Question

A client who had a below-the-knee amputation 12 hours ago is being prepared for discharge. The nurse explains the importance of using compression socks or bandages at home, Which of the following statements by the client indicates an understanding of the purpose of compression therapy?

Answer 1

Correct Answers:

"They will reduce swelling and help the stump mold for a prosthesis."

Rationale :

🦿Compression therapy helps decrease postoperative edema in the residual limb.

🩹It also promotes proper shaping and contouring of the limb for future prosthetic fitting.

📏Consistent compression helps the residual limb gradually achieve a stable size and shape.

🧑‍🦽Proper residual-limb shaping improves the likelihood of an effective and comfortable prosthesis fit.

📌Core Message

Compression therapy reduces edema and shapes the residual limb for prosthetic fitting.

Answer 2

Correct Answers:

Tension Pneumothorax

Rationale :

🫁A tension pneumothorax occurs when air enters the pleural space and cannot escape, causing increasing intrathoracic pressure.

➡️The increasing pressure shifts the mediastinum and produces tracheal deviation away from the affected side.

🩸Compression of major thoracic vessels decreases venous return, resulting in hypotension and jugular venous distention.

🚨The combination of unilateral absent breath sounds, hypotension, and tracheal deviation represents a life-threatening respiratory emergency.

📌Core Message

Tension pneumothorax causes unilateral absent breath sounds, tracheal deviation, JVD, and hypotension and requires emergency treatment.

Answer 3

Correct Answers:

"I'll use my corticosteroid inhaler when I start to wheeze."

Rationale :

💨An inhaled corticosteroid is a controller medication, not a rapid-relief medication.

📅It should generally be used regularly as prescribed to decrease chronic airway inflammation.

🚑Acute wheezing is treated with a short-acting bronchodilator, such as albuterol, when prescribed.

🫁Consistent corticosteroid use helps decrease airway hyperresponsiveness and asthma exacerbations.

📌Core Message

Inhaled corticosteroids prevent and control airway inflammation; they are not rescue medications for sudden wheezing.

Answer 4

Correct Answers:

Tachypnea, accessory muscle use, and SpO₂ of 86%; administer supplemental oxygen and prepare for further respiratory interventions.

Rationale :

🫁An SpO₂ of 86%, tachypnea, cyanosis, and accessory-muscle use indicate significant hypoxemia and respiratory distress.

🚨Using the ABC priority framework, impaired breathing and oxygenation require immediate intervention.

💨Supplemental oxygen should be initiated and titrated appropriately while the patient's respiratory response is closely monitored.

🩺Further assessment and respiratory interventions may be required because worsening work of breathing can progress to respiratory failure.

📌Core Message

Severe hypoxemia with increased work of breathing requires immediate oxygen support and respiratory intervention.

Answer 5

Correct Answers:

Gently using the fingertips of the hands to move the cast every 2 hours to help with drying

Rationale :

🖐️A newly applied wet cast should be handled with the palms of the hands, not the fingertips.

🕳️Fingertips can create indentations or pressure points in a wet cast.

🩸These pressure areas can compress underlying tissue and impair circulation or skin integrity.

🦴Proper handling maintains the cast's shape and protects the affected extremity while the cast dries and hardens.

📌Core Message

Handle a wet cast with the palms, because fingertips can create harmful pressure indentations.

Answer 6

Correct Answers:

Assess airway patency and provide oxygen.

Rationale :

🫁The immediate priority is to determine whether the airway is patent because sudden respiratory distress may indicate obstruction.

💨Providing oxygen addresses the patient's immediate hypoxemia while the cause is being assessed.

🔍Assessment may reveal mucus plugging, tube displacement, or another form of airway obstruction.

🚨Once obstruction is identified, rapid interventions such as suctioning can be performed based on the assessment findings.

📌Core Message

With sudden tracheostomy distress, immediately assess airway patency and oxygenation, then correct the identified obstruction.

Answer 7

Correct Answers:

Neurovascular status of the affected extremity

Rationale :

🩸Skeletal traction can compromise circulation and nerve function in the affected limb.

🦶The nurse should regularly assess pulses, color, temperature, movement, sensation, and capillary refill.

⚠️Changes can indicate complications such as neurovascular compromise or compartment syndrome.

⏱️Early recognition is essential because prolonged impairment can result in permanent tissue or nerve damage.

📌Core Message

The priority in skeletal traction is frequent assessment of neurovascular status in the affected extremity.

Answer 8

Correct Answers:

Encourage the patient to cough and deep breathe every 2 hours

Rationale :

🫁Coughing and deep breathing help mobilize respiratory secretions and improve ventilation in a patient with pneumonia.

💨Deep breathing promotes alveolar expansion and can improve oxygen exchange.

🧹Effective coughing helps clear accumulated mucus and secretions from the airways.

⏱️Performing these exercises regularly helps reduce airway obstruction and atelectasis.

📌Core Message

Regular coughing and deep breathing promotes both airway clearance and improved ventilation in pneumonia.

Answer 9

Correct Answers:

The client holds the cane or the left side and advances the cane and weak leg forward at the same time.

Rationale :

🦯A cane should generally be held on the stronger side, opposite the weak extremity.

⬅️With right-sided weakness, the client should hold the cane in the left hand.

