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 is an important component of residual-limb care following a below-the-knee amputation.

♦️ Compression socks or elastic bandages help decrease postoperative edema by applying controlled pressure to the residual limb.

♦️ Reducing edema promotes healing and helps stabilize the size of the residual limb.

♦️ Compression also helps shape the residual limb into a more conical configuration appropriate for prosthetic fitting.

♦️ Proper shaping prevents development of an irregular or bulbous residual limb that could interfere with prosthesis placement.

♦️ Consistent compression can also support venous and lymphatic return, helping control fluid accumulation.

♦️ Compression should be applied correctly to prevent excessive pressure that could compromise circulation or skin integrity.

♦️ Effective edema control and residual-limb shaping therefore help prepare the client for successful prosthetic fitting and rehabilitation.

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Answer 2

Correct Answers:

Tension Pneumothorax

Rationale :

♦️ A tension pneumothorax occurs when air enters the pleural space and becomes trapped, causing progressively increasing intrapleural pressure.

♦️ The increasing pressure collapses the affected lung, explaining the absent breath sounds on the left side.

♦️ Rising pressure pushes the mediastinum and trachea away from the affected side, producing tracheal deviation to the right.

♦️ Compression of the great vessels decreases venous return to the heart and causes jugular vein distention.

♦️ Reduced venous return decreases cardiac output, resulting in hypotension and obstructive shock.

♦️ Sudden dyspnea and sharp unilateral chest pain are also characteristic manifestations.

♦️ Trauma from a motor vehicle collision can injure the chest and allow air to accumulate under pressure within the pleural cavity.

♦️ Tension pneumothorax is a life-threatening emergency requiring immediate decompression followed by definitive chest-tube management.

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Answer 3

Correct Answers:

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

Rationale :

♦️ Inhaled corticosteroids are primarily controller medications used for long-term management of persistent asthma.

♦️ Corticosteroids decrease airway inflammation, edema, mucus production, and airway hyperresponsiveness over time.

♦️ They should generally be taken regularly as prescribed, even when the client is not experiencing asthma symptoms.

♦️ Inhaled corticosteroids do not provide the rapid bronchodilation needed during an acute episode of wheezing or bronchospasm.

♦️ A short-acting beta₂-agonist (SABA) such as albuterol is traditionally used as a rapid-relief medication when prescribed; some current asthma plans instead use an ICS-formoterol reliever, depending on the regimen.

♦️ Waiting until wheezing begins before using a prescribed daily corticosteroid can result in inadequate control of chronic airway inflammation.

♦️ The client should also be instructed to rinse the mouth after corticosteroid inhalation to reduce the risk of oral candidiasis.

♦️ This statement demonstrates a misunderstanding of the difference between controller therapy and rapid-relief treatment.

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Answer 4

Correct Answers:

Tachypnea (28 breaths/min) and use of accessory muscles; administer supplemental oxygen and prepare for A further respiratory interventions

Rationale :

🖍️ The client demonstrates significant respiratory distress, evidenced by tachypnea, accessory muscle use, cyanosis, and difficulty breathing.

🖍️ An SpO₂ of 86% on room air indicates clinically significant hypoxemia and represents the most urgent respiratory concern.

🖍️ Cyanosis around the lips further indicates inadequate arterial oxygenation and requires prompt intervention.

🖍️ The client's upright, forward-leaning position and accessory muscle use demonstrate increased work of breathing and an attempt to improve ventilation.

🖍️ Supplemental oxygen should be initiated promptly and titrated according to the prescribed or emergency target range, with many COPD patients targeted around 88% to 92% when hypercapnic respiratory failure is a concern.

🖍️ The nurse should continuously reassess oxygen saturation, respiratory effort, mental status, and breath sounds for evidence of deterioration.

🖍️ Additional interventions may include prescribed bronchodilators, arterial blood gases, chest imaging, and ventilatory support depending on the response to treatment.

🖍️ The combination of hypoxemia and increased work of breathing takes priority under the airway-breathing-circulation framework.

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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 cast should not be handled with the fingertips while it is still wet or drying.

✍️ Fingertip pressure can create indentations or dents in the soft cast material before it has completely hardened.

✍️ These indentations can produce localized pressure against the underlying skin and tissues.

✍️ Excessive pressure can contribute to skin breakdown, pressure injury, impaired circulation, and neurovascular compromise.

✍️ A wet cast should be handled using the palms of the hands to distribute pressure evenly across a larger surface area.

✍️ The cast should also be repositioned periodically during drying to allow adequate air circulation around its surfaces.

✍️ The nurse should continue frequent neurovascular assessments, including circulation, movement, sensation, pulses, and capillary refill distal to the cast.

