Exam 2 practice questions- S'23

Which landmarks should the nurse use to identify the vastus lateralis site? 1. Locate the greater trochanter and the posterior superior iliac spine; draw an imaginary line between the two sites and inject above the line. 2. Palpate the lower edge of the acromion process; place 2-3 fingerbreadths below it; inject in the space formed by the triangle below fingers and above the axilla. 3. Identify the greater trochanter; point the index finger toward the anterior superior iliac spine and the middle finger toward the iliac crest; inject in the "V" space between the two fingers 4. Divide the area between the greater trochanter and the lateral femoral condyle into thirds; inject into the outer middle-third on the anterior of the thigh.

4. Divide the area between the greater trochanter and the lateral femoral condyle into thirds; inject into the outer middle-third on the anterior of the thigh.

The home health nurse is assessing a client for the first time and these are the results of his assessment findings: grating noise with joint movement in the client's right knee, joint pain that intensifies with activity but diminishes with rest, stiffness in the right knee joint, and the client stated, "Feels like the bones in my knee are rubbing together." Which disease process is the client exhibiting on the nurse's assessment findings? 1. Rheumatoid arthritis 2. Lupus erythematosus 3. Osteoporous 4. Osteoarthritis

4. Osteoarthritis

A client taking oxybutynin for urinary incontinence asks why she is having trouble having bowel movements. What is the appropriate response from the nurse? 1. Oxybutynin decreases the need to void, as well as the need to relieve the bowels. 2. Oxybutynin relaxes the muscle contractions in the bowel and bladder to control frequency. 3. Oxybutynin increases muscle spasticity, resulting in constipation. 4. Oxybutynin suppresses peristalsis in the gut, resulting in constipation.

4. Oxybutynin suppresses peristalsis in the gut, resulting in constipation.

The nurse is setting up supplies to complete a dressing change at 2000 hours on the client's residual limb following a right leg BKA. The client looks away and angrily says, "I don't want to look at that thing. Can't you come back later?" Which is the nurse's best action? 1. Put the supplies away and reattempt the dressing change in 1 hour. 2. Complete the dressing change because it is prescribed for 2000. 3. Ask the client, "Why don't you want your dressing changed now?" 4. Restate, "You don't want to look at your leg?" and allow time for a response.

4. Restate, "You don't want to look at your leg?" and allow time for a response.

A thin client with a deep vein thrombosis in the right leg is receiving heparin subcutaneously every 12 hours. How should heparin be administered? 1. Using an 18-gauge ½ inch needle at a 90 degree angle. 2. Using a 20-gauge ¾ inch needle at a 15 degree angle. 3. Using a 22-gauge ⅓ inch needle at a 25 degree angle. 4. Using a 25-gauge ⅝ inch needle at a 45 degree angle.

4. Using a 25-gauge ⅝ inch needle at a 45 degree angle.

Which of the following patients would be expected to benefit from a moist to dry dressing (mechanical debridement)? (select all that apply) A. 24 year old with an open infected wound from a spider bite B. 7 year old with an abrasion on bilateral knees C. 50 year old with a post operative knee replacement incision D. 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound

A. 24 year old with an open infected wound from a spider bite D. 30 year old who had a large cyst removed and now has some necrotic tissue present in the crater type wound

Which of the following may indicate internal hemorrhage? (select all that apply) A. distention or swelling of the affected body part. B. elevated WBC C. decrease in blood pressure and increase in pulse D. change in the type and amount of drainage.