🚶The cane and the weak right leg advance together, followed by the stronger left leg.

⚖️This sequence increases the base of support and helps transfer weight away from the weaker extremity.

📌Core Message

Hold the cane on the strong side and advance it together with the weak leg.

Answer 10

Correct Answers:

Remind the patient to avoid hip flexion past 90° and assist with dressing

Rationale :

🦴After total hip replacement, excessive hip flexion can increase the risk of prosthetic joint dislocation.

📐Bending at the waist to put on shoes can cause the hip to flex beyond the commonly prescribed 90-degree restriction, depending on the surgical approach and surgeon's protocol.

👟The nurse should stop the unsafe movement and assist the patient with adaptive dressing techniques or equipment.

🛡️Following prescribed hip precautions helps protect the new joint during the early postoperative healing period.

📌Core Message

After hip replacement, prevent unsafe excessive hip flexion and use assistance or adaptive equipment for dressing.

1 :
A client who had a below-the-knee amputation 12 hours ago is being prepared for discharge. The nurse explains the importance of using compression socks or bandages at home, Which of the following statements by the client indicates an understanding of the purpose of compression therapy?

📌Core Message

📌Core Message

3 :
A nurse is reinforcing teaching to a client newly diagnosed with asthma. Which statement by the client indicates a need for further education?

📌Core Message

4 :
A 69-year-old female presents to the emergency department.

Answer Options

📌Core Message

5 :
You are the preceptor for a student nurse and are caring for a patient who is 2 hours post-op from a cast placement on the right leg. Which action by the student nurse requires further teaching about cast care?

📌Core Message

6 :
A patient with a new tracheostomy suddenly develops labored breathing, increased work of breathing, and a drop in oxygen saturation. Which is the nurse's first action?

📌Core Message

7 :
A patient is in skeletal traction for a fractured femur. Which of the following is the nurse's priority assessment?

📌Core Message

8 :
A nurse is caring for a patient with pneumonia who is experiencing increased shortness of breath and decreased oxygen saturation. Which of the following interventions is most appropriate to promote oxygenation and airway clearance?

📌Core Message

9 :
A nurse is evaluating a client learning to ambulate with a new cane due to right-sided weakness. Which of the following observations indicates that the client understands how to use a cane correctly?

📌Core Message

10 :
A patient who had a total hip replacement via a lateral approach yesterday is attempting to bend at the waist to put on shoes. What is the nurse's priority action?

📌Core Message

1 : A client who had a below-the-knee amputation 12 hours ago is being prepared for discharge. The nurse explains the importance of using compression socks or bandages at home, Which of the following statements by the client indicates an understanding of the purpose of compression therapy?

📌Core Message

📌Core Message

3 : A nurse is reinforcing teaching to a client newly diagnosed with asthma. Which statement by the client indicates a need for further education?

📌Core Message

4 : A 69-year-old female presents to the emergency department.

Answer Options

📌Core Message

5 : You are the preceptor for a student nurse and are caring for a patient who is 2 hours post-op from a cast placement on the right leg. Which action by the student nurse requires further teaching about cast care?

📌Core Message

6 : A patient with a new tracheostomy suddenly develops labored breathing, increased work of breathing, and a drop in oxygen saturation. Which is the nurse's first action?

📌Core Message

7 : A patient is in skeletal traction for a fractured femur. Which of the following is the nurse's priority assessment?

📌Core Message

8 : A nurse is caring for a patient with pneumonia who is experiencing increased shortness of breath and decreased oxygen saturation. Which of the following interventions is most appropriate to promote oxygenation and airway clearance?

📌Core Message

9 : A nurse is evaluating a client learning to ambulate with a new cane due to right-sided weakness. Which of the following observations indicates that the client understands how to use a cane correctly?

📌Core Message

10 : A patient who had a total hip replacement via a lateral approach yesterday is attempting to bend at the waist to put on shoes. What is the nurse's priority action?

📌Core Message

1 :
A client who had a below-the-knee amputation 12 hours ago is being prepared for discharge. The nurse explains the importance of using compression socks or bandages at home, Which of the following statements by the client indicates an understanding of the purpose of compression therapy?

3 :
A nurse is reinforcing teaching to a client newly diagnosed with asthma. Which statement by the client indicates a need for further education?

4 :
A 69-year-old female presents to the emergency department.

5 :
You are the preceptor for a student nurse and are caring for a patient who is 2 hours post-op from a cast placement on the right leg. Which action by the student nurse requires further teaching about cast care?

6 :
A patient with a new tracheostomy suddenly develops labored breathing, increased work of breathing, and a drop in oxygen saturation. Which is the nurse's first action?

7 :
A patient is in skeletal traction for a fractured femur. Which of the following is the nurse's priority assessment?

8 :
A nurse is caring for a patient with pneumonia who is experiencing increased shortness of breath and decreased oxygen saturation. Which of the following interventions is most appropriate to promote oxygenation and airway clearance?

9 :
A nurse is evaluating a client learning to ambulate with a new cane due to right-sided weakness. Which of the following observations indicates that the client understands how to use a cane correctly?

10 :
A patient who had a total hip replacement via a lateral approach yesterday is attempting to bend at the waist to put on shoes. What is the nurse's priority action?