic calcium deficiency or malnutrition, they are not acute symptoms of hypocalcemia. These changes are more commonly seen in long-term calcium or nutritional deficiencies.

EXPLANATION

✔Correct answer:

The client’s hematocrit level is 26%.  A hematocrit level of 26% is significantly low (normal range for adult females: 36–48%, and for adult males: 42–52%) and indicates anemia, likely due to blood loss during or after surgery. This finding requires immediate physician notification, as a low hematocrit level can compromise oxygen delivery to tissues and delay recovery. It may also indicate ongoing blood loss, necessitating further evaluation and possible interventions such as blood transfusion, fluid resuscitation, or surgical exploration.

Key Consideration in Post-Operative Care:  

Blood loss is a common complication of major surgeries like a total knee replacement. A hematocrit level below 30% is generally concerning in the immediate post-operative period, as it suggests that the client may have lost a significant volume of blood. Early identification and treatment are critical to prevent complications such as hypovolemia, hypoxia, or hemodynamic instability.

Think of hematocrit like the fuel level in a car’s gas tank. If the fuel level drops too low, the car (the body) won’t have enough energy to function properly. In this case, a low hematocrit means there aren’t enough red blood cells to "fuel" oxygen delivery to the tissues.

If a low hematocrit level is identified, the nurse should take the following steps:

• Notify the physician immediately, as further evaluation (e.g., additional labs or imaging) and treatment may be required.
• Monitor the client for signs and symptoms of hypovolemia or anemia, such as dizziness, tachycardia, hypotension, fatigue, or pallor.
• Assess the surgical site for excessive bleeding or hematoma formation that may contribute to blood loss.
• Ensure adequate IV access in case blood transfusion or fluid resuscitation is needed.
• Reassure the client and provide education about potential interventions (e.g., transfusion) to alleviate anxiety.

✘Incorrect answer options:

A 3 cm area of bleeding on the surgical dressing. Some drainage or bleeding on the surgical dressing is normal after surgery. A 3 cm area of bleeding is minimal and does not typically require immediate physician notification unless the bleeding increases significantly or is accompanied by signs of hemodynamic instability.

The client’s body temperature is 99.6°F. A mild elevation in body temperature is common in the immediate post-operative period and is often due to the inflammatory response to surgery. It does not indicate fever (fever is typically >100.4°F) or infection and does not require immediate physician notification.

The urinary output over the last 2 hours is 60 mL. A urinary output of 30 mL per hour is considered adequate in adults. A total of 60 mL over 2 hours meets this criterion and does not require immediate intervention. However, the nurse should continue to monitor urinary output as part of routine post-operative care.

EXPLANATION

✔Correct answer:

Notify your healthcare provider immediately if you experience chest pain.  Celecoxib is a selective cyclooxygenase-2 (COX-2) inhibitor, which is a type of nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to manage pain and inflammation in conditions such as osteoarthritis. A critical risk associated with celecoxib is an increased likelihood of cardiovascular events, such as myocardial infarction (heart attack) or stroke. Therefore, it is essential for clients to be instructed to report any signs of cardiovascular issues immediately, such as chest pain, shortness of breath, or sudden weakness. Early recognition and intervention are vital to prevent serious complications.

The cardiovascular risks of COX-2 inhibitors are thought to result from their suppression of prostacyclin (a vasodilator and inhibitor of platelet aggregation) without also inhibiting thromboxane A2 (a pro-thrombotic factor). This imbalance increases the likelihood of clot formation, vasoconstriction, and cardiovascular events.

Think of celecoxib as fixing a squeaky door hinge (inflammation and pain) but accidentally making the door harder to open (increased cardiovascular risks). Reporting chest pain is like noticing that the "door" is no longer functioning properly and calling a repair technician before it becomes stuck completely.

When educating clients about celecoxib, nurses should emphasize the following key points:

• Monitor for and report symptoms of cardiovascular events, including chest pain, shortness of breath, and weakness on one side of the body.
• Take the medication as prescribed and avoid exceeding the recommended dosage to minimize risks.
• Discuss the importance of using the lowest effective dose for the shortest possible duration to reduce the likelihood of adverse effects.
• Be aware of potential gastrointestinal side effects, such as abdominal pain, nausea, or ulcers, despite celecoxib’s lower risk of GI bleeding compared to non-selective NSAIDs.
• Inform the healthcare provider of any personal or family history of cardiovascular disease, as this increases the client’s risk of complications.

✘Incorrect answer options:

Take the medication alongside milk to prevent stomach upset. While taking NSAIDs with food or milk can reduce the risk of gastrointestinal irritation, celecoxib is less likely to cause GI side effects compared to non-selective NSAIDs like ibuprofen or aspirin. This instruction is helpful but not the most critical compared to monitoring for cardiovascular symptoms.

Stay upright for 30 minutes after taking the medication. This instruction is specific to medications like bisphosphonates (e.g., alendronate), which can cause esophageal irritation. It is not relevant for celecoxib, as it does not carry this risk.

Expect the medication to take 6 weeks to achieve its full effect. This timeline is associated with disease-modifying anti-rheumatic drugs (DMARDs) used in rheumatoid arthritis, such as methotrexate, rather than celecoxib. Celecoxib provides relatively fast-acting pain relief and does not require weeks to take effect.

EXPLANATION

✔Correct answers:

• "Take acarbose with the first bite of each main meal."
• "Monitor for signs of low blood sugar, such as shakiness or sweating."
• "Report symptoms of gas, bloating, or diarrhea to your healthcare provider."

Acarbose is an alpha-glucosidase inhibitor used to manage type 2 diabetes mellitus by slowing the breakdown of complex carbohydrates in the small intestine, which helps prevent postprandial (after-meal) blood sugar spikes. Nurse Hannah must educate the client about proper administration, side effects, and how to respond to potential complications.

"Take acarbose with the first bite of each main meal.": Acarbose must be taken with the first bite of food to ensure it works effectively, as its action is to delay carbohydrate digestion in the intestines. Taking it at the wrong time, such as after a meal or on an empty stomach, reduces its effectiveness.

"Monitor for signs of low blood sugar, such as shakiness or sweating.": While acarbose itself does not cause hypoglycemia, it may contribute to hypoglycemia if combined with other diabetes medications like sulfonylureas or insulin. Clients should be educated on recognizing and treating low blood sugar. Since acarbose delays carbohydrate digestion, glucose tablets or gels (not complex carbohydrates like bread) should be used to treat hypoglycemia.

"Report symptoms of gas, bloating, or diarrhea to your healthcare provider.": Gastrointestinal side effects such as flatulence, abdominal bloating, and diarrhea are common with acarbose due to fermentation of undigested carbohydrates in the colon. While these symptoms are often mild and improve over time, the client should report severe or persistent symptoms to their healthcare provider, as adjustments to the dosage or treatment plan may be necessary.

Think of acarbose as a "traffic controller" for carbohydrate digestion, slowing down the flow of sugar into the bloodstream. However, this controller needs food (a meal) to do its job, so it only works if taken at the right time.

Nurse Hannah should educate and support the client with the following key points to ensure safety and optimize blood sugar management:

• Reinforce the importance of taking acarbose with the first bite of food at every main meal.
• Explain that mild gastrointestinal side effects are common but often improve with continued use.
• Encourage the client to monitor blood sugar levels regularly, especially when acarbose is combined with other diabetes medications.
• Instruct the client to keep glucose tablets or gels on hand to treat hypoglycemia, as complex carbohydrates may not be effective during acarbose therapy.
• Advise the client to maintain a well-balanced diet and adhere to the prescribed diabetes management plan.

✘Incorrect answer options:

"If you skip a meal, you should still take acarbose to prevent blood sugar spikes.": This is incorrect. Acarbose should only be taken with meals. If the client skips a meal, they should also skip the dose of acarbose because its action depends on the presence of dietary carbohydrates. Taking it without a meal serves no purpose and could cause unnecessary side effects.

"Chew acarbose thoroughly before swallowing.": This is incorrect because acarbose is swallowed whole and does not need to be chewed. Its effect occurs in the small intestine, not in the mouth, so chewing does not enhance its efficacy.

EXPLANATION

✔Correct answer:

A 12-year-old male with a fractured femur.  The most suitable roommate for a 6-year-old boy in Russell's traction is a 12-year-old male with a fractured femur. Both children have similar conditions (fractures), which minimizes the risk of cross-contamination from communicable diseases. Additionally, the 12-year-old is close enough in developmental stage to provide companionship while still being able to empathize with the shared experience of immobility and healing from a fracture. Although there is an age difference, the shared medical experience fosters a sense of connection and understanding.