A. distention or swelling of the affected body part. C. decrease in blood pressure and increase in pulse

Which of the following are functions of dressings? (select all that apply) A. promote hemostasis B. keep wound bed dry C. wound debridement D. prevent contamination E. increase circulation

A. promote hemostasis C. wound debridement D. prevent contamination

What evaluation criteria are included in the Braden Risk assessment? (select all that apply) A. sensory perception B. medications C. mobility D. friction and shear E. mental status F. moisture

A. sensory perception C. mobility D. friction and shear F. moisture

Why does a wound bed need to stay moist? A. to support healing by enabling granulation tissue to grow. B. to prevent excessive fluid loss from the body C. to determine if the area has reactive hyperemia D. to decrease patient discomfort

A. to support healing by enabling granulation tissue to grow.

A 60-year-old female client comes to the clinic with complaints of fatigue, weight loss of 10 pounds in the past month, morning joint stiffness, and severe pain in the small joints of the hands. I feel better when I am doing any activity and have more pain at rest. The client asks the nurse, "Do I have rheumatoid arthritis (RA) or osteoarthritis (OA)?" What is the nurse's best response? 1. "According to your signs/symptoms, you probably have rheumatoid arthritis." 2. "According to your signs/symptoms, you probably have osteoarthritis." 3. "Why would you think you have rheumatoid arthritis or osteoarthritis, you may have something else going on." 4. "Have you been reading about rheumatoid arthritis and osteoarthritis?"

1. "According to your signs/symptoms, you probably have rheumatoid arthritis."

The nurse is preparing an IM injection of gentamicin for a client with a bacterial infection. Which options would be best for the nurse to use when giving the injection? Select all that apply. 1. 1½ in 20 gauge 2. 1 in 22 gauge 3. ½ in 24 gauge 4. 1½ in 21 gauge 5. ½ in 25 gauge

1. 1½ in 20 gauge 2. 1 in 22 gauge 4. 1½ in 21 gauge

Which of the following needles should the nurse select for an intramuscular (IM) injection for the ventrogluteal site? 1. 22-gauge, 1 1/2-inch 2. 25-gauge, 1-inch 3. 26-gauge, 5/8-inch 4. 29-gauge, 1/2-inch

1. 22-gauge, 1 1/2-inch

The nurse is taking care of a client with a surgical wound. Which action by the nurse reflects a need for further teaching by the charge nurse? Select all that apply. 1. Applies betadine on the surgical incision 2. Uses sterile water to clean the surgical incision. 3. Uses as little tape as possible if client is bed bound 4. Signs and dates dressing before leaving client

1. Applies betadine on the surgical incision

The client continues to have phantom limb pain following an AKA, despite receiving the prescribed morphine sulfate and using distraction. Which interventions, if prescribed, should the nurse plan to implement? Select all that apply. 1. Apply lidocaine patch 5% to the residual limb. 2. Start transcutaneous electrical nerve stimulation. 3. Give atenolol 12.5 mg orally bid with food. 4. Give oxcarbazepine 300 mg orally bid. 5. Limit activity until the sensations resolve.

1. Apply lidocaine patch 5% to the residual limb. 2. Start transcutaneous electrical nerve stimulation. 3. Give atenolol 12.5 mg orally bid with food. 4. Give oxcarbazepine 300 mg orally bid.

The 78-year-old client who has arthritis is being discharged from the hospital with a Jackson-Pratt (JP) wound drainage system. To teach the client, the nurse should plan to take which action? Select all that apply. 1. Assess the client's manual dexterity in compressing the device and replacing the stopper. 2. Provide a group teaching session with younger and older adults who have JP drains. 3. Provide Web-based references for additional reading on emptying and caring for JP drains. 4. Provide sufficient opportunities for the client to return-demonstrate emptying the reservoir. 5. Evaluate the client's learning, and if unable to manage the drain, initiate a home care referral.

1. Assess the client's manual dexterity in compressing the device and replacing the stopper. 4. Provide sufficient opportunities for the client to return-demonstrate emptying the reservoir. 5. Evaluate the client's learning, and if unable to manage the drain, initiate a home care referral.

