Critical Care 2 Exam 3

Which action should the nurse take to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? a. Assess for hip pain. b. Check for contractures. c. Palpate peripheral pulses. d. Monitor for hip dislocation.

a. Assess for hip pain. Buck's traction is used to reduce painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse including in discharge teaching? a. "Check and clean the pin insertion sites daily." b. "Remove the external fixator for your shower." c. "Remain on bed rest until bone healing is complete." d. "Take prophylactic antibiotics until the fixator is removed."

a. "Check and clean the pin insertion sites daily." Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given during external fixator use.

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first? a. A patient with a red tag b. A patient with a blue tag c. A patient with a black tag d. A patient with a yellow tag

a. A patient with a red tag The red tag indicates a patient with a life-threatening injury requiring rapid treatment. The other tags indicate patients with less urgent injuries or those who are likely to die.

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patienUt's cSoreNtemTperaturOe is 105.4° F (40.8° C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take? a. Apply wet sheets and a fan to the patient. b. Provide O2 at 2 L/min with a nasal cannula. c. Start lactated Ringer's solution at 1000 mL/hr. d. Give acetaminophen (Tylenol) rectal suppository.

a. Apply wet sheets and a fan to the patient. The priority intervention is to cool the patient. Antipyretics are not effective in decreasing temperature in heat stroke and 100% O2 should be given, which requires a high flowrate through a non-rebreather mask. An older patient would be at risk for developing complications such as pulmonary edema if given fluids at 1000 mL/hr.

Which action would the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia? a. Assess fluid and dietary intake. b. Apply ice packs for 20 minutes. c. Teach facial relaxation techniques. d. Spend time talking with the patient.

a. Assess fluid and dietary intake. The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. What should the nurse do when the patient arrives on the orthopedic unit after surgery? a. Assess the surgical site for hemorrhage. b. Remove the prosthesis and wrap the site. c. Place the patient in a side-lying position. d. Keep the residual limb elevated on a pillow.

a. Assess the surgical site for hemorrhage. The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. Unless contraindicated, the patient will be placed in a prone position for 30 minutes several times a day to prevent hip flexion contracture.

Which interventions will the nurse plan for a comatose patient who will have targeted temperature management/therapeutic hypothermia? (Select all that apply.) a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring. d. Prepare to give sympathomimetic drugs. e. Obtain a prescription for patient restraints.

a. Assist with endotracheal intubation. b. Insert an indwelling urinary catheter. c. Begin continuous cardiac monitoring Cooling can produce dysrhythmias, so the patient's heart rhythm should be continuously monitored, and dysrhythmias treated if necessary. Bladder catheterization and endotracheal intubation are needed during cooling. Sympathomimetic drugs tend to stimulate the heart and increase the risk for fatal dysrhythmias such as ventricular fibrillation. Patients receiving therapeutic hypothermia are comatose, so restraints are not indicated.

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate 4 times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.

a. Catheterize patient every 3 to 4 hours. Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome, and the patient will be unable to ambulate. The head and neck will not need to be stabilized after a cauda equina injury, which affects the lumbar and sacral nerve roots.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? a. Check the patient's prescribed weight-bearing status. b. Use a mechanical lift to transfer the patient to the chair. c. Decrease the pain medication before getting the patient up. d. Have the unlicensed assistive personnel (UAP) transfer the patient.

a. Check the patient's prescribed weight-bearing status. The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer.

A patient is admitted with possible botulism poisoning after eating home-canned green beans. Which intervention ordered by the health care provider should the nurse question? a. Encourage oral fluids to 3 L/day. b. Document neurologic symptoms. c. Position patient lying on the side. d. Observe respiratory status closely.

a. Encourage oral fluids to 3 L/day. The patient should be maintained NPO because neuromuscular weakness increases risk for aspiration. Side-lying position is not contraindicated. Assessment of neurologic and respiratory status is appropriate.

A patient arrives in the emergency department (ED) several hours after taking "25 to 30" acetaminophen (Tylenol) tablets. Which action will the nurse plan to take? a. Give N-acetylcysteine. b. Discuss the use of chelation therapy. c. Start oxygen using a non-rebreather mask. d. Have the patient drink large amounts of water.

a. Give N-acetylcysteine. N-acetylcysteine is the recommended treatment to prevent liver damage after acetaminophen overdose. The other actions might be used for other types of poisoning, but they will not be appropriate for a patient with acetaminophen poisoning.