When assigning roommates in a pediatric setting, nurses must consider:  

• Minimizing risk of infection: Children in traction are at risk for complications such as infection at the pin site (if skeletal traction is used). Assigning a roommate without an infectious condition (e.g., osteomyelitis) reduces this risk.
• Providing age-appropriate companionship: Close proximity in age and similar developmental levels are important for providing emotional support and minimizing feelings of isolation.
• Shared medical experiences: Having a roommate with a similar condition allows children to relate to one another and may improve their overall experience during hospitalization.

Think of assigning roommates like pairing study buddies in school. A good match would be two students working on similar topics (fractures) at a comparable level of understanding (developmental stage), so they can help and encourage each other.

When caring for a child in traction, nurses must prioritize physical and emotional well-being. Important interventions include:

• Monitor the traction setup to ensure proper alignment and prevent complications, such as skin breakdown or nerve damage.
• Perform neurovascular assessments regularly to ensure adequate circulation, sensation, and movement in the affected limb.
• Provide age-appropriate activities to reduce boredom and promote psychological well-being during prolonged immobility.
• Encourage social interaction, including appropriate roommate pairings, to foster emotional support and companionship.
• Educate the child and family about traction care, including preventing infection and ensuring safety.

✘Incorrect answer options:

A 16-year-old female being treated for scoliosis. While scoliosis treatment may also involve immobility, the age and developmental gap between a 16-year-old and a 6-year-old would make it challenging for them to connect or provide meaningful companionship. The wide age difference is not ideal for emotional support.

A 10-year-old male diagnosed with sarcoma. While the 10-year-old male is closer in age, a diagnosis of sarcoma (a type of cancer) may involve treatments like chemotherapy or radiation, which can weaken the immune system and increase the risk of infection for both children. This pairing may expose the 6-year-old to unnecessary risks.

A 6-year-old male with osteomyelitis. Osteomyelitis is a bone infection, and pairing a child with this condition alongside a child in traction significantly increases the risk of cross-infection. Children with traction setups are vulnerable to infections, particularly at pin sites, making this pairing unsafe.

EXPLANATION

✔Correct answer:

"Elevate the client’s hips to relieve pressure." A prolapsed umbilical cord is a medical emergency that occurs when the umbilical cord slips ahead of the presenting part of the fetus during labor. This can result in cord compression, leading to reduced blood flow and oxygen delivery to the baby, potentially causing fetal hypoxia or death. Elevating the client’s hips is a key immediate intervention because it uses gravity to reduce pressure on the cord, which helps restore blood flow and oxygen to the baby.

Elevating the hips can be achieved through various positioning techniques, such as the Trendelenburg position (client lying flat with the bed tilted so the pelvis is higher than the head) or the knee-chest position (client on her hands and knees with the chest lowered to the bed and hips elevated). Both positions help relieve cord compression until definitive care (e.g., an emergency cesarean section) can be provided.

Imagine stepping on a garden hose (the umbilical cord) while water is flowing (blood and oxygen). Elevating the client’s hips is like lifting the foot off the hose to restore water flow.

In addition to elevating the hips, the nurse should perform other critical interventions to protect the baby and prepare for emergency delivery:

• Call for immediate medical assistance and notify the obstetric team for an emergency cesarean section.
• If possible, use a sterile gloved hand to apply upward pressure on the presenting part to relieve cord compression (manual elevation).
• Cover the exposed cord with sterile gauze soaked in warm, sterile saline to prevent drying and maintain cord viability.
• Administer oxygen to the client to optimize fetal oxygenation.
• Monitor fetal heart rate continuously to assess for signs of fetal distress (e.g., variable decelerations).

✘Incorrect answer options:

"Try to reposition the cord manually." Manually repositioning the umbilical cord is contraindicated because it can cause further cord compression, vascular spasm, or trauma to the cord. The priority is to relieve pressure on the cord rather than attempting to reposition it.

"Turn the client onto her left side." While the left lateral position is beneficial for improving maternal-fetal circulation in other situations (e.g., uteroplacental insufficiency), it does not effectively relieve pressure on the prolapsed cord. Elevating the hips or using the knee-chest position is far more effective in this scenario.

"Cover the cord with dry, sterile gauze." Covering the cord is important, but it should be done with sterile gauze soaked in warm saline rather than dry gauze. Dry gauze can cause the cord to dehydrate, compromising its viability and increasing the risk of complications. However, covering the cord is a secondary intervention; relieving cord compression takes priority.

EXPLANATION

✔Correct answer:

Praise the LPN for following proper pin site care protocol.  The LPN is correctly performing pin site care by wearing sterile gloves and using sterile cotton-tipped applicators to clean the pin sites. While clean gloves may suffice in many situations for pin site care, some facilities and providers prefer or require sterile gloves to reduce the risk of infection, especially in cases of fresh pin insertions or high-risk patients. Using sterile applicators and maintaining aseptic technique are key components of proper pin site care. Therefore, Nurse Taylor should acknowledge and praise the LPN for adhering to correct protocol.

Pin sites are a potential source of infection because they provide a direct pathway into the bone. Proper pin site care minimizes the risk of infection and other complications, such as osteomyelitis. Facilities may have varying protocols regarding the use of sterile versus clean gloves, but the LPN’s actions demonstrate adherence to a more stringent aseptic technique.

Think of pin site care like maintaining a clean window into the body. Sterile gloves and applicators act like high-quality cleaning tools that keep the window free of dirt (bacteria) without introducing contaminants.

To ensure safe and effective pin site care, nurses must follow evidence-based practices and institutional protocols. Key considerations include:

• Follow aseptic technique by using sterile gloves, sterile supplies, and an appropriate cleaning solution (e.g., chlorhexidine or sterile saline).
• Clean the pin sites starting from the insertion site and moving outward in a circular motion to avoid introducing bacteria into the site.
• Assess the pin sites for signs of infection, such as redness, swelling, purulent drainage, or foul odor, and report findings promptly.
• Educate the patient and family on proper pin site care if care will be continued at home, emphasizing hand hygiene and infection prevention.
• Monitor for systemic signs of infection, such as fever or elevated white blood cell count, which could indicate osteomyelitis.

✘Incorrect answer options:

Instruct the LPN to use clean gloves instead of sterile gloves. While clean gloves are often acceptable for pin site care, the use of sterile gloves is not incorrect. Sterile gloves provide an added layer of infection prevention, particularly for fresh pin sites or high-risk patients. Advising the LPN to switch to clean gloves would not be appropriate in this case.

Advise the LPN to use alcohol-based solution for cleaning the pin sites. Alcohol-based solutions are not routinely recommended for pin site care because they can irritate the skin and delay healing. Preferred cleaning agents include sterile saline or chlorhexidine, as specified by the facility's protocol or provider’s orders.

Remind the LPN to clean the entire external fixator device, not just the pin sites. Cleaning the entire external fixator device is not required as part of pin site care. The focus of the procedure is to clean the pin insertion sites, as these are the areas most prone to infection. Cleaning the entire device could introduce contaminants to the pin sites if not done carefully.

EXPLANATION

✔Correct answer:

Monitor the child’s bowel sounds for any changes.  One of the primary nursing priorities specific to a spica cast is monitoring for gastrointestinal complications, such as bowel obstruction or paralytic ileus. Spica casts, which immobilize the lower body and encase the abdomen and hips, can put pressure on the abdomen, potentially affecting gastrointestinal motility. Children in spica casts are particularly vulnerable to constipation, bloating, and more serious complications like bowel obstruction due to reduced mobility and the restrictive nature of the cast. Monitoring bowel sounds helps detect early signs of gastrointestinal dysfunction, allowing for prompt intervention.

Children in spica casts often experience difficulty with toileting, reduced appetite, and decreased physical activity, all of which contribute to the risk of constipation or ileus. Early identification of gastrointestinal issues is critical to prevent discomfort and further complications.

Think of the cast as a snug belt around the abdomen. If the belt is too tight or limits movement, it can slow down digestion, leading to discomfort and blockages. Monitoring bowel sounds ensures the "digestive traffic" is still flowing smoothly.

To prevent complications specific to a spica cast, nurses must focus on maintaining gastrointestinal health and promoting the child’s overall well-being. Key actions include:

• Monitor for changes in bowel sounds, abdominal distension, or discomfort, which may indicate constipation or bowel obstruction.
• Encourage adequate hydration and a high-fiber diet to promote regular bowel movements.
• Administer stool softeners or laxatives as prescribed to prevent or treat constipation.
• Educate caregivers on proper toileting techniques for a child in a spica cast, such as using a bedpan or specially designed toileting devices.
• Regularly reposition the child to relieve pressure on the abdomen and prevent complications like skin breakdown.

