Adult Med-Surg- Integ/Musc

A nurse is reinforcing teaching with a client who has a skin lesion and is scheduled for an excisions skin biopsy. Which of the following information should the nurse include in the teaching?

"You will need to change the dressing daily" The nurse should instruct the client that a dressing will be applied after the biopsy which will need a daily dressing change.

A nurse is reinforcing teaching about dietary measures with a client who is at risk for developing osteoporosis. Which of the following food choices should the nurse recommend to increase the client's calcium level?

One cup of cooked spinach

A nurse is caring for a client who has balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following actions should the nurse take to prevent skin breakdown?

Pad the top of the splint with protective dressings.

A nurse is collecting data from a client who has herpes zoster (shingles). Which of the following is an unexpected finding?

Painful vesicles following a nerve pathway

A nurse is reinforcing preoperative teaching with a client who is scheduled to have hip arthroplasty. Which of the following information should the nurse provide in the teaching?

"Bending the hip within 90 degrees is allowed" The nurse should instruct the client that bending beyond 90 degrees could result in dislocation of the hip

A nurse is reviewing discharge instructions with a client who has pruritus following treatment for scabies. Which of the following instructions should the nurse include?

"Wear loose fitting clothing while you are experiencing itching" The nurse should advise the client that to help relieve the itching of pruritus, the home environmental temperature should be slightly cool and the client should wear loose clothing.

A nurse is reinforcing teaching with a client who has genital herpes simplex virus type 2 (HSV 2) Which statement by the client indicates understanding of the teaching?

"I can transmit the infection to another person even when I don't have symptoms"

A nurse is reinforcing teaching with a client who has rheumatoid arthritis. Which of the following statements by the client indicates understanding of the information?

"I can use heat or cold to help relieve my pain" The client might find heat to be effective for stiffness, but cold more effective on days when the client is experiencing acute inflammation. Therefore the nurse should identify this statement as understanding of the teaching.

A nurse is reinforcing teaching with a client who is postoperative following the insertion of a femoral head prosthesis. Which of the following client statements should indicate to the nurse the need for further instruction?

"I will bend from my hip to tie my shoes" The client should not bend over from the hip. This can cause the hip to flex greater than 90 degrees, which increases the risk of dislocation of the prosthesis.

A nurse is evaluating understanding of medicated baths for a client who has psoriasis. Which of the following client statements should the nurse identify as understanding of the information?

"I will remain in the tub for 25 min" The client should stay in the medicated bath for 20-30 min. Therefore, this statement indicates understanding of the instructions.

A nurse provides teaching to a client who is being fitted for a prosthetic leg. Which of the following statements indicate to the nurse a need for further instruction?

"I'll learn to balance well on one leg so I don't have to use crutches"

A nurse is reinforcing discharge teaching with a client who has osteoarthritis. Which of the following statements by the client indicates an understanding of the teaching?

"Osteoarthritis occurs due to the aging process and results in disintegration of cartilage in a joint"

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse, Which of the following statements should the nurse make?

"Russels traction uses a sling under the knee to treat a fracture of the femur"

A nurse is caring for a client who has widespread psoriasis. The nurse should prepare the client for which of the following treatments?

Exposure to photo chemotherapy Photo chemotherapy combined with mediation treatment, through the use of ultraviolet light, has been shown to be effective in the treatment of widespread psoriasis.

A client who has a lower leg cast reports skin irritation around the upper edge of the cast. Which of the following actions should the nurse take?

Petal the edges of the cast

A nurse is collecting data from an older adult client who had a femoral head fracture 24 hr ago and is in Bucks traction. Which of the following findings is an indication of fat embolism syndrome?

Petechiae on the chest A red rash on the client's abdomen, chest, neck or upper arms is a manifestation of fat embolism.

A nurse in a provider's office is reinforcing teaching with a female client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching?

Sedentary lifestyle Aging Excessive Caffeine

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

Hardened skin Hardened, tight skin is an expected finding with scleroderma. In addition to rigid skin and subcutaneous tissues, the distal extremities stiffen and lose mobility. It can also cause disorders of the heart, lungs and kidneys.

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time.

Have the client lie prone several times each day. The nurse should encourage the client to lie prone for 20-30 min every 3-4 hr to help prevent hip flexion contractors.

A nurse is in a provider's office is collecting data from an older adult client who has type 2 diabetes mellitus. Which of the following findings is a manifestation of hyperglycemia?

History of poor wound healing The presence of hyperglycemia leads to poor wound healing due to decreased blood supply to the tissue.

A nurse is reinforcing teaching with a client prescribed celeoxib to treat osteoarthritis symptoms. The nurse should remind the client to monitor for and report which of the following findings?