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate? a. Infusion of immunoglobulin b. Administration of corticosteroids c. Intubation and mechanical ventilation d. Insertion of a nasogastric (NG) feeding tube

a. Infusion of immunoglobulin Because Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and enteral nutrition may be used later in the progression of the syndrome but are not needed now. Corticosteroids are not helpful in reducing the duration or symptoms of the syndrome.

After the return of spontaneous circulation following the resuscitation of a patient who had a cardiac arrest, therapeutic hypothermia is prescribed. Which action will the nurse include in the plan of care? a. Initiate cooling per protocol. b. Avoid the use of sedative drugs. c. Check mental status every 15 minutes. d. Rewarm if temperature is below 91° F (32.8° C).

a. Initiate cooling per protocol. When therapeutic hypothermia is used postresuscitation, external cooling devices or cold normal saline infusions are used to rapidly lower body temperature to 89.6° to 93.2° F (32° to 34° C). Because hypothermia will decrease brain activity, assessing mental status every 15 minutes is not done at this stage. Sedative drugs are given during therapeutic hypothermia.

he emergency department (ED) nurse is starting targeted temperature management/therapeutic hypothermia in a patient who has been resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be delegated to an experienced licensed practical/vocational nurse (LPN/VN)? (Select all that apply.) a. Insert a urinary catheter to drainage. b. Continuously monitor heart rhythm. c. Assess neurologic status every 2 hours. d. Place cooling blankets above and below patient. e. Attach rectal temperature probe to cooling blanket control panel.

a. Insert a urinary catheter to drainage. d. Place cooling blankets above and below patient. e. Attach rectal temperature probe to cooling blanket control panel. Experienced LPN/VNs have the education and scope of practice to implement hypothermia measures (e.g., cooling blanket, temperature probe) and insert a urinary catheter under the supervision of a registered nurse (RN). Assessment of neurologic status and monitoring the heart rhythm require RN-level education and scope of practice and should be done by the RN

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

a. Notify the health care provider. The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

What should the occupational health nurse advise a patient whose job involves many hours of typing? a. Obtain a keyboard pad to support the wrist. b. Do stretching exercises before starting work. c. Wrap the wrists with compression bandages every morning. d. Avoid using nonsteroidal antiinflammatory drugs (NSAIDS).

a. Obtain a keyboard pad to support the wrist. Repetitive strain injuries caused by prolonged work at a keyboard can be prevented by using a pad to keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting work. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to decrease swelling.

An unresponsive patient is admitted to the emergency department (ED) after falling through the ice while ice skating. Which assessment will the nurse obtain first? a. Pulse b. Heart rhythm c. Breath sounds d. Body temperature

a. Pulse The priority assessment in an unresponsive patient relates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse

For a patient who has had right hip arthroplasty, which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain intensity and tolerance.

a. Reposition the patient every 1 to 2 hours. Repositioning of orthopedic patients is within the scope of practice of UAP after they have been trained and evaluated in this skill. The other actions should be done by licensed nursing staff members.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse's best response? a. Respect the patient's feelings and arrange for privacy at mealtimes. b. Teach the patient to chew food on the unaffected side of the mouth. c. Offer the patient liquid nutritional supplements at frequent intervals. d. Discuss the patient's concerns with visitors who arrive at mealtimes.

a. Respect the patient's feelings and arrange for privacy at mealtimes. The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements may help maintain nutrition but will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? (Select all that apply.) a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature

a. Urinary catheter care c. Continuous cardiac monitoring d. Administration of H2 receptor blockers e. Maintenance of a warm room temperature The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers. Gastrointestinal motility is decreased initially, and NG suctioning is indicated.

The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite? a. Use tweezers to remove any remaining ticks. b. Check the vital signs, including temperature. c. Give doxycycline (Vibramycin) 100 mg orally. d. Obtain information about recent outdoor activities.

a. Use tweezers to remove any remaining ticks. Because neurotoxic venom is released as long as the tick is attached to the patient, the initial action should be to remove any ticks using tweezers or forceps. The other actions are also appropriate, but the priority is to minimize venom release.