✘Incorrect answer options:

Evaluate the child’s blood pressure regularly. While monitoring blood pressure is part of routine assessments, it is not specific to managing a spica cast. Blood pressure changes are not directly related to the cast itself and are not the primary concern in this situation.

Administer pain relief medication as needed. Pain management is important for any child recovering from surgery or in a cast, but it is not specific to a spica cast. Additionally, pain relief alone does not address potential complications unique to spica casts, such as gastrointestinal issues.

Inspect for any signs of swelling near the cast edges. Inspecting for swelling near cast edges is a general intervention for all types of casts to monitor for circulation issues. However, this is not a priority specific to a spica cast. The risk of gastrointestinal complications takes precedence in this scenario.

EXPLANATION

✔Correct answer:

Swaddling the newborn securely in a blanket.  Swaddling is a priority intervention for a newborn experiencing narcotic abstinence syndrome (NAS), also known as neonatal abstinence syndrome. Swaddling provides a sense of security by mimicking the confined environment of the womb, helping to reduce irritability and excessive crying, which are hallmark symptoms of NAS. It also minimizes external stimuli that might exacerbate the newborn's hyperactive central nervous system response, promoting comfort and reducing stress.

NAS occurs when a newborn is exposed to narcotics or opioids in utero and then experiences withdrawal after birth. Symptoms often include excessive crying, tremors, irritability, poor feeding, hypertonia, and disrupted sleep. By swaddling, the overstimulated newborn is comforted and better able to regulate their behavior and physiological responses.

Imagine wrapping a baby bird in a soft, warm nest to keep it calm and secure. Without the nest, the baby bird might flail and get overstimulated, but the nest gives it a safe, cozy environment to rest and grow.

Managing NAS involves a combination of pharmacological and non-pharmacological approaches. Swaddling is a key non-pharmacological strategy. Other important nursing actions include:

• Minimize environmental stimuli, such as noise and bright lights, to prevent overstimulation.
• Provide small, frequent feedings to address feeding difficulties and prevent excessive hunger.
• Administer medications (e.g., morphine or methadone) as prescribed for severe withdrawal symptoms.
• Encourage skin-to-skin contact when appropriate to promote bonding and relaxation.
• Monitor for complications, such as dehydration or poor weight gain, and intervene accordingly.
• Provide education and emotional support to the family regarding NAS and newborn care.

✘Incorrect answer options:

Educating the mother to provide frequent tactile stimulation. While maternal involvement is essential, frequent tactile stimulation is not ideal for newborns with NAS because they are hypersensitive to touch. Excessive handling can worsen irritability and stress. Instead, education should focus on promoting gentle, calming interactions.

Positioning the newborn in an infant car seat. This action is not appropriate for managing NAS symptoms. Positioning in a car seat may increase discomfort, as it restricts movement and does not provide the snug, secure feeling of swaddling.

Starting an early infant-stimulation program. Although early stimulation programs are beneficial for newborn development in general, they are not suitable during the acute phase of NAS. The priority is to reduce stimulation and calm the newborn's overstimulated nervous system, not to introduce additional stimuli.

EXPLANATION

✔Correct answer:

"The client’s palms rest lightly on the walker handles." Proper use of a walker includes maintaining a relaxed grip on the walker handles, allowing the client’s palms to rest lightly. This ensures adequate support without placing excessive strain on the wrists or arms. Maintaining a slight bend (about 15–30 degrees) at the elbows is crucial for comfort, balance, and functionality. The client should not grip the handles tightly, as this can cause fatigue and increase the risk of improper body mechanics, potentially leading to falls or injury.

A walker is an assistive device used to provide stability, improve balance, and promote safe mobility for clients recovering from injuries, surgeries, or conditions that affect ambulation. Proper technique is essential to ensure safety and maximize the benefits of using the walker.

Using a walker correctly is like holding a steering wheel lightly when driving—it provides control without overexertion or strain, allowing smooth and safe movement.

Nurses should educate clients on the proper use of walkers and assess their technique to prevent injuries. Recommendations include:

• Ensuring that the walker’s height is adjusted so the handles are at the level of the client’s wrists when their arms are relaxed at their sides.
• Instructing the client to keep a slight bend (15–30 degrees) in their elbows while using the walker for optimal comfort and safety.
• Teaching the client to step into the walker rather than walking up to its front edge.
• Reinforcing that the walker should be pushed forward rather than lifted, unless uneven terrain necessitates lifting.
• Monitoring for fatigue, dizziness, or improper technique during ambulation and making adjustments as needed.

✘Incorrect answer options:

"The client’s elbows remain fully extended at 0° flexion." This is incorrect because keeping the elbows fully extended places undue strain on the shoulders, arms, and wrists, which can lead to discomfort, fatigue, or injury. A slight bend in the elbows (15–30 degrees) is required for proper alignment and functionality.

"The client walks up to the front edge of the walker." Walking up to the front edge of the walker is unsafe because it places the client at risk for tipping the walker forward, leading to imbalance and potential falls. The client should remain inside the walker frame, stepping forward in alignment with the walker’s rear legs.

"The client lifts and carries the walker during use." While lifting the walker may be necessary on uneven terrain, such as stairs or curbs, the walker is designed to glide or roll in most cases. Lifting it unnecessarily increases the risk of fatigue and injury. Rolling or gently pushing the walker forward ensures smoother and safer ambulation.

EXPLANATION

✔Correct answer:

"Taking photos of the client without their permission." Invasion of privacy refers to the unauthorized exposure of a client’s personal information, image, or private matters, which violates their right to confidentiality and dignity. Taking photos of a client without their explicit consent is a clear example of invasion of privacy. This action disregards the client’s autonomy and exposes them to potential misuse of their image or personal information, even if the nurse does not intend harm. The right to privacy is a fundamental component of client rights and professional nursing ethics.

Nurses are obligated to uphold client privacy and confidentiality under the Health Insurance Portability and Accountability Act (HIPAA) and professional codes of ethics, such as those outlined by the American Nurses Association (ANA). Consent must be obtained before taking photos, even if the intent is for medical documentation, education, or research purposes. Without permission, such actions can result in legal consequences and damage trust between the client and healthcare provider.

Imagine someone taking a photo of you in your home without asking—you would feel like your personal space and rights were violated. Similarly, clients have the right to control how their image or information is shared in a healthcare setting.

To avoid violations of privacy, nurses should take proactive steps to protect client information and ensure informed consent is obtained:

• Always ask for the client’s written consent before taking photos or recording any personal information beyond routine medical care.
• Explain the purpose of taking photos or gathering specific information, such as medical documentation or teaching purposes.
• Ensure that client information is only shared with individuals directly involved in their care.
• Secure electronic and physical storage of client photos or data to comply with HIPAA regulations.
• Report any observed or suspected breaches of privacy to the appropriate authority within the organization.

✘Incorrect answer options:

"Threatening the client with the use of restraints." This action is an example of assault, not invasion of privacy. Assault involves threatening harm to the client, which can cause fear and anxiety, but it does not pertain to the unauthorized exposure of personal information or images.

"Carrying out a surgical procedure without obtaining consent." Performing a procedure without consent is an example of battery, as it involves intentional, unauthorized physical contact with the client. It does not fall under the category of invasion of privacy.

"Informing the client that leaving the hospital is not allowed." This action constitutes false imprisonment, which involves unlawfully restricting a client’s freedom of movement without justification. It is a violation of client autonomy but is not related to their right to privacy.

EXPLANATION

✔Correct answer:

Circulation, sensation, and movement (CSM) of the affected limb.  After an open reduction and internal fixation (ORIF) for a fractured hip, the priority assessment is circulation, sensation, and movement (CSM) of the affected limb. This is because post-operative complications such as neurovascular compromise, including impaired blood flow, nerve damage, or compartment syndrome, can occur. Early detection of changes in circulation, sensation, or movement is critical to prevent permanent damage or limb loss. Assessing CSM ensures that the blood supply and nerve function in the affected limb are intact, allowing timely intervention if abnormalities are detected.

Key Components of CSM Assessment:

1. Circulation: Assess for adequate blood flow by checking capillary refill, skin color, and temperature of the affected limb. Diminished pulses or cool, pale skin may indicate compromised blood flow.
2. Sensation: Evaluate the client’s ability to feel light touch or pressure in the affected limb. Numbness or tingling may indicate nerve impairment.
3. Movement: Ask the client to move the toes or ankle of the affected limb. Inability to move the limb may indicate nerve damage or impaired muscle function.