✍️ Using the fingertips to manipulate a newly applied cast therefore indicates a need for further teaching about safe cast handling.

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Answer 6

Correct Answers:

Assess airway patency and provide oxygen.

Rationale :

🖍️ Sudden labored breathing, increased work of breathing, and decreased oxygen saturation indicate acute respiratory compromise.

🖍️ The priority is to immediately assess whether the tracheostomy airway is patent because obstruction can rapidly become life-threatening.

🖍️ A new tracheostomy can become obstructed by thick secretions, mucus plugs, blood, or displacement of the tube.

🖍️ Supplemental oxygen should be provided while the nurse evaluates the airway and the client's respiratory status.

🖍️ Assessment includes observing airflow through the tracheostomy, chest movement, breath sounds, oxygen saturation, and signs of obstruction.

🖍️ The airway-breathing-circulation (ABC) framework makes airway assessment the immediate priority before determining the specific corrective intervention.

🖍️ If secretions are identified as the cause of obstruction, tracheostomy suctioning should then be performed promptly.

🖍️ Rapid assessment and oxygenation help prevent progression from acute airway compromise to severe hypoxemia and respiratory arrest.

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Answer 7

Correct Answers:

Neurovascular status of the affected extremity

Rationale :

✍️ Neurovascular assessment is the priority for a client in skeletal traction because the fracture, swelling, or traction can compromise circulation and nerve function.

✍️ The nurse should assess the affected extremity for the 6 Ps: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia.

✍️ Peripheral pulses and capillary refill help determine whether adequate arterial blood flow is reaching tissues distal to the injury.

✍️ Skin color and temperature provide additional information about circulation to the affected extremity.

✍️ Sensation should be assessed for numbness and tingling, which can indicate nerve compression or impaired perfusion.

✍️ Motor function should also be evaluated by assessing the client's ability to move the toes when permitted.

✍️ Increasing pain that is disproportionate to the injury can indicate compartment syndrome, which requires immediate intervention.

✍️ Frequent neurovascular assessment allows early detection of limb-threatening circulatory or neurologic compromise.

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Answer 8

Correct Answers:

Encourage the patient to cough and deep breathe every 2 hours

Rationale :

✏️ Coughing and deep-breathing exercises help improve ventilation and promote clearance of respiratory secretions in a client with pneumonia.

✏️ Deep breathing promotes alveolar expansion, allowing air to reach areas of the lungs that may be poorly ventilated.

✏️ Effective coughing helps mobilize and remove mucus and inflammatory secretions from the airways.

✏️ Removing retained secretions improves airflow and can enhance oxygen exchange at the alveolar level.

✏️ Pneumonia can cause alveoli to fill with inflammatory fluid and secretions, contributing to hypoxemia and shortness of breath.

✏️ Performing these exercises regularly also helps reduce the development of atelectasis and secretion retention.

✏️ Positioning the client upright and maintaining appropriate hydration can further support lung expansion and mucus clearance when not contraindicated.

✏️ Regular coughing and deep breathing therefore address both oxygenation and airway clearance, making this the most appropriate intervention described.

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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 :

🌻 The cane should be held on the strong side, which is the left side for a client with right-sided weakness.

🌻 Holding the cane opposite the weak leg provides greater stability and balance during ambulation.

🌻 The client should advance the cane and the weak right leg together.

🌻 Body weight can then be supported through the cane while the weakened extremity moves forward.

🌻 The client subsequently advances the strong left leg past the cane and weakened leg.

🌻 This sequence creates a wider base of support and decreases the amount of weight placed on the weak extremity.

🌻 Proper cane height should allow approximately 20° to 30° of elbow flexion when the client holds the handle.

🌻 Correct cane placement and sequencing promote safe ambulation while reducing fall risk.

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Answer 10

Correct Answers:

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

Rationale :

🏵️ Following a total hip replacement, preventing hip dislocation is an important postoperative safety priority.

🏵️ Bending forward at the waist to put on shoes can cause hip flexion beyond 90°, depending on the prescribed precautions.

🏵️ Excessive hip flexion can place stress on the newly replaced joint and increase the risk of prosthetic dislocation.

🏵️ The nurse should immediately stop the unsafe movement and reinforce the client's prescribed hip precautions.

🏵️ Assistance with dressing helps the client maintain proper alignment while recovering from surgery.

🏵️ Adaptive devices such as a long-handled shoehorn, dressing stick, or reacher can reduce the need for excessive bending.

🏵️ The client should follow the surgeon's specific precautions because restrictions can vary according to the surgical approach and individual procedure.

🏵️ Immediate correction of unsafe positioning helps protect the prosthesis while supporting safe postoperative mobility and independence.

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QLexNursing

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?

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?

QLexNursing

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?

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?

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?

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?