When requested to plan the response to the potential use of smallpox as a biological weapon, what should the emergency department (ED) nurse manager expect to obtain? a. Vaccine b. Atropine c. Antibiotics d. Whole blood

a. Vaccine Smallpox infection can be prevented or ameliorated by the administration of vaccine given rapidly after exposure. The other interventions would be helpful for other agents of terrorism but not for smallpox.

When assessing an older patient admitted to the emergency department (ED) with a broken arm and facial bruises, the nurse observes several additional bruises in various stages of healing. Which statement or question by the nurse should be first? a. "You should not go home." b. "Do you feel safe at home?" c. "Would you like to see a social worker?" d. "I need to report my concerns to the police."

b. "Do you feel safe at home?" The nurse's initial response should be to further assess the patient's situation. Telling the patient not to return home may be an option once further assessment is done. A social worker or police report may be appropriate once further assessment is completed.

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."

b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage hip flexion contracture.

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. Which information will the nurse include in postoperative teaching? a. "You will not be able to serve a tennis ball again." b. "You will begin work with a physical therapist tomorrow." c. "Keep the shoulder immobilizer on for the first 4 days to minimize pain." d. "The surgeon will use the drop arm test to determine the success of surgery."

b. "You will begin work with a physical therapist tomorrow." Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion. The drop arm test is used to test for rotator cuff injury but not after surgery. The patient may be able to return to tennis after rehabilitation.

A patient who has experienced blunt abdominal trauma during a motor vehicle collision reports increasing abdominal pain. What topic will the nurse plan to teach the patient? a. Peritoneal lavage b. Abdominal ultrasonography c. Nasogastric (NG) tube placement d. Magnetic resonance imaging (MRI)

b. Abdominal ultrasonography For patients who are at risk for intraabdominal bleeding, focused abdominal ultrasonography is the preferred method to assess for intraperitoneal bleeding. An MRI would not be used. Peritoneal lavage is an alternative, but it is more invasive. An NG tube would not be helpful in the diagnosis of intraabdominal bleeding.

21. What action should the nurse identify as most important before administering botulinum antitoxin to a patient in the emergency department? a. Obtain the patient's temperature. b. Administer an intradermal test dose. c. Document the neurologic symptoms. d. Ask the patient about an allergy to eggs.

b. Administer an intradermal test dose. To assess for possible allergic reactions, the nurse should administer an intradermal test dose of the antitoxin. Although temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will not affect the decision to administer the antitoxin.

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

b. Administer prescribed PRN O2 at 4 L/min. The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism.

The day after a having a right below-the-knee amputation, a patient reports pain in the missing right foot. Which action is most important for the nurse to take? a. Explain the reasons for the pain. b. Administer prescribed analgesics. c. Reposition the patient to assure good alignment. d. Tell the patient that the pain will diminish over time.

b. Administer prescribed analgesics. Acute phantom limb sensation is treated as any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicare the patient. Alignment is important but is unlikely to relieve the pain. Although the pain may decrease over time, it currently requires treatment.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take? a. Observe output from the surgical drain. b. Administer prescribed pain medication. c. Instruct the patient about benefits of early ambulation. d. Change the dressing and document the wound appearance

b. Administer prescribed pain medication. The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having had a tetanus booster 6 years ago. What intervention should the nurse anticipate? a. IV infusion of tetanus immune globulin (TIG) b. Administration of the tetanus-diphtheria (Td) booster c. Intradermal injection of an immune globulin test dose d. Initiation of the tetanus-diphtheria immunization series

b. Administration of the tetanus-diphtheria (Td) booster If the patient has not been immunized in the past 5 years, administration of the Td booster is indicated because the wound is deep. Immune globulin administration is given by the IM route if the patient has no previous immunization. Administration of a series of immunization is not indicated. TIG is not indicated for this patient, and a test dose is not needed for immune globulin.

Which action should the urgent care nurse take for a patient with a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Apply an immobilizer to the affected leg. c. Avoid palpation or movement of the knee. d. Administer intravenous opioids for pain management.

b. Apply an immobilizer to the affected leg. A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration. Nonsteroidal antiinflammatory drugs (NSAIDs) are recommended for pain management.