Imagine a garden hose (blood vessels and nerves) supplying water to plants (the limb). If the hose gets pinched or blocked, the plants will wilt (poor circulation and sensation). Checking circulation, sensation, and movement is like inspecting the hose to ensure water is flowing freely to keep the plants healthy.

Ensuring neurovascular integrity is essential in the immediate post-operative period. Key nursing actions include:

• Perform CSM checks regularly (e.g., every 1-2 hours initially) and document findings.
• Notify the surgeon immediately if signs of compromised CSM are observed, such as diminished pulses, pallor, or inability to move the limb.
• Ensure the limb is properly positioned to prevent additional pressure or compromise of blood flow (e.g., avoid crossing legs or tight bandaging).
• Monitor for other signs of complications, such as increased swelling, severe pain unrelieved by medication, or changes in the client’s level of consciousness, which may indicate compartment syndrome.
• Educate the client and family on the importance of reporting any changes in sensation, color, or movement in the affected limb.

✘Incorrect answer options:

Pain level and the effectiveness of the prescribed analgesics. While pain management is essential after surgery, it is not the first priority. Pain can often be managed with medication, but unrelieved pain may also indicate neurovascular compromise. Assessing CSM takes precedence to rule out life- or limb-threatening complications.

The dressing for signs of bleeding or drainage. While assessing the surgical dressing for bleeding or drainage is important, it is not the immediate priority compared to assessing CSM. Significant neurovascular impairment can occur even without visible signs of bleeding.

The client’s ability to ambulate with assistance. Assessing the client’s ability to ambulate is important for recovery, but it is not appropriate in the immediate post-operative period, as ambulation is typically delayed after an ORIF to allow healing and stabilization. Early ambulation will only be considered after ensuring neurovascular integrity and clearance by the healthcare provider.

EXPLANATION

✔Correct answer:

"It’s perfectly fine for your friends to autograph the cast."  Fiberglass casts are strong, durable, and resistant to moisture and wear, making them a suitable surface for writing or decorating with markers. Autographing the cast is a harmless and common way for friends to offer encouragement and emotional support to the individual wearing it. Allowing the teenager's friends to autograph the cast promotes social engagement and helps maintain a positive outlook during the healing process, which is especially important for adolescents.

Fiberglass casts are much more resistant to damage compared to plaster-of-Paris casts. Writing or drawing on a fiberglass cast using appropriate materials (e.g., permanent markers) does not compromise the cast’s integrity or function.

Think of a fiberglass cast like a sturdy notebook cover—you can write or decorate it with markers without damaging the notebook’s function. Similarly, the cast can safely handle autographs or drawings.

While autographs are allowed on fiberglass casts, clients and caregivers should still be educated about general cast care to ensure proper healing. Key points include:

• Explain that it is safe to write or draw on the cast using permanent markers but not to use sharp objects or anything that might puncture or damage the cast.
• Encourage the client to avoid exposing the cast to excessive moisture, as prolonged water exposure can compromise the padding underneath and lead to skin irritation.
• Instruct the client not to stick objects inside the cast to scratch an itch, as this can cause skin damage or infection.
• Advise monitoring for signs of complications, such as swelling, pain, or changes in circulation (e.g., cold fingers or toes), and report these to the healthcare provider immediately.

✘Incorrect answer options:

"Since the cast is fiberglass, autographing won’t weaken it." While this statement is factually correct, it is overly technical and misses the opportunity to acknowledge and support the teenager’s emotional needs. A more encouraging and socially supportive response is ideal in this context.

"As long as they don’t use chalk, it should be okay." Chalk is not a typical material used for autographing casts, and its mention is unnecessary. There is no indication that chalk or similar materials would pose any significant risk to the fiberglass cast.

"Writing on the cast in any way could damage it, so it’s not recommended." This statement is incorrect and could unnecessarily discourage the teenager. Writing or drawing on a fiberglass cast does not damage it and is a common and acceptable practice.

EXPLANATION

✔Correct answer:

Leg shortening and external rotation on the affected side.  Hip fractures, particularly those involving the femoral neck or intertrochanteric region, commonly present with a characteristic deformity: shortening and external rotation of the affected leg. This occurs due to the powerful muscles surrounding the hip joint, which pull the fractured bone fragments out of alignment. The shortening results from the overriding of the fractured bone ends, while the external rotation is caused by the pull of the external rotator muscles of the hip. This presentation is a classic sign of a hip fracture and should prompt immediate further investigation, such as X-rays.

The hip joint is a ball-and-socket joint connecting the femur (thigh bone) to the pelvis. A hip fracture typically occurs in the proximal femur, either at the femoral neck (the area just below the ball) or in the intertrochanteric region (the area below the neck). When a fracture occurs, the strong muscles attached to the femur, such as the gluteus medius and minimus, as well as the external rotators, exert a pull on the bone fragments. This muscular pull leads to the characteristic shortening and external rotation of the affected leg.

Imagine a straight stick (the femur) breaking in the middle. If you try to hold the broken pieces together, they might overlap (shortening) and twist outwards (external rotation) due to the forces acting on them. The muscles around the hip act like these forces, causing the fractured femur to shorten and externally rotate.

When assessing a patient with a suspected hip fracture, nurses should prioritize pain management and prevention of further injury.

• Pain Management: Hip fractures are extremely painful. Nurses should administer analgesics as prescribed and monitor the patient's pain level regularly.
• Immobilization: The affected leg should be immobilized to minimize further displacement of the fracture fragments and reduce pain. This can be achieved using traction, splints, or other appropriate devices as ordered.
• Neurovascular Assessment: Nurses should perform regular neurovascular assessments of the affected limb, checking for pulses, capillary refill, sensation, and movement. This helps to identify any potential vascular or nerve damage associated with the fracture.
• Pre-operative Care: If surgery is planned, nurses should prepare the patient for the procedure, including obtaining necessary consents, completing pre-operative assessments, and providing patient education.

✘Incorrect answer options:

Severe swelling and bruising of the knee. While swelling and bruising can occur with a hip fracture, it is usually localized to the hip and groin area, not the knee. Knee involvement is more indicative of a knee injury.

Numbness and tingling radiating down the affected leg. Numbness and tingling (paresthesia) may occur if there is nerve damage associated with the fracture, but it is not the most common finding. The characteristic shortening and external rotation are more specific to a hip fracture.

Difficulty moving the toes on the affected side. Difficulty moving the toes can indicate nerve damage, but it is not the primary sign of a hip fracture. The shortening and external rotation of the leg are the most reliable indicators.

EXPLANATION

✔Correct answer:

Advises waiting 24 hours before bearing weight on the cast.  Plaster-of-Paris casts are used to immobilize fractures and support healing. Unlike synthetic fiberglass casts, plaster casts take approximately 24 to 72 hours to fully dry and harden, depending on the size and thickness of the cast. Advising the client to avoid bearing weight on the cast for at least 24 hours allows sufficient time for the plaster to set and ensures the cast maintains its shape and integrity. Premature weight-bearing can weaken or damage the cast, compromising its ability to immobilize the affected limb.

Plaster casts are porous when wet, and improper handling or early weight-bearing can cause cracks, pressure points, or deformities, increasing the risk of complications such as delayed healing or skin irritation.

Think of a plaster cast like a freshly poured cement sidewalk. You wouldn’t walk on it immediately because it needs time to harden. Similarly, a plaster cast requires time to set properly before it can support weight.

Proper care of a plaster-of-Paris cast is crucial to ensure it functions effectively and promotes healing. Key nursing actions include:

• Handle the wet cast with the palms of the hands (not fingertips) to prevent creating indentations that could lead to pressure sores.
• Keep the cast exposed to air and support it on a firm surface with soft padding underneath while drying to maintain its shape.
• Educate the client to avoid placing objects inside the cast to relieve itching, as this can cause skin damage or infection.
• Apply "petaling" (lining the edges with soft material) once the cast is dry to prevent sharp edges from irritating the skin.
• Monitor for signs of complications, such as poor circulation (swelling, numbness, or discoloration), and notify the provider immediately if any issues arise.

✘Incorrect answer options:

Handles the cast using her fingertips. Handling the cast with fingertips can create indentations in the wet plaster, which may lead to pressure points and subsequent skin breakdown. Instead, the cast should be handled with the palms of the hands until it has fully dried and hardened.

Applies petaling to the edges of the cast. While petaling is an important step in cast care to prevent sharp edges from irritating the skin, it should only be done after the cast has fully dried and hardened. Applying petaling too soon could damage the still-soft plaster.

Uses a hair dryer to accelerate drying of the cast. A hair dryer or external heat source should never be used to dry a plaster cast, as it can cause the cast to dry unevenly or crack. The heat may also increase the risk of burns or skin irritation. Plaster casts should be allowed to air dry naturally.