A client is to receive a subcutaneous injection of enoxaparin. Which nursing action is a priority? 1. Assessing a platelet count of 80,000 mm 2. Selecting the site 2-inches away from the umbilicus 3. Checking injection sites for hematomas 4. Grasping a 1-2 inch fold of adipose tissue for the injection

1. Assessing a platelet count of 80,000 mm

A 55 year old client undergoing a total hip arthroplasty. The nurse is preparing a teaching plan for the client including activity restriction after surgery. Which of the following should the nurse include in the teaching plan? Select all that apply 1. Avoid hip flexion >90 2. Sit in a lower recliner 3. Avoid external rotation of toes 4. Use an abduction pillow while lying on your side in bed 5. Continue isometric exercise

1. Avoid hip flexion >90 4. Use an abduction pillow while lying on your side in bed 5. Continue isometric exercise

The nurse receives report that a client's JP drain has purulent exudate. The nurse expects to assess drainage that is: 1. Cloudy, yellow or green 2. Clear, straw-colored 3. Dark red with clots 4. Pink to pale pink

1. Cloudy, yellow or green

The nurse is providing education for a client with rheumatoid arthritis on management of the disease. Which of these should be included in the instructions? Select all that apply. 1. Do not elevate knees with pillows at night. 2. Take prednisone and methotrexate as ordered. 3. Take a warm shower before bed. 4. Perform range-of-motion (ROM) exercises. 5. Report fever over 98.6°F to the health care provider (HCP). 6. After one month of treatment for RA, you may get pregnant.

1. Do not elevate knees with pillows at night. 2. Take prednisone and methotrexate as ordered. 3. Take a warm shower before bed. 4. Perform range-of-motion (ROM) exercises.

The nurse is caring for the client following a knee arthroscopy. What information should the nurse teach? Select all that apply. 1. Elevate the involved extremity on pillows for 24 to 48 hours. 2. Apply an ice pack continually to the involved joint for 24 hours. 3. Report severe joint pain immediately to the HCP. 4. Resume usual activities to minimize joint stiffness and swelling. 5. Treat pain with a mild analgesic such as acetaminophen.

1. Elevate the involved extremity on pillows for 24 to 48 hours. 3. Report severe joint pain immediately to the HCP. 5. Treat pain with a mild analgesic such as acetaminophen.

Identify which of the following client characteristics a nurse should recognize is indicative of OA. Select all that apply 1. Herberden's nodes 2. Systemic resposne 3. Small body frame 4. Pain with activity 5. Need for total joint arthroplasty

1. Herberden's nodes 4. Pain with activity 5. Need for total joint arthroplasty

A client with a recent diagnosis of gout is seeking effective treatment for pain. Which of the following analgesic drugs is most appropriate for the client? 1. Naproxen 2. Acetaminophen 3. Morphine 4. Fentanyl

1. Naproxen

Which of the following is the most common pharmacological agent given for mild to moderate pain? 1. Naproxen 2. Acetaminophen 3. Morphine 4. Fentanyl

1. Naproxen

A nurse is admitting a client to the orthopedic unit from the PACU who had a total hip arthroplasty. Which of the following are the appropriate nursing interventions for this client? 1. Obtain VS 2. Assess pulses in the surgical extremity and unaffected extremity 3. Assess pain 4. Remove surgical drains 5. Apply heat to the post op hip 6. Initiate continuous passive motion machine or LRU if ordered

1. Obtain VS 2. Assess pulses in the surgical extremity and unaffected extremity 6. Initiate continuous passive motion machine or LRU if ordered

The nurse is caring for the client 24 hours following total hip arthroplasty using the traditional posterior approach. Which interventions should the nurse plan to implement? Select all that apply. 1. Place pillows or a wedge pillow between the client's legs to keep them abducted. 2. Have the client flex the unaffected hip and use the trapeze to help move up in bed. 3. Raise the head of the bed to no more than 90 degrees when the bed is placed contour. 4. Place a pillow between the client's knees when initially assisting the client out of bed. 5. Apply antiembolism stockings that should be kept on for 24 hours postoperatively.