A 20-yr-old patient who sustained a T2 spinal cord injury 10 days ago tells the nurse, "I want to be transferred to a hospital where the nurses know what they are doing." Which action should the nurse appropriately take? a. Perform care without responding to the comments. b. Ask the patient to provide input for the plan of care. c. Tell the patient abusive language will not be tolerated. d. Reassure the patient about the competence of the nursing staff.

b. Ask the patient to provide input for the plan of care. The patient is demonstrating behaviors consistent with the anger phase of the grief process. The nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in addressing the patient's concerns. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

A triage nurse in a busy emergency department (ED) assesses a patient who reports 7/10 abdominal pain and states, "I had a temperature of 103.9° F (39.9° C) at home." What should be the nurse's first action? a. Give acetaminophen (Tylenol). b. Assess the patient's current vital signs. c. Ask the patient to provide a clean-catch urine for urinalysis. d. Tell the patient that it may be 1 to 2 hours before seeing a health care provider.

b. Assess the patient's current vital signs. The patient's pain and statement about an elevated temperature indicate that the nurse should obtain vital signs before deciding how rapidly the health care provider should see the patient. A urinalysis may be appropriate, but this would be done after the vital signs are taken. The nurse will not give acetaminophen before confirming a current temperature elevation.

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Administration of low-molecular-weight heparin d. Application of pneumatic compression devices to legs

b. Assessment of respiratory rate and effort Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort.

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first? a. Insert a large-bore orogastric tube. b. Assist with intubation of the patient. c. Prepare a 60-mL syringe with saline. d. Give first dose of activated charcoal.

b. Assist with intubation of the patient. In an unresponsive patient, intubation is done before gastric lavage and activated charcoal administration to prevent aspiration. The other actions will be implemented after intubation.

The nurse should instruct a patient with a nondisplaced fractured left radius that the cast willneed to remain in place for what amount of time? a. Two weeks b. At least six weeks c. Until swelling of the wrist has resolved d. Until x-rays show complete bony union

b. At least six weeks Bone healing starts immediately after the injury, but because ossification does not begin until 3 weeks after injury, the cast will need to be worn for at least 3 weeks. Complete union may take up to 1 year. Resolution of swelling does not indicate bone healing.

The following interventions are part of the emergency department (ED) protocol for a patient who has been admitted with multiple bee stings to the hands. Which action should the nurse take first? a. Apply ice packs to both hands. b. Attempt to remove the patient's rings. c. Apply calamine lotion to itching areas. d. Give diphenhydramine (Benadryl) 50 mg PO.

b. Attempt to remove the patient's rings. The patient's rings should be removed first because it might not be possible to remove them if swelling develops. The other actions should also be implemented as rapidly as possible after the nurse has removed the jewelry.

What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia? a. Visual problems caused by ptosis. b. Poor appetite caused by loss of taste. c. Triggers leading to facial discomfort. d. Weakness on the affected side of the face.

c. Triggers leading to facial discomfort. The major clinical manifestation of trigeminal neuralgia is severe facial pain triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.

A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. What should the nurse do during the primary survey of the patient? a. Obtain a complete set of vital signs. b. Check a Glasgow Coma Scale score. c. Attach an electrocardiogram monitor. d. Ask about chronic medical conditions.

b. Check a Glasgow Coma Scale score. The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Check the O2 saturation. c. Assess patient orientation. d. Observe for facial asymmetry.

b. Check the O2 saturation The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses O2 saturation.

The nurse is caring for a patient who is using Buck's traction after a hip fracture. Which action can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Remove and reapply traction periodically. b. Ensure the weight for the traction is hanging freely. c. Monitor the skin under the traction boot for redness. d. Check for intact sensation and movement in the affected leg.

b. Ensure the weight for the traction is hanging freely. UAP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment of skin integrity and circulation should be done by the registered nurse (RN).

What should the nurse explain to the patient who has a T2 spinal cord transection injury? a. Total loss of respiratory function may occur. b. Function of both arms should be maintained. c. Use of the patient's shoulders will be limited. d. Tachycardia is common with this type of injury.

b. Function of both arms should be maintained. The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

Which information should the nurse include in discharge teaching for a patient who has had a repair of a fractured mandible? a. Administration of nasogastric tube feedings b. How and when to cut the immobilizing wires c. The importance of high-fiber foods in the diet d. The use of sterile technique for dressing changes

b. How and when to cut the immobilizing wires The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw.