Black, tarry stools The nurse should instruct the client to monitor and report black, dark-colored, or bloody stools, abdominal pain, or coffee-ground emesis. One of the side effects of celecoxib is gastrointestinal bleeding. The nurse should also instruct the client to take celecoxib with food to reduce gastric irritation.

A nurse is caring for a client who has a new cast place for fractured tibia. The nurse should recognize that which of the following interventions is a priority?

Check for capillary refill distal to the client's cast. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to check capillary refill. Reduced capillary refill can indicate a change in neurovascular status due to the injury or pressure from the cast. The nurse should monitor color, movement, temperature, sensation, and capillary refill of the toes on the affected extremities.

A nurse is planning to change an abdominal dressing for a client who has an incision with a drain. Which of the following actions should the nurse plan to take?

Don clean gloves to remove the dressing. Standard precautions require the nurse to don clean gloves whenever there is a possibility of coming into contact with secretions. Sterile gloves are not necessary until applying the new sterile dressing.

A nurse is reinforcing teaching about prosthesis care for a client following a below-the-knee amputation. Which of the following statements should the nurse include in the teaching?

Dry the prosthesis socket completely before applying it to the limb. The client should dry the prosthesis socket thoroughly with a clean cloth. Moisture between the socket and the stump can put the client at risk for fungal or bacterial infection and skin breakdown

A nurse is collecting data on a client who has manifestation of osteoporsis. The nurse anticipates the provider will prescribe which of the following diagnostic tests?

Dual energy absorptiometry Mostly commonly used screening and diagnostic tool for measuring bone mineral density.

A nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. Which of the following actions should the nurse take?

Elevate the head of the bed To keep the client from migrating toward the head of the bed while using cervical halter traction, the nurse should elevate the head of the bed.

A nurse is assisting with the care of a client who has frostbite on both legs after prolonged exposure to outdoor temperatures around 12.2 degrees celsius (10 degrees F) Which of the following actions should the nurse plan to take?

Elevate the lower extremities after rewarming the nurse should plan to elevate the client's legs to help minimize edema.

A nurse is contributing to the plan of care for a client who has a long leg cast to treat a femoral fracture. Which of the following interventions should the nurse include in the plan?

Encourage a high-fiber diet. A client who is immobilized with a long leg cast is at risk for constipation. The client should be encouraged to consume a diet high in fiber to prevent constipation. Other measures include encourage fluid intake of 2 to 3 L each day.

A nurse is collecting data from a client who has severe burn injuries. The nurse shades in the diagram indicating the burned surface areas. What percentage of body surface area should the nurse estimate the client has burned?

31.5

A nurse in a clinic is collecting data from an older adult client who has a new diagnosis of osteoarthritis. Which of the following medications should the nurse anticipate the provider will initially prescribe to the client?

Acetaminophen The nurse should anticipate a prescription for acetaminophen. The discomfort of osteoarthritis can be managed with the use of mild analgesics such as acetaminophen or NSAIDs. Acetaminophen is preferred over NSAIDs for the older adult client because it has fewer toxic side effects.

A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?

Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises

A nurse is collecting data from a client who sustained severe burn injuries. The nurse notes a diagram indicating the burned surface areas. What percentage of client's body surface are should the nurse estimate has been burned?

54%

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

A client who has swelling and tenderness around the wound. Manifestations of infection include purulent drainage, swelling, warmth, tenderness around the wound, and a failure to heal.

A nurse is assisting with the care of a newly-admitted client who has acute osteomyelitis. which of the following interventions is the priority for the nurse to implement?

Antibiotic therapy Osteomyelitis is a bone infection. Antibiotic therapy is the priority treatment.

A nurse is collecting data from an older adult client who has a hip fracture and is in Bucks traction. The nurse notes the client has a sudden decrease in level of consciousness, dyspnea, and crackles to the lungs upon auscultation. Which of the following actions should the nurse take?

Apply high-flow oxygen

A nurse in a providers office is collecting data from a client who reports pruritus and reddened, fluid-filled vesicles on her lower leg. The nurse should suspect which of the following disorders?

Contact dermatitis

A nurse is completing a neurovascular check for a client who had an open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome?

Cool skin Absence of pulse altered sensation of the toes

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device placed over it. Which of the following findings by the nurse indicates healing of the wound?

Granulation tissue on the surface of the wound. As the wound heals, the nurse should expect the wound base to become redder as granulation tissue lines the surface of the wound. Therefore, this is an expected finding. The vacuum-assisted closure device assists in wound closure by applying a localized negative pressure to draw the edges of the wound together. The device consists of a suction tube embedded in a foam dressing. The foam dressing is applied to the wound bed and sealed in place with occlusive dressing. The suction is then attached to the vacuum unit, causing the foam to collapse and resulting in drainage of excess fluids, and increasing circulation to the wound bed.