1. Place pillows or a wedge pillow between the client's legs to keep them abducted. 2. Have the client flex the unaffected hip and use the trapeze to help move up in bed. 4. Place a pillow between the client's knees when initially assisting the client out of bed.

The nurse is teaching a class on strategies of pressure injury prevention. What should be included in the information? Select all that apply. 1. Pressure redistribution-turn every 1-2 hours. 2. Use strong deodorant soaps when bathing clients. 3. Encourage a diet high in protein and calories. 4. Keep clients clean and dry by managing incontinence. 5. Rub and massage the client's pressure injuries. 6. Utilize moisturizers and creams after baths/showers daily.

1. Pressure redistribution-turn every 1-2 hours. 3. Encourage a diet high in protein and calories. 4. Keep clients clean and dry by managing incontinence. 6. Utilize moisturizers and creams after baths/showers daily.

The client has Buck's traction to temporarily immobilize a fracture of the proximal femur prior to surgery. Which assessment finding requires the nurse to intervene immediately? 1. Reddened area at the client's coccygeal area 2. Voiding concentrated urine at 50 mL/hr 3. Capillary refill 3 seconds, pedal pulses palpable 4. Ropes, pulleys intact; 5-1b weight hangs freely

1. Reddened area at the client's coccygeal area

A client comes to the outpatient clinic to diagnose rheumatoid arthritis. Which tests does the nurse anticipate the health care provider (HCP) to order? Select all that apply. 1. Rheumatoid factor (RF) 2. Erythrocyte sedimentation rate (ESR) 3. C-reactive protein (CRP) 4. White blood cell count (WBC) 5. Synovial fluid aspiration

1. Rheumatoid factor (RF) 2. Erythrocyte sedimentation rate (ESR) 3. C-reactive protein (CRP) 5. Synovial fluid aspiration

The nurse is assessing the client 3 months following a left shoulder arthroplasty. Which assessment findings should prompt the nurse to consider that the client may have developed osteomyelitis? Select all that applv. 1. Sudden onset of chills 2. Temperature 103°F (39.4°C) 3. Sudden onset of bradycardia 4. Pulsating shoulder pain that is worsening 5. Painful, swollen area on the left shoulder

1. Sudden onset of chills 2. Temperature 103°F (39.4°C) 4. Pulsating shoulder pain that is worsening 5. Painful, swollen area on the left shoulder

Which of the following is important teaching for the client prescribed rivaroxaban? Select all that apply. 1. Teach methods to reduce bleeding. 2. Teach to use a soft toothbrush. 3. Teach to use an electric razor. 4. Teach it is safe to eat foods high in vitamin K. 5. Teach if the client has a nosebleed, black tarry stools, or spitting up blood, to call the healthcare provider immediately.

1. Teach methods to reduce bleeding. 2. Teach to use a soft toothbrush. 3. Teach to use an electric razor. 4. Teach it is safe to eat foods high in vitamin K. 5. Teach if the client has a nosebleed, black tarry stools, or spitting up blood, to call the healthcare provider immediately.

The nurse receives a report at the beginning of shift regarding the surgical client's abdominal incision healing by "primary intention". What does healing by "primary intention" mean? 1. The wound has little drainage with approximated edges. 2. Purulent drainage is present at the incision site 3. The wound is still open and not healing 4. The client has poor circulation for healing

1. The wound has little drainage with approximated edges.

The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse's best action? 1. Withdraw the sterile water from the balloon and advance the catheter farther. 2. Continue inflating the balloon as this finding is expected during catheter insertion. 3. Remove the catheter and reattempt insertion with a smaller urinary catheter. 4. Reposition the catheter by rotating it slightly and continue to inflate the balloon.