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock? a. Involuntary and spastic movement b. Hypotension and warm extremities c. Hyperactive reflexes below the injury d. Lack of sensation or movement below the injury

b. Hypotension and warm extremities Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.

Which patient assessment would help the nurse identify potential complications of trigeminal neuralgia? a. Have the patient clench the jaws. b. Inspect the oral mucosa and teeth. c. Palpate the face to compare skin temperature bilaterally. d. Identify trigger zones by lightly touching the affected side.

b. Inspect the oral mucosa and teeth. Oral hygiene is frequently neglected because of fear of triggering facial pain and may lead to gum disease, dental caries, or an abscess. Having the patient clench the facial muscles will not be useful because the sensory branches (rather than motor branches) of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care? a. Teach the patient to use the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

b. Instruct the patient how to self-catheterize. Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.

A patient who arrives at the emergency department with severe left knee pain is diagnosed with a patellar dislocation. What should be the nurse's initial focus for patient teaching? a. Use of a knee immobilizer b. Monitored anesthesia care c. Physical activity restrictions d. Performance of gentle knee flexion

b. Monitored anesthesia care The first goal of interprofessional management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care, formerly called conscious sedation. Immobilization, gentle range-of-motion exercises, and discussion about activity restrictions will be implemented after the patella is realigned.

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses. b. Observe the patient's respiratory effort. c. Check the patient's level of consciousness. d. Examine the patient for any external bleeding.

b. Observe the patient's respiratory effort. Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey, but assessment of breathing should be done immediately after assessing for airway patency.

Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the health care provider? a. Patient declines to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

b. Patient has been incontinent of urine and stool. Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention.

After change-of-shift report on the neurology unit, which patient should the nurse assess first? a. Patient with Bell's palsy who has herpes vesicles in front of the ear. b. Patient with botulism who is drooling and experiencing difficulty swallowing. c. Patient with neurosyphilis who has tabes dorsalis and decreased deep tendon reflexes. d. Patient with an abscess caused by injectable drug use who needs tetanus immune globulin.

b. Patient with botulism who is drooling and experiencing difficulty swallowing. The patient's diagnosis and difficulty swallowing indicate the nurse should rapidly assess for respiratory distress. The information about the other patients is consistent with their diagnoses and does not indicate any immediate need for assessment or intervention.

After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is reporting facial pain. b. Patient with repaired right femoral shaft fracture who reports tightness in the calf. c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity. d. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated.

b. Patient with repaired right femoral shaft fracture who reports tightness in the calf. Calf swelling after a femoral shaft fracture suggests possible DVT or compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention.

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury? a. Drive a car with powered hand controls. b. Propel a manual wheelchair on a flat surface. c. Turn and reposition independently when in bed. d. Transfer independently to and from a wheelchair.

b. Propel a manual wheelchair on a flat surface. The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

Which action should the nurse take when caring for a patient who develops tetanus from injectable substance use? a. Avoid use of sedatives. b. Provide a quiet environment. c. Provide range-of-motion exercises daily. d. Check pupil reaction to light every 4 hours.

b. Provide a quiet environment. In patients with tetanus, jarring, loud noises or bright lights can precipitate painful seizures. The nurse will minimize noise and avoid shining light into the patient's eyes. Range-of-motion exercises may also stimulate the patient and cause seizures. Although the patient has a history of injectable drug use, sedative medications will be needed to decrease spasms.

A 60-yr-old patient had open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, What should the nurse identify as the priority patient problem? a. Acute pain b. Risk for infection c. Activity intolerance d. Risk for constipation

b. Risk for infection A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are mobilized starting the first postoperative day, so the problems caused by immobility are not as likely. Pain management is important, but the most important action is to prevent infection.

A patient arrives in the emergency department (ED) after topical exposure to powdered lime at work. Which action should the nurse take first? a. Obtain the patient's vital signs. b. Obtain a baseline complete blood count. c. Brush visible powder from the skin and clothing. d. Decontaminate the patient by showering with water.

c. Brush visible powder from the skin and clothing. The initial action should be to protect staff members and decrease the patient's exposure to the toxin by decontamination. Patients exposed to powdered lime should not be showered; instead, any and all visible powder should be brushed off. The other actions can be done after the decontamination is completed.

A patient who is to have no weight bearing on the left leg is learning to use crutches. Which observation by the nurse indicates the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

b. The patient advances the left leg and both crutches together and then advances the right leg. Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. If the 2- or 4-point gait is to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid brachial plexus damage.