A nurse is talking with a client who has osteoporosis and needs to increase her vitamin D intake as part of the her treatment plan. Which of the following recommendations should the nurse reinforce with the client to help ensure an adequate intake of vitamin D?

Increase her daily amount of sunlight exposure There are two sources of vitamin D: sunlight and diet. Increasing the client's daily exposure to sunlight is essential for calcium absorption and metabolism.

A nurse is reviewing the prescriptions for a client who had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?

Instruct the client to restrict flexion of the hip past 120 degrees. The nurse should seek verification of the prescription. The nurse should instruct the client to restrict flexion of the hip past 90 degrees to avoid dislocation of the hip.

A nurse is reinforcing teaching with a client who is 2 days postoperative following a left hip arthroplasty. Which of the following information should the nurse include in the teaching?

Maintain foam wedge between legs

A nurse is caring for a client who is in Bucks traction. Which of the following actions should the nurse take?

Monitor peripheral pulses in the affected extremity Examine the skin under the traction splint Assess the temperature of the affected extremity

A nurse is caring for a client who has a surgical wound. Which of the following factors places the client at risk for dehiscence?

Poor nutritional state Obesity wound infection

A nurse in a clinic is collecting data from a client who reports wrist pain caused by carpal tunnel syndrome. The nurse should expect which of the following findings?

Positive phalens sign

a nurse is reinforcing teaching with a client who has herpes zoster. The nurse should include which of the following statements in the teaching?

Recurrence of infection can be triggered by stress or trauma

A client who is postoperative returns to the unit in skeletal traction. When collecting data from the client, the nurse should expect which of the following findings?

Redness at the pin sites Warmth at the pin sites

A charge nurse is observing a nurse who is caring for a client who has continuous skeletal traction of a lower extremity. For which of the following actions should the charge nurse intervene?

Removes the traction weights for a brief period each day. Traction applies a pulling force to an injured extremity and helps immobilize and reduce the fracture. The nurse should not remove the weights because doing so can further injure the client.

A nurse is reinforcing teaching about cast care with a client who has a long-leg fiberglass cast on the right tibia. Which of the following instructions should the nurse include in the teaching?

Report any worsening or unrelieved pain. Pain can be a sign of complications such as compartment syndrome or skin breakdown. The client should report it to the provider.

A nurse is planning preventative care for a client who is at risk for pressure ulcers and requires bed rest. Which of the following actions should the nurse take?

Reposition the client at least every 2 hrs

A nurse is reviewing the medical record of a client who has osteoarthritis. Which of the following findings should the nurse expect?

Stiffness of the joints The nurse may expect the client to have stiff joints due to failure to move painful joints.

A nurse is reinforcing instructions with a client who has contact dermatitis and reports increased pruritus during the winter months. Which of the following information should the nurse include?

Stroke itchy skin with the palm of the hand

A nurse is assisting with the care of a client who has multiple facial injuries. Which of the following equipment should the nurse place at the client's bedside?

Suction catheter. Establishment and maintenance of a patient airway is the primary nursing goal for client who has facial injuries. Because the facial injuries can make it difficult for the client to manage secretions or emesis safely, the nurse must be prepared to suction the client's airway.

A nurse is collecting data on a client who has major burn injury. The nurse should recognize which of the following findings as a priority?

The client produces black colored sputum

Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statement by the nurse describes a stage 3 pressure ulcer?

There is full-thickness skin loss with a crater

A nurse is reinforcing teaching about ergonomic principles with a group of assistive personnel. Which of the following strategies should the nurse include in the teaching?

Tighten the abdominal muscles when lifting objects Flex knees and hips periodically when standing for a period of time Enlarge the distance between the front foot and the back foot when pulling a client towards you.

A nurse is assisting with the development of a teaching plan for a client who has psoriasis. Which of the following statements should the nurse include in the plan?

Treatment will include coal tar preparations. Coal tar preparations are used in the treatment of psoriasis; therefore, the nurse should include this treatment in the teaching plan.

A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client's risk of skin breakdown?

Use pillows to keep heels of the bed surface Minimize skin exposure to moisture is correct.

A nurse is reinforcing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins should the nurse include in the teaching as promoting wound healing?

Vitamin A Vitamin C

A nurse at a provider's office is reviewing information about management of osteoarthritis with a client. which of the following interventions should the nurse recommend?

Weight management Aerobic excercise Massage therapy Isometric excercise

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

infection An area of warmth on a cast is an indication of an infection, therefore the nurse should report this finding to the provider.