A nurse is caring for a client who is post-operative following an open reduction internal fixation (ORIF) of a femur fracture. What is NOT included in the evaluation of the neurovascular status of the client's affected extremity?

Correct Answer: D

Rationale: In the context of caring for a client post-ORIF of a femur fracture, evaluating neurovascular status is crucial to monitor for complications like compartment syndrome or impaired circulation. The correct answer, D) Skin integrity, is not typically included in the assessment of neurovascular status. Skin integrity is important for wound healing and infection prevention but is not a direct indicator of neurovascular status. A) Color, B) Temperature, and C) Sensation are all key components in assessing neurovascular status. Color changes can indicate perfusion issues, abnormal temperature can signal circulation problems, and altered sensation can point to nerve damage. Understanding these indicators helps nurses detect early signs of complications and provide timely interventions. In an educational context, this question highlights the importance of a comprehensive assessment in post-operative care. By understanding which assessments are relevant to neurovascular status, nurses can ensure thorough monitoring and prompt response to any emerging issues, ultimately promoting better patient outcomes.

Correct Answer: C

Rationale: In the context of multi-dimensional care, collecting a reliable source of pain assessment is crucial for providing effective patient care. The correct answer, option C - From the client, is the most reliable source of pain assessment because pain is a subjective experience that can only be truly described and understood by the individual experiencing it. The client's self-report is considered the gold standard in pain assessment as it directly reflects their personal perception of pain intensity, quality, and location. Option A - From the nurse-to-nurse bedside report, is incorrect because pain is highly individualized, and relying on second-hand information may not accurately capture the client's experience. Option B - From a medical-surgical book, is also incorrect as pain assessment should be based on the client's current and unique situation rather than generalized information from a book. Option D - From the client's chart, may contain valuable information about the client's pain history and previous assessments, but it may not reflect the client's current pain status or changes in their condition. Therefore, while the client's chart can provide supplementary information, it should not be the primary source for assessing current pain levels. In an educational context, it is essential for nursing students to understand the importance of utilizing the client's self-report as the cornerstone of pain assessment. Teaching students to prioritize the client's voice in pain management empowers them to provide patient-centered care and ensures that interventions are tailored to meet the individual needs and experiences of each client.

Correct Answer: D

Rationale: The most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery is option D) Client will remain free from falls throughout their hospital stay. Rationale: 1. Correct Answer: Option D is the most appropriate goal because preventing falls is crucial for an elderly client post-hip surgery. Falls can lead to serious complications such as fractures, delayed healing, and increased pain, which can further exacerbate the client's condition. 2. Incorrect Options: - Option A: Increasing mobility by discharge may not be realistic or safe for an elderly client immediately post-hip surgery as it can increase the risk of falls. - Option B: Demonstrating effective breathing patterns while ambulating is important, but it does not directly address the risk for injury post-hip surgery. - Option C: Increasing activity tolerance is important for rehabilitation, but the immediate focus should be on preventing falls to ensure the client's safety. Educational Context: Understanding the specific needs of elderly clients post-hip surgery is crucial for nursing practice. Emphasizing fall prevention as a priority goal aligns with best practices in geriatric care and patient safety. By setting realistic and targeted goals, healthcare providers can ensure optimal outcomes and promote the well-being of elderly clients during their recovery process.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Put on non-sterile gloves. This is the nurse's first action because it is essential to ensure infection control measures are in place before any direct contact with the wound. By putting on non-sterile gloves, the nurse is preventing the introduction of pathogens into the wound and reducing the risk of cross-contamination. Option A) Label the specimen tube is incorrect because this step should come after the wound culture is obtained, not as the first action. Option C) Gently remove the soiled dressings is incorrect because it should not be the first action without ensuring proper infection control measures. Option D) Irrigate the wound is incorrect as irrigation should be performed after initial precautions are taken to prevent introducing contaminants. Educationally, this question highlights the importance of infection control and proper wound care procedures in nursing practice. Nurses must prioritize patient safety by following correct protocols when dealing with wounds to prevent complications and promote healing. Understanding the sequence of actions in wound care is crucial for providing effective care to patients with non-healing wounds.

Correct Answer: C

Rationale: In the context of rheumatoid arthritis, a positive rheumatoid factor (RF) is typically seen in clients experiencing a flare-up of the disease. The presence of RF indicates the production of autoantibodies against the individual's own healthy tissues, which is a hallmark characteristic of rheumatoid arthritis. This autoimmune response leads to inflammation, joint damage, and other symptoms associated with the condition. Option A, stating that the factor does not change, is incorrect because in active rheumatoid arthritis, there is often an increase in RF levels due to the heightened immune response. Option B, suggesting a decreased level of rheumatoid arthritis, is incorrect as RF levels are not expected to decrease during a flare-up. Option D, a negative rheumatoid factor, is also incorrect as a negative RF result is not typically associated with rheumatoid arthritis. From an educational standpoint, understanding the significance of rheumatoid factor in the diagnosis and monitoring of rheumatoid arthritis is crucial for healthcare providers involved in the care of patients with this condition. Recognizing the relationship between RF levels and disease activity can help guide treatment decisions and improve patient outcomes.