A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action? a. The patient reports chronic severe back pain. b. The patient has new-onset weakness of both legs. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.

b. The patient has new-onset weakness of both legs. The new symptoms indicate spinal cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also need nursing action but do not require intervention as rapidly as the new-onset weakness.

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective? a. "I'll take salt tablets when I work outdoors in the summer." b. "I should take acetaminophen (Tylenol) if I start to feel too warm." c. "I need to drink extra fluids when working outside in hot weather." d. "I'll move to a cool environment if I notice that I'm feeling confused"

c. "I need to drink extra fluids when working outside in hot weather." Oral fluids and electrolyte replacement solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather. Salt tablets are not recommended because of the risks of gastric irritation and hypernatremia. Antipyretic drugs are not effective in lowering body temperature elevations caused by excessive exposure to heat. A patient who is confused is likely to have more severe hyperthermia and will be unable to remember to take appropriate action.

Which patient statement indicates understanding of the nurse's teaching about a new short-arm synthetic cast? a. "I can remove the cast in 4 weeks using industrial scissors." b. "I should avoid moving my fingers until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. The cast is typically removed in the outpatient setting. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."

c. "I will be able to use my fingers with more flexibility to grasp things." The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

c. "Tell me what you know about your options for treatment." The initial nursing action should be to assess the patient's knowledge and feelings about the available options. Discussion of the patient's option to refuse the procedure, seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current knowledge and emotional state.

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? a. A patient with no pedal pulses b. A patient with an open femur fracture c. A patient with paradoxical chest motion d. A patient with bleeding facial lacerations

c. A patient with paradoxical chest motion Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.

11. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding should indicate to the nurse a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. The patient reports pelvic pain with palpation. c. Abdomen is distended, and bowel sounds are absent. d. Ecchymoses are visible across the abdomen and hips.

c. Abdomen is distended, and bowel sounds are absent. The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

Family members are in the patient's room when the patient has a cardiac arrest and the staffstart resuscitation measures. Which action should the nurse take next? a. Keep the family in the room and assign a staff member to explain the care given and answers questions. b. Ask the family to wait outside the patient's room with a staff member to provideemotional support. c. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. d. Tell the family members that patients are comforted by having family members present during resuscitation efforts.

c. Ask the family members whether they would prefer to remain in the patient's room or wait outside the room. Although many family members and patients report benefits from family presence during resuscitation efforts, the nurse's initial action should be to determine the preference of these family members. The other actions may be appropriate, but this will depend on what is learned when assessing family preferences.

What action would help the nurse evaluate outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia? a. Inquire if the patient is doing daily facial exercises. b. Question if the patient is using an eye shield at night. c. Ask the patient about social activities with family and friends. d. Observe the patient chewing with the unaffected side of the mouth.

c. Ask the patient about social activities with family and friends. Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating if the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action should the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Assess leg pulses and sensation. d. Place ice packs on the lower leg.

c. Assess leg pulses and sensation. The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed antiemetic. c. Assess the blood pressure (BP). d. Notify the health care provider.

c. Assess the blood pressure (BP). The BP should be assessed immediately when a patient with an injury at the T6 level or higher reports a headache. This will help determine if autonomic hyperreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated if autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a sling. Which intervention should the nurse include in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

c. Assess the left axilla and change absorbent dressings as needed. The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take? a. Elevate the right leg. b. Splint the lower leg. c. Assess the pedal pulses. d. Verify tetanus immunization.

c. Assess the pedal pulses. The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus immunizations should be obtained if there is an open wound.

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist to plan a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.

c. Assist to plan a prescribed bowel program. Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.

What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs on the floor in the home. b. Expect most falls to happen outside the home in the yard. c. Buy shoes that provide good support and are comfortable to wear. d. Get instruction in range-of-motion exercises from a physical therapist.

c. Buy shoes that provide good support and are comfortable to wear. Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range-of-motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

Which information should the nurse include in discharge instructions for a patient with comminuted left forearm fractures and a long-arm cast? a. Keep the left shoulder elevated on a pillow or cushion. b. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). c. Call the health care provider for numbness of the hand. d. Keep the hand immobile to prevent soft tissue swelling.

c. Call the health care provider for numbness of the hand. Increased swelling or numbness may indicate increased pressure at the injury, and the healthcare provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture.