EXPLANATION

✔Correct answer:

Perform thorough handwashing for 2 minutes before providing care.  Hand hygiene is the single most effective action to prevent healthcare-associated infections, including wound infections. Performing thorough handwashing before providing care removes transient microorganisms that can be introduced to the patient or the wound, significantly reducing the risk of infection. Handwashing with soap and water for at least 20 seconds (or longer if visibly soiled or dealing with high-risk patients) disrupts and removes pathogens from the skin, providing a critical barrier against contamination.

Post-operative wounds are highly susceptible to infection due to the disruption of the skin barrier, which is the body’s first line of defense. Pathogens can be introduced to the wound through contact with unclean hands, contaminated surfaces, or improper aseptic techniques. Thorough handwashing reduces the microbial load on the caregiver's hands, ensuring a safer environment for the patient.

Think of your hands like a paintbrush covered in invisible paint (germs). If you use the brush on a clean canvas (the patient) without washing it first, the canvas gets stained. Proper handwashing is like cleaning the brush thoroughly, ensuring no paint is transferred onto the canvas.

In addition to handwashing, nurses should implement a variety of strategies to prevent post-operative wound infections. Key actions include:

• Use alcohol-based hand sanitizers if hands are not visibly soiled and soap and water are unavailable.
• Maintain strict aseptic technique during dressing changes or wound care.
• Educate the patient on proper wound care, including hand hygiene before touching the wound.
• Ensure timely administration of prescribed antibiotics to prevent infection if indicated.
• Monitor the wound for signs of infection, such as redness, swelling, warmth, or purulent drainage, and report findings promptly.

✘Incorrect answer options:

Administer the prescribed antibiotic as ordered. While antibiotics can help prevent or treat infections, they are not a primary preventive measure against introducing pathogens. Antibiotics target existing infections or provide prophylaxis for specific risks but do not address the immediate risk of contamination caused by improper hygiene practices.

Wear a protective mask while delivering patient care. Wearing a mask is useful for preventing droplet transmission of respiratory pathogens but does not prevent the introduction of pathogens to a surgical wound caused by poor hand hygiene. Masks are not the primary intervention for wound infection prevention.

Encourage the patient to cover her mouth when coughing. Encouraging patients to cover their mouths when coughing helps prevent the spread of respiratory infections, but it does not directly address the risk of post-operative wound infections. Proper wound care and hand hygiene are more critical in this context.

EXPLANATION

✔Correct answer:

Monitoring the patient’s blood pressure.  After initiating epidural anesthesia, the nurse’s priority is to monitor the patient’s blood pressure. Epidural anesthesia can cause vasodilation and a significant drop in blood pressure (hypotension), which is one of the most common side effects. Maternal hypotension can decrease uteroplacental perfusion, compromising oxygen delivery to the fetus and potentially leading to fetal distress. Therefore, frequent blood pressure assessments are essential to detect hypotension early and intervene promptly.

Epidural anesthesia works by blocking nerve impulses in the lower spine, resulting in decreased pain sensation. However, this blockade also affects the sympathetic nervous system, leading to peripheral vasodilation and a reduction in cardiac output. If maternal blood pressure falls, it can impair blood flow to the uterus and placenta, affecting fetal oxygenation. Interventions such as repositioning the patient, administering IV fluids, or giving vasopressors (e.g., ephedrine) may be necessary to manage hypotension.

Imagine a water pump (maternal heart) supplying water (blood) to a garden (placenta and fetus). If the pump pressure drops (maternal hypotension), the garden doesn't get enough water (oxygen), and the plants (baby) may start to wither. Regularly checking the pump's pressure ensures the garden stays healthy.

After epidural placement, nurses should prioritize maternal and fetal well-being through ongoing monitoring and prompt intervention. Key steps include:

• Monitor the patient’s blood pressure every 2-5 minutes immediately after the epidural is initiated and during bolus dosing, then every 15-30 minutes as needed.
• Position the patient laterally (not flat on her back) to avoid vena cava compression, which can exacerbate hypotension.
• Monitor fetal heart rate for signs of distress, such as bradycardia or late decelerations, which may result from reduced placental perfusion.
• Administer IV fluids (e.g., a bolus of lactated Ringer's solution) to help maintain blood pressure and prevent dehydration.
• Collaborate with the anesthesiologist to administer vasopressors if blood pressure does not respond to initial interventions.

✘Incorrect answer options:

Assessing the progress of cervical dilation. While cervical dilation assessment is important during labor, it is not the immediate priority after epidural administration. Monitoring for complications, such as hypotension, takes precedence.

Positioning the patient flat on her back. Positioning the patient flat on her back is contraindicated after an epidural because it can compress the inferior vena cava, reducing venous return and exacerbating hypotension. Instead, the patient should be positioned laterally or with a slight tilt to optimize blood flow.

Evaluating the fetal heart rate. Monitoring the fetal heart rate is essential after an epidural, as fetal distress may indicate maternal hypotension. However, monitoring the mother’s blood pressure takes priority because it directly impacts fetal oxygenation. Detecting and correcting hypotension helps prevent fetal heart rate abnormalities.

EXPLANATION

✔Correct answer:

The buttocks are elevated about 15° off the bed.  Bryant's traction is specifically designed for children under 2-3 years old or weighing less than 35 pounds who have femur fractures or developmental hip issues. The traction works by applying a vertical pull on the lower extremities to maintain alignment and facilitate proper healing. For the traction to function correctly, the child’s buttocks should be slightly elevated (approximately 15° off the bed) to allow the pull of the traction to align the femur properly. This position ensures effective traction force and prevents complications like pressure injuries to the sacrum.

In Bryant’s traction, both legs are suspended vertically at a 90° angle with the hips slightly lifted. This position uses the weight of the child as countertraction to align the fractured bone and reduce muscle spasms. The slight elevation of the buttocks ensures that the pull is correctly distributed to maintain proper alignment and prevent complications.

Imagine a puppet on strings. For the puppet to stay upright and balanced, there has to be tension on the strings, lifting it slightly off the surface. If the puppet rests completely on the ground, the strings can’t do their job properly. In this case, the traction works like the strings, and the slight lift ensures proper alignment.

Effective management of Bryant's traction includes frequent assessments to ensure proper functioning, as well as interventions to promote comfort and safety:

• Assess the traction setup to ensure the buttocks are elevated about 15° and the legs are suspended correctly.
• Ensure the child’s hips are flexed at a 90° angle, as improper positioning may reduce traction effectiveness.
• Monitor for signs of neurovascular compromise (e.g., color, temperature, pulses, capillary refill, and sensation of the affected extremities).
• Inspect the skin under the straps or bandages for signs of pressure, irritation, or breakdown.
• Provide comfort measures, such as distractions and pain management, as children may find this position uncomfortable.
• Educate caregivers about the importance of maintaining the proper traction setup and positioning.

✘Incorrect answer options:

The child reports no more pain. While pain relief is an important goal, it is not a direct indicator that the traction is functioning as intended. Pain can be managed with medication or other interventions, even if the traction setup is incorrect.

The legs are appropriately suspended within the traction. Proper suspension of the legs is important, but this statement alone does not indicate that the traction is functioning correctly. The elevation of the buttocks is the key assessment point to confirm effective traction.

The traction pins are securely fixed within the pulley system. While securing the traction pins is essential for the mechanical setup, it does not necessarily ensure that the traction is functioning properly. The effectiveness of the traction depends on the correct positioning and elevation of the child.

EXPLANATION

✔Correct answer:

Active phase.  The active phase of labor is part of the first stage of labor, during which the cervix dilates from 4 cm to 7 cm and effacement progresses. In this phase, contractions become stronger, more frequent, and more regular, and the laboring individual typically begins to experience increasing discomfort. Since the patient’s cervix is 5 cm dilated and 75% effaced, these findings clearly place her in the active phase of labor.

Phases of the First Stage of Labor:

1. Latent Phase: This is the initial phase, where the cervix dilates from 0 to 3 cm, and effacement begins. Contractions are usually mild and irregular.
2. Active Phase: This is the middle portion of the first stage of labor, where dilation progresses more rapidly (4 to 7 cm), and contractions intensify.
3. Transition Phase: This is the final part of the first stage, where the cervix dilates from 8 to 10 cm. This phase is characterized by very strong contractions, rapid progression, and increased pressure as the fetus moves further into the birth canal.

Think of cervical dilation like opening a door to let a guest into your home. In the latent phase, the door is barely cracked open (0–3 cm). In the active phase, the door is halfway open and continues to open steadily (4–7 cm). In the transition phase, the door is almost fully open (8–10 cm), preparing for the guest to enter (delivery of the baby).