1. Withdraw the sterile water from the balloon and advance the catheter farther.

The nurse must give a client 3 units of regular insulin and 4 units of NPH. What is the correct order of preparation? 1. Gather supplies; perform hand hygiene 2. Cleanse the tops of both vials 3. Inject 3 units of air into the regular insulin vial 4. Inject 4 units of air into the NPH insulin vial 5. Withdraw syringe 6. Withdraw 3 units of regular insulin 7. Withdraw 4 units of NPH insulin 8. Verify the dosage in the syringe with another nurse 1) 1, 2, 3, 6, 5, 8, 4, 7, 8 2) 1, 2, 4, 5, 3, 6, 8, 7, 8 3) 1, 2, 4, 7, 8, 5, 3, 7, 8 4) 1, 2, 3, 5, 4, 7, 8, 6, 8

2) 1, 2, 4, 5, 3, 6, 8, 7, 8

While reviewing the actions of regular insulin with the graduate nurse (GN), which benefit will the registered nurse (RN) identify? Select all that apply. 1. "Regular insulin has a prolonged onset time, which decreases the risk of hypoglycemia." 2. "Regular insulin is the only insulin that has been approved for intravenous administration." 3. "Regular insulin works well in combination with NPH insulin when two different peaks are needed." 4. "Regular insulin is the type of insulin that is ordered to be used for sliding-scale dosing based on bedside blood glucose results." 5. "Regular insulin is the only insulin that can be given in combination with insulin detemir, in the same syringe."

2. "Regular insulin is the only insulin that has been approved for intravenous administration." 3. "Regular insulin works well in combination with NPH insulin when two different peaks are needed." 4. "Regular insulin is the type of insulin that is ordered to be used for sliding-scale dosing based on bedside blood glucose results."

Which tests may be used to diagnose osteoarthritis? Select all that apply. 1. C-reactive protein (CRP) 2. CT scan 3. MRI 4. Erythrocyte sedimentation rate (ESR) 5. Arthroscopy 6. X-rays

2. CT scan 3. MRI 5. Arthroscopy 6. X-rays (ESR is for general inflammation)

The client has an indwelling urinary catheter. Which information should the nurse include in the discharge teaching plan? Select all that apply. 1. Plan to change the urinary catheter once a week. 2. Clean the perineal area daily with soap and water. 3. Secure the catheter tubing to the thigh with tape. 4. Avoid showering while the catheter is in place. 5. Do hand hygiene before and after catheter care.

2. Clean the perineal area daily with soap and water. 3. Secure the catheter tubing to the thigh with tape. 5. Do hand hygiene before and after catheter care.

The nurse is teaching the client who has a lower leg plaster of Paris cast. Which self-care instructions should the nurse include? Select all that apply. 1. Sprinkle powder in the cast to decrease moisture from sweating. 2. Direct cool air from a hair dryer into the cast to relieve itching. 3. Cover the cast with a plastic wrap before bathing in a tub. 4. Use hot, soapy water to wash the cast if it becomes very soiled. 5. Avoid the cast's contact with hard surfaces while it is drying

2. Direct cool air from a hair dryer into the cast to relieve itching. 5. Avoid the cast's contact with hard surfaces while it is drying

The nurse teaches the postoperative adult client how to perform incision care. Prior to discharge, how should the nurse best evaluate the client's learning? 1. Ask the client questions and discuss the steps for performing incision care. 2. Have the client return-demonstrate cleansing and dressing the incision. 3. Reinforce the teaching with a handout at the time of the client's discharge. 4. Ask a family member to be present when the client is being discharged.

2. Have the client return-demonstrate cleansing and dressing the incision.

The client had a THR. The nurse is discussing home modifications with the client's son. Which modifications should the nurse recommend? Select all that apply. 1. Pad bedside rails. 2. Install safety bars around the toilet and shower. 3. Install an elevated toilet seat in the bathroom. 4. Plan for the client's bed to be in a main floor room. 5. Use a nonskid bathmat in the bathtub for the client's daily bath. 6. Remove scatter rugs and secure electrical cords against baseboards.

2. Install safety bars around the toilet and