Which finding in a patient with a Colles' fracture of the left wrist should the nurse identify as most important to communicate immediately to the health care provider? a. The patient reports severe pain. b. Swelling is noted around the wrist. c. Capillary refill to the fingers is slow. d. The wrist has a deformed appearance

c. Capillary refill to the fingers is slow. Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action should the nurse take first? a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's O2 saturation using pulse oximetry. d. Ask the patient the date of the last tetanus immunization.

c. Check the patient's O2 saturation using pulse oximetry. Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation.

Which assessment finding in a patient with a spinal cord tumor requires immediate action by the nurse? a. Depression about the diagnosis b. Anxiety about scheduled surgery c. Decreased ability to move the legs d. Back pain that worsens with coughing

c. Decreased ability to move the legs Decreasing sensation and leg movement indicates spinal cord compression, an emergency that will require rapid action (such as surgery) to prevent paralysis. The other findings will require nursing action but are not emergencies.

A 38-yr-old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. What should the nurse identify as the most appropriate action at this phase of rehabilitation? a. Remind the patient about the importance of independence in daily activities. b. Tell the spouse to stop helping because the patient can perform activities independently. c. Develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. Recognize that it is important for the spouse to be involved in the patient's care and encourage participation.

c. Develop a plan to increase the patient's independence in consultation with the patient and the spouse. The best action by the nurse will be to involve all parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to believe their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding should the nurse identify as most important to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

c. The right arm appears shorter than the left. A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function.

The nurse is caring for a patient who has a pelvic fracture and an external fixation device. How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum? a. Ask the patient to turn to the side independently. b. Defer back assessment until the patient is ambulatory. c. Have the patient lift the back and buttocks using a trapeze. d. Roll the patient over to the side by pushing on the patient's hips.

c. Have the patient lift the back and buttocks using a trapeze. The patient can lift the back slightly off the bed by using a trapeze. The patient may find it very difficult to turn to the side without assistance while in a fixator device. Delaying assessment and skin care may put the patient at risk for an undetected pressure injury. Pushing on the patient's hips may cause additional injury.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? a. Using crutches with a swing-to gait b. Sitting upright on the edge of the bed c. Leaning over to pull on shoes and socks d. Bending over the sink while brushing teeth

c. Leaning over to pull on shoes and socks Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

A patient with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information should the nurse include in an initial response? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

c. Multiple options are available to maintain sexuality after spinal cord injury. Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

A patient is hospitalized with new onset of Guillain-Barré syndrome. What should the nurse recognize as the most essential assessment to Complete? a. Determining level of consciousness b. Checking strength of the extremities c. Observing respiratory rate and effort d. Monitoring the cardiac rate and rhythm

c. Observing respiratory rate and effort The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will be included in nursing care, but they are not as important as respiratory assessment.

A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which action should the nurse include in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patient's left leg when turning the patient d. Teaching the patient to verify the position of the right leg

c. Positioning the patient's left leg when turning the patient The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost in the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.

A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. What initial intervention should the nurse perform? a. Suction the patient's nasopharynx. b. Notify the patient's health care provider. c. Push upward on the epigastric area as the patient coughs. d. Encourage incentive spirometry every 2 hours during the day.

c. Push upward on the epigastric area as the patient coughs. Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the patient's ability to mobilize secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action. The health care provider should be notified if airway clearance interventions are not effective or additional collaborative interventions are needed.

A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider? a. Bruising of the left thigh b. Reports of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

c. Slow capillary refill of the left foot Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture.

A patient who has deep human bite wounds on the left hand is being treated in the urgent care center. Which action will the nurse plan to take? a. Prepare to administer rabies immune globulin. b. Assist the health care provider with suturing the wounds. c. Teach the patient the reason for the use of prophylactic antibiotics. d. Keep the wounds dry until the health care provider can assess them.

c. Teach the patient the reason for the use of prophylactic antibiotics. Because human bites of the hand frequently become infected, prophylactic antibiotics are usually prescribed to prevent infection. To minimize infection, deep bite wounds on the extremities are left open. Rabies immune globulin might be used after an animal bite. Initial treatment of bite wounds includes copious irrigation to help clean out contaminants and microorganisms.