Nurses play a crucial role in supporting the laboring patient during the active phase. The following interventions are essential:

• Monitor the frequency, duration, and intensity of contractions and document findings.
• Perform regular assessments of fetal heart rate to detect any signs of fetal distress.
• Provide emotional support and reassurance, as this is often a challenging phase for the patient.
• Encourage breathing techniques and relaxation strategies to help manage pain and anxiety.
• Administer pain relief measures as requested or prescribed, such as epidural anesthesia or analgesics.
• Assist with positioning changes to promote comfort and optimize fetal descent.

✘Incorrect answer options:

Latent phase. The latent phase is the early part of the first stage of labor, during which the cervix dilates from 0 to 3 cm. Contractions are mild and irregular, which is not consistent with the patient’s findings of 5 cm dilation and 75% effacement.

Transition phase. The transition phase occurs later in labor, with cervical dilation from 8 to 10 cm. This is the most intense and rapid phase of cervical dilation, which does not match the patient’s cervical dilation of 5 cm.

Early phase. This term is synonymous with the latent phase of labor and also describes cervical dilation from 0 to 3 cm. It is therefore incorrect for a patient with 5 cm dilation.

EXPLANATION

✔Correct answer:

A high-seat commode.  A high-seat commode is crucial for patients recovering from total hip replacement because it helps maintain hip precautions. These precautions typically include avoiding hip flexion greater than 90 degrees, adduction (crossing the legs), and internal rotation. A standard toilet seat is often too low, forcing the patient to flex the hip beyond the safe range, which could lead to dislocation of the new hip joint. A high-seat commode elevates the seating surface, reducing the amount of hip flexion required and allowing the patient to maintain proper alignment during toileting.

After a total hip replacement, the surrounding muscles, tendons, and ligaments are healing. Excessive hip flexion, adduction, or internal rotation can put stress on the surgical site and potentially dislocate the prosthetic hip joint. Maintaining proper hip precautions is essential during the initial healing phase to prevent this complication and promote optimal recovery.

Imagine the new hip joint as a delicate puzzle piece that has just been put in place. If you bend or twist the area around the puzzle piece too much, it could pop out of place. A high-seat commode is like a raised platform that keeps the area around the puzzle piece stable, preventing it from being disturbed during sitting and standing.

Nurses play a vital role in educating patients about hip precautions and ensuring they have the necessary equipment for safe mobility and activities of daily living.

• Patient Education: Nurses should thoroughly educate patients and their families about hip precautions, including proper positioning, transfers, and activities to avoid.
• Environmental Modifications: Nurses should assess the patient's home environment and recommend modifications, such as raised toilet seats, grab bars, and removal of throw rugs, to minimize fall risks and promote safe mobility.
• Assistive Devices: In addition to high-seat commodes, other assistive devices, such as long-handled shoehorns, reachers, and dressing sticks, can help patients maintain hip precautions while performing daily activities.
• Pain Management: Adequate pain management is essential for promoting patient comfort and facilitating participation in rehabilitation exercises.

✘Incorrect answer options:

A reclining chair. While a reclining chair can provide comfort, it does not specifically address the hip precautions necessary after a total hip replacement. Some reclining positions might even promote excessive hip flexion.

A transcutaneous electrical nerve stimulation (TENS) unit. A TENS unit is used for pain management by delivering electrical impulses to the nerves. While it can be helpful for some types of pain, it does not address the crucial need to maintain hip precautions after a total hip replacement.

An abduction pillow. An abduction pillow is used to keep the legs separated and prevent adduction (crossing the legs). While this is an important hip precaution, it is primarily used while the patient is in bed or lying down. A high-seat commode is more relevant for toileting activities.

EXPLANATION

✔Correct answer:

The child lives in a home built before 1978 with peeling paint.  Plumbism, also known as lead poisoning, is a serious condition caused by the accumulation of lead in the body. The most common source of lead exposure for children is lead-based paint, which was used in many homes built before 1978 (when its use was banned in residential paint). Peeling or chipping paint can create lead dust that children can ingest through hand-to-mouth contact, contaminated toys, or by breathing in the dust. This is particularly concerning for young children due to their normal hand-to-mouth exploratory behavior.

Once ingested or inhaled, lead is absorbed into the bloodstream and distributed throughout the body, affecting multiple organ systems. Lead interferes with various bodily processes, including the development of the nervous system, red blood cell production, and kidney function. In children, lead poisoning can lead to developmental delays, learning disabilities, behavioral problems, and even seizures or coma in severe cases.

Imagine lead as a harmful substance that sneaks into a child’s body like tiny invaders. Old houses with peeling paint are like a battlefield where these invaders (lead particles) are scattered everywhere. Children playing in this environment can accidentally pick up these invaders on their hands or toys and unknowingly bring them into their bodies, causing damage.

Nurses play a crucial role in the prevention and management of lead poisoning.

• Risk Assessment: Nurses should assess children for risk factors of lead exposure, including living in older homes, recent renovations, and exposure to lead-containing products.
• Education: Educating families about the dangers of lead exposure and preventive measures, such as wet cleaning to remove lead dust and proper home maintenance, is essential.
• Screening: Lead screening is recommended for children at risk. Nurses should follow recommended guidelines for blood lead level testing.
• Referral and Follow-up: If elevated blood lead levels are detected, nurses should refer the child to appropriate healthcare providers for further evaluation and management, which may include chelation therapy to remove lead from the body.

✘Incorrect answer options:

The child’s diet consists mostly of carbohydrates and processed foods. While a poor diet can contribute to various health problems, it is not directly linked to lead poisoning. Lead exposure is primarily related to environmental factors, such as lead-based paint.

The child has a history of frequent ear infections. Frequent ear infections are a common childhood ailment but are not associated with lead poisoning.

The child recently started attending daycare. While daycare can expose children to various infections, it is not a risk factor for lead poisoning. Lead exposure is primarily related to environmental factors in the home or other older buildings.

EXPLANATION

✔Correct answer:

Fetal heart rate and tones.  After an amniotomy, the priority is to assess the fetal heart rate (FHR) and tones immediately. This is because amniotomy, which involves the artificial rupture of membranes (AROM), can potentially cause umbilical cord prolapse or compression. Umbilical cord prolapse occurs when the umbilical cord slips into the birth canal ahead of the presenting part of the fetus, which can compromise blood flow and oxygen delivery to the fetus. Monitoring the FHR helps detect any signs of fetal distress, such as bradycardia or variable decelerations, which may indicate cord prolapse or compression.

The amniotic sac serves as a cushion and a protective barrier for the fetus. When the membranes are artificially ruptured, there is a sudden release of amniotic fluid, which can create space for the umbilical cord to slip downward, particularly if the presenting part of the fetus is not well engaged in the pelvis. Fetal heart rate monitoring is the most reliable method to detect complications arising from these events and ensure timely interventions.

Think of the umbilical cord like a garden hose providing nutrients and oxygen to the fetus (like water to plants). If the hose gets pinched or blocked after the membranes rupture, it disrupts the flow, which could harm the baby. Checking the fetal heart rate is like ensuring the water is still flowing smoothly through the hose.

Nurses should act swiftly and decisively after an amniotomy to ensure the safety of the fetus. The following steps are essential:

• Immediately assess the fetal heart rate and document the findings to detect any abnormalities.
• Observe the amniotic fluid for color, odor, and presence of meconium or blood, as these may indicate fetal distress or infection.
• Position the patient to optimize fetal oxygenation if there are signs of fetal heart rate abnormalities, such as left lateral positioning.
• Prepare for emergency interventions, such as notifying the physician or initiating intrauterine resuscitation if fetal distress is detected.
• Continuously monitor the patient and fetus for changes throughout the labor process.

✘Incorrect answer options:

Progression of cervical dilation. While cervical dilation is important to monitor during labor, it is not the immediate priority after an amniotomy. Cervical changes progress over time and are not directly impacted by the rupture of membranes.

The patient’s vital sign status. Assessing maternal vital signs is part of routine care, especially to monitor for infection or hemodynamic stability. However, maternal vital signs do not provide immediate information about fetal well-being and are not the first priority after an amniotomy.

The patient’s level of pain or discomfort. Pain assessment is important during labor to ensure adequate pain management and maternal comfort. However, it does not take precedence over fetal monitoring when evaluating the immediate effects of an amniotomy.

EXPLANATION

✔Correct answers:

• Monitor daily weight and fluid balance.
• Administer prescribed diuretics.

