INTEGRATED HESI EXIT PRACTICE QUESTIONS AND RATIONALE

INTEGRATED HESI EXIT PRACTICE QUESTIONS AND RATIONALE The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? 1."Changes in the shape of the knee are expected." 2."Fever, redness, and increased pain are expected." 3."All caregivers should be told about the metal implant." 4."Bleeding gums or black stools may occur, but this is normal." - CORRECT ANSWER -3 A TJR is also known as a total joint arthroplasty (TJA). The client must inform other caregivers of the presence of the metal implant because certain tests and procedures will need to be avoided. After total knee replacement, the client should report signs and symptoms of infection and any changes in the shape of the knee. These could indicate developing complications. With a metal implant, the client may be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from a variety of sources, and the client will need antibiotic prophylaxis for invasive procedures. The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. 1.Capillary refill is less than 3 seconds 2.Pulses present and with swollen, pink fingers 3.Client report of severe, deep, unrelenting pain 4.Client report of pain as nurse assesses finger movement 5.Client report of numbness and tingling sensation in the fingers - CORRECT ANSWER -3, 4, 5 The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome. A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. 1.Ice 2.Heat 3.Analgesics 4.Muscle relaxers 5.Intermittent traction - CORRECT ANSWER -2, 3, 4, 5 Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the health care provider's preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled. The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action should the nurse teach the client to avoid? 1.Crossing legs at the ankle 2.Using an elevated toilet seat 3.Placing a pillow between the legs 4.Keeping the legs abducted from the midline - CORRECT ANSWER -1 Following surgery to repair a fractured hip using a posterior approach, client education should include the following: avoiding crossing the legs at the ankle or the knee, using an elevated toilet seat, placing a pillow between the legs while lying down for the first 6 weeks, keeping the legs abducted from the midline, and keeping the hip in a neutral position at all times. An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? 1.Anemia 2.Fractures 3.Infection 4.Muscle sprains - CORRECT ANSWER -2