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? a. the patient's sacral area skin is reddened. b. The patient reports severe pain in the feet c. The patient is continuously drooling saliva d. The patient's blood pressure (bp) is 150/82 mm hg.

c. The patient is continuously drooling saliva Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.

When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

c. Use a cervical collar to stabilize the spine. Patients who have facial fractures are at risk for cervical spine injury and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury

Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

c. Use pillows to elevate the ankle above the heart. Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient? a. "You may be able to prevent Bell's palsy by doing facial exercises regularly." b. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." c. "Medications to treat Bell's palsy work only if started before paralysis onset." d. "Call the doctor if you experience pain or develop herpes lesions near the ear"

d. "Call the doctor if you experience pain or develop herpes lesions near the ear" Pain or herpes lesions near the ear may indicate the onset of Bell's palsy, and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which patient statement to the nurse indicates that additional teaching is needed? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

d. "I can sleep in any position that is comfortable for me." The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching.

A 22-yr-old patient who experienced a drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period? a. Auscultate heart sounds. b. Palpate peripheral pulses c. Check mental orientation d. Auscultate breath sounds

d. Auscultate breath sounds Because pulmonary edema is a common complication after drowning, the nurse should assess the breath sounds frequently. The other information also will be obtained by the nurse, but it is not as pertinent to the patient's admission diagnosis.

A factory line worker has repetitive strain syndrome in the left elbow. What topic should the nurse plan to include in patient teaching? a. Surgical options b. Elbow injections c. Wearing a left wrist slint d. Modifying arm movements

d. Modifying arm movements Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

Which nursing action for a patient with Guillain-Barré syndrome should the nurse identify as appropriate to delegate to experienced unlicensed assistive personnel (UAP)? a. Instilling artificial tears b. Assessing for bladder distention c. Administering bolus enteral nutrition d. Performing passive range of motion to extremities

d. Performing passive range of motion to extremities Assisting a patient with movement is included in UAP education and scope of practice. Administration of enteral nutrition, administration of ordered medications, and assessment are skills requiring more education and expanded scope of practice, and the RN should perform these skills.

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next? a. Send blood to the lab for a complete blood count. b. Assess further for a cause of the decreased circulation c. Finish the airway, breathing, circulation, disability survey d. Start normal saline fluid infusion with a large-bore IV line.

d. Start normal saline fluid infusion with a large-bore IV line. The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

Which action should the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty? a. Avoid extension of the right knee beyond 120 degrees. b. Use a compression bandage to keep the right knee flexed. c. Teach about the need to avoid weight bearing for 4 weeks. d. Start progressive knee exercises to obtain 90-degree flexion.

d. Start progressive knee exercises to obtain 90-degree flexion. After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Protected weight bearing is typically not ordered after this procedure.

A 19-yr-old patient is brought to the emergency department (ED) with multiple lacerations and tissue avulsion of the left hand. When asked about tetanus immunization, the patient denies having any previous vaccinations. What should the nurse anticipate giving? a. Tetanus immunoglobulin (TIG) only b. TIG and tetanus-dipheteria toxoid (td) c. Tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap)

d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap) For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

Which finding indicates that the nurse should discontinue active rewarming of a patient admitted with hypothermia? a. The patient begins to shiver. b. The BP decreases to 86/42 mm Hg. c. The patient develops atrial fibrillation. d. The core temperature is 94° F (34.4° C).

d. The core temperature is 94° F (34.4° C). A core temperature of at least 89.6° to 93.2° F (32° to 34° C) indicates that sufficient rewarming has occurred. Dysrhythmias, hypotension, and shivering may occur during rewarming, and should be treated but are not an indication to stop rewarming the patient.

A patient has possible right carpal tunnel syndrome. What symptom should the nurse expect with a positive Tinel's sign? a. Weakness in the right little finger b. Burning in the right elbow and forearm c. Tremor when gripping with the right hand d. Tingling in the right thumb and index finger

d. Tingling in the right thumb and index finger Testing for Tinel's sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome.

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which prescribed action will the nurse implement first? a. Send the patient for ankle x-rays. b. Administer naproxen (Naprosyn). c. Give acetaminophen with codeine. d. Wrap the ankle and apply an ice pack.

d. Wrap the ankle and apply an ice pack. Immediate care after a sprain or strain injury includes application of cold and use of compression to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.