Cushing’s syndrome is caused by prolonged exposure to high levels of cortisol, which can lead to fluid retention, weight gain, and signs of fluid overload such as edema and hypertension. Addressing fluid overload requires careful monitoring and interventions aimed at reducing excess fluid accumulation while preventing further complications.

Monitor daily weight and fluid balance: Daily weight measurement is one of the most accurate ways to assess fluid retention or loss. Monitoring intake and output (I&O) also helps track fluid balance and detect worsening fluid overload. Any sudden weight gain should prompt immediate investigation, as it may indicate worsening edema or fluid retention.

Administer prescribed diuretics: Diuretics are often prescribed to promote the excretion of excess fluid and relieve symptoms of fluid overload. Nurse Rachel should monitor the client’s response to the medication, assess for signs of electrolyte imbalances, and ensure adequate hydration while avoiding overhydration.

Think of the body as a sponge. In Cushing’s syndrome, the sponge absorbs too much water (fluid retention). Monitoring weight ensures you measure how much water is in the sponge, and diuretics are like wringing out the excess water to restore balance.

In addition to the above interventions, Nurse Rachel should educate the client and implement strategies to prevent complications related to fluid overload:

• Monitor vital signs regularly, especially blood pressure, as fluid overload can lead to hypertension.
• Implement a low-sodium diet to reduce water retention, as sodium exacerbates fluid retention.
• Monitor for signs of pulmonary edema, such as dyspnea, crackles, or decreased oxygen saturation.
• Assess for peripheral edema by evaluating dependent areas such as the ankles, feet, or sacral region.
• Educate the client on recognizing symptoms of worsening fluid retention, such as rapid weight gain or increased swelling.

✘Incorrect answer options:

Encourage fluid intake to flush out excess fluids: This is incorrect because encouraging fluid intake in a client with fluid overload could worsen the condition. Fluid restriction, rather than encouragement, may be necessary depending on the severity of the fluid retention.

Provide a high-sodium diet to balance fluids: A high-sodium diet would exacerbate fluid retention, as sodium promotes water retention in the body. Clients with Cushing’s syndrome should follow a low-sodium diet to help manage fluid overload and reduce the risk of complications such as hypertension.

Restrict potassium-rich foods: This is incorrect because Cushing’s syndrome often leads to hypokalemia (low potassium levels) due to the effects of excess cortisol and aldosterone. Instead, the client may need to increase their intake of potassium-rich foods, such as bananas, oranges, and spinach, or receive potassium supplements as prescribed.

EXPLANATION

✔Correct answer:

"I’ll give my child cough syrup if they start coughing."  This statement suggests that the mother requires further clarification because cough syrups, especially those containing suppressants or sedatives, are typically not recommended for children with croup. Croup is a viral infection characterized by a "barking" cough, stridor, and swelling of the upper airway. Suppressing the cough can interfere with the child's ability to clear secretions and may exacerbate breathing difficulties. Instead, treatment focuses on managing airway swelling, keeping the child calm, and ensuring adequate hydration. Non-pharmacologic measures such as exposure to cool air or steam and positioning to facilitate breathing are more effective and safer.

Cough syrups may also contain ingredients inappropriate for young children (e.g., sedatives or alcohol) and can pose risks, especially for children under 6 years old, as per guidelines from the American Academy of Pediatrics (AAP).

Giving cough syrup to a child with croup is like trying to muffle the alarm on a smoke detector instead of addressing the fire—it may mask the symptom but doesn't help fix the underlying problem.

Nurses should ensure parents understand the appropriate home management of croup to promote recovery and prevent complications:

• Encourage parents to create a cool or moist environment during coughing or breathing difficulties (e.g., using a cool-mist humidifier or taking the child outside in cool air).
• Advise against the use of over-the-counter cough syrups unless specifically directed by a healthcare provider.
• Stress the importance of maintaining hydration with fluids like water, juice, or broth to thin mucus and soothe the throat.
• Explain that acetaminophen or ibuprofen (age-appropriate dosing) can be used to reduce fever and discomfort.
• Instruct parents to seek immediate medical attention if the child develops severe symptoms, such as persistent stridor at rest, difficulty breathing, or cyanosis.

✘Incorrect answer options:

"If my child has an attack, I’ll take them to a cool environment." This statement demonstrates appropriate understanding. Exposure to cool air helps reduce airway inflammation and ease breathing, making it a recommended strategy during a croup attack.

"I’ll use acetaminophen if my child develops a fever." This is a correct statement. Acetaminophen is commonly used to manage fever and mild discomfort in children with croup. Parents should follow age-appropriate dosing instructions.

"I’ll make sure my child drinks at least three to four glasses of fluids daily." This statement is also correct. Adequate fluid intake is essential to prevent dehydration and soothe the throat in children with croup.

EXPLANATION

✔Correct answer:

"I need to flush the tube with water after each feeding and then clamp it closed."  Flushing the percutaneous gastrostomy (PEG) tube with water after each feeding is an essential aspect of proper care and maintenance. This practice helps to prevent clogging of the tube by clearing any residual formula or medications and ensures that the tube remains patent for future feedings. Clamping the tube after flushing also prevents air or gastric contents from backing up, promoting effective feeding and reducing the risk of leakage or contamination.

Key Components of PEG Tube Care:  

• Flushing: Flushing the tube with water (usually 30-60 mL, depending on provider instructions) after each feeding or medication administration is critical for maintaining tube patency. Sterile or filtered water is often recommended for clients with compromised immune systems.
• Clamping: After flushing, the tube should be clamped to maintain hygiene and prevent reflux of gastric contents.

Think of the PEG tube like a drinking straw. After using it, you rinse it out to keep it clean and ensure nothing gets stuck inside. Flushing the tube works the same way—keeping it clean and open for the next use.

Proper PEG tube care and maintenance are essential for preventing complications such as tube occlusion, infection, or displacement. Key nursing actions include:

• Teach caregivers to flush the tube with water before and after feedings or medications to prevent clogging.
• Instruct on inspecting the site daily for redness, swelling, or signs of infection (e.g., purulent drainage) and reporting any abnormalities promptly.
• Demonstrate the correct technique for clamping and securing the tube to prevent displacement or leakage.
• Emphasize the importance of using liquid or finely crushed medications dissolved in water to avoid clogging.
• Encourage caregivers to keep feeding supplies clean and replace them as instructed to reduce infection risk.

✘Incorrect answer options:

"I should check the tube’s placement four times every day." Checking tube placement is essential for nasogastric (NG) or nasoenteric tubes, but for a PEG tube, placement verification is not routinely required since the tube is surgically placed and secured at the abdominal wall. However, caregivers should be taught to check for signs of dislodgement, such as increased leakage or external movement of the tube.

"I will notify the doctor if there are any signs of indigestion." While indigestion may be concerning, it is not directly related to PEG tube maintenance. Caregivers should be educated to watch for signs of more serious complications, such as site infection, tube dislodgement, or feeding intolerance (e.g., vomiting, diarrhea, or abdominal distension), and notify the healthcare provider if these occur.

"If my father can’t swallow, I’ll stop the feeding and contact the clinic immediately." PEG tubes are specifically used for clients who cannot swallow safely. Feeding does not rely on the client’s ability to swallow since nutrients are delivered directly to the stomach or small intestine. This statement reflects a misunderstanding of the purpose of the PEG tube.

EXPLANATION

✔Correct answer:

Halo traction.  Halo traction is the most appropriate type of traction for discharge in a patient with a cervical spine fracture. The halo device provides external fixation and stabilization of the cervical spine, allowing the patient to safely continue healing at home while maintaining proper spinal alignment. The halo device consists of a metal ring (halo) secured to the skull with pins or screws, connected to a rigid vest worn on the chest. It immobilizes the head and neck, reducing movement and promoting proper healing of the cervical spine.

Halo traction is designed for long-term use in ambulatory patients with cervical spine fractures or instability. Unlike other forms of traction, such as Buck's or Crutchfield tong traction, halo traction allows for patient mobility, making it suitable for discharge and home care.

Think of the halo device like a neck brace that’s extra secure. It keeps the head and neck perfectly aligned, like a scaffold stabilizing a building under construction, while allowing the patient to move around safely.

Preparing a patient for discharge with a halo traction device requires detailed education to ensure safety and prevent complications. Key nursing interventions include:

• Teach the patient and family how to clean the pin sites using sterile saline or chlorhexidine to prevent infection.
• Emphasize the importance of inspecting the pin sites daily for signs of infection, such as redness, swelling, or drainage, and reporting abnormalities promptly.
• Instruct the patient to avoid grabbing or pulling on the halo device to prevent loosening or misalignment.
• Provide guidance on wearing clothing that accommodates the halo device, such as button-up shirts.
• Educate the patient about proper sleeping positions to maintain alignment and prevent discomfort (e.g., lying on their back with a pillow under the shoulders).
• Ensure the patient understands activity restrictions and the importance of adhering to follow-up appointments for device adjustments and monitoring.

✘Incorrect answer options:

Russell’s traction. Russell’s traction is used primarily for fractures of the lower extremities, such as femur fractures. It is not appropriate for cervical spine injuries and is not suitable for home use because it requires specialized equipment.

Buck’s traction. Buck’s traction is commonly used as a temporary measure for conditions like hip fractures or soft tissue injuries. It involves skin traction with weights, making it impractical for long-term or home use, especially in cases of cervical spine fractures.

Crutchfield tong traction. Crutchfield tong traction is used for cervical spine fractures in the acute setting, such as in the hospital, to provide skeletal traction. It is not designed for home use because it requires continuous weight application and strict bedrest, making it inappropriate for discharge planning.

EXPLANATION

✔Correct answer:

It involves the use of a Steinman pin for stabilization.  Balanced skeletal traction is a method used to stabilize and align fractures, especially in long bones like the femur, or to address skeletal deformities. It often involves the use of a Steinman pin, which is surgically inserted through the bone to provide a stable anchor for the traction. This setup ensures that the skeletal traction exerts a consistent pull directly on the bone, helping to maintain alignment and promote healing while relieving muscle spasms. Balanced traction uses counterweights and pulleys to balance the force applied to the injured limb, allowing for effective immobilization and alignment without undue pressure on the patient.

Key Features of Balanced Skeletal Traction:  

• A Steinman pin or similar hardware (e.g., Kirschner wires) is inserted into the bone to provide direct skeletal traction.
• Counterweights and pulley systems are used to balance the traction, ensuring constant force while allowing some mobility in the bed (e.g., lifting the body off the bed).
• It is often used for long-term immobilization in severe fractures or when surgery is delayed.

Think of balanced skeletal traction like a carefully calibrated suspension bridge. The Steinman pin acts as the anchor point, and the counterweights and pulleys act as the cables holding the bridge steady, ensuring proper alignment without collapsing or causing excess strain.

Balanced skeletal traction requires careful monitoring and management to prevent complications and promote healing. Key nursing actions include:

• Perform neurovascular assessments regularly (e.g., circulation, sensation, and movement of the affected limb) to monitor for signs of compromised blood flow or nerve injury.
• Inspect the insertion site of the Steinman pin for signs of infection (e.g., redness, drainage, or swelling) and provide appropriate pin care to prevent complications.
• Ensure the weights and pulleys are functioning correctly and are not resting on the bed or floor, as this would compromise the traction’s effectiveness.
• Provide skin care and reposition the patient as needed to prevent pressure ulcers and discomfort.
• Educate the patient about the importance of not adjusting the weights or traction setup without assistance from healthcare staff.

✘Incorrect answer options:

It requires immobilization of both legs for balance. Balanced skeletal traction does not inherently require immobilization of both legs. It focuses on applying traction to the affected limb, using counterweights and pulleys for balance. Immobilization of the contralateral limb is not typically necessary.

It makes use of Kirschner wires for securing alignment. While Kirschner wires (K-wires) can be used in skeletal traction, the more common hardware for balanced skeletal traction is the Steinman pin. The use of K-wires is generally more common in specific orthopedic procedures, such as smaller fractures.

It is mainly intended to facilitate healing of hip fractures. Balanced skeletal traction is not primarily used for hip fractures. Instead, hip fractures are often managed with Buck's traction (a skin traction method) as a temporary measure before surgical intervention. Balanced skeletal traction is more commonly used for long bone fractures, such as those of the femur.

EXPLANATION

✔Correct answer:

Keep naloxone (Narcan) readily available.  After abdominal surgery, elderly clients are at higher risk for complications related to anesthesia and narcotics, particularly respiratory depression, which is a known side effect of opioid medications used for pain management. Naloxone (Narcan) is an opioid antagonist that rapidly reverses the effects of opioids, including respiratory depression. Nurse Dana should prioritize having naloxone readily available in case the client exhibits signs of respiratory depression, such as slow or shallow breathing, decreased oxygen saturation, or unresponsiveness. Early recognition and intervention can prevent life-threatening complications.

Key Consideration in Post-Operative Care:  

Older adults are particularly vulnerable to the effects of narcotics due to age-related changes in metabolism, excretion, and sensitivity to medications. This can result in prolonged drug effects and an increased risk of opioid-induced complications. As such, monitoring for respiratory depression and ensuring rapid access to naloxone is a priority.

Think of opioids as a dimmer switch for the body. While they reduce pain by "dimming" the nervous system, they can sometimes dim it too much, leading to dangerously slow breathing. Naloxone acts like a reset button, restoring the switch to normal levels immediately.

In addition to having naloxone readily available, the nurse should take steps to prevent and manage opioid-related complications. Key nursing actions include:

• Perform regular respiratory assessments, including rate, depth, oxygen saturation, and level of consciousness, especially within the first 24 hours after surgery.
• Administer opioids at the lowest effective dose and titrate carefully to balance pain relief with the risk of respiratory depression.
• Educate the client and family about reporting symptoms such as severe drowsiness, confusion, or difficulty breathing.
• Encourage the use of adjunct pain management strategies, such as non-opioid medications and non-pharmacologic interventions (e.g., repositioning, relaxation techniques).
• Ensure the oxygen delivery system is functional in case supplemental oxygen is required.

✘Incorrect answer options:

Administer oxygen using a nasal cannula. While supplemental oxygen may be necessary if the client shows signs of hypoxia, it does not address the root cause of respiratory depression due to opioids. The priority is to ensure naloxone is available to reverse opioid effects if respiratory depression occurs.

Be prepared to administer blood products if needed. Administering blood products may be required if the client experiences post-operative bleeding or anemia, but this is not directly related to anesthesia or narcotics. Respiratory depression from opioids is a more immediate concern.

Have equipment ready for cardiac resuscitation. While cardiac arrest is a rare complication, it is not the most likely issue following anesthesia or narcotic use. Respiratory depression is a more common and immediate risk, and it can usually be reversed with naloxone before escalating to cardiac complications.

EXPLANATION

✔Correct answer:

Hormonal fluctuations or disturbances.  The most likely contributing factor to osteoporosis in a 60-year-old female is hormonal changes, specifically the decline in estrogen levels associated with menopause. Estrogen plays a critical role in maintaining bone density by inhibiting bone resorption (the breakdown of bone tissue). After menopause, estrogen levels drop significantly, leading to an imbalance in bone remodeling where bone resorption outpaces bone formation. This results in reduced bone mineral density (BMD), increasing the risk of osteoporosis and fractures.

Bone remodeling is a lifelong process where old bone is resorbed by osteoclasts and new bone is formed by osteoblasts. Estrogen regulates this process by suppressing osteoclast activity. When estrogen levels decline during menopause, osteoclast activity becomes unchecked, leading to excessive bone loss. Women can lose up to 20% of their bone mass in the first 5-7 years after menopause due to this hormonal shift.

Imagine bones as a bank account where deposits (bone formation) and withdrawals (bone resorption) need to stay balanced. Estrogen acts like a financial advisor, ensuring that too many withdrawals don’t occur. After menopause, this "advisor" is gone, leading to rapid withdrawals (bone loss) without enough deposits (bone formation).

To reduce the risk of osteoporosis, nurses should educate and empower clients to adopt preventive measures. Important actions include:

• Encourage a diet rich in calcium and vitamin D to support bone health.
• Promote weight-bearing and resistance exercises to strengthen bones and improve BMD.
• Discuss the potential benefits of pharmacological interventions (e.g., bisphosphonates, hormone replacement therapy) with the healthcare provider if the client is at high risk.
• Educate the client on lifestyle changes such as smoking cessation and limiting alcohol intake, as both are associated with increased bone loss.
• Screen for bone density through dual-energy X-ray absorptiometry (DEXA) scans as recommended.

✘Incorrect answer options:

Reduced physical activity levels. While physical inactivity can contribute to bone loss, it is not the primary factor driving osteoporosis in postmenopausal women. Hormonal changes have a more significant and direct impact on bone density.

Low dietary calcium intake. Inadequate calcium intake can exacerbate bone loss, but it is not the most likely factor in this case. Hormonal changes due to menopause play a more central role, although calcium supplementation is essential for prevention.

Hereditary predisposition to osteoporosis. Genetics can influence bone density and osteoporosis risk, but aging and hormonal changes are more immediate factors in this scenario. Even individuals without a family history can develop osteoporosis after menopause due to estrogen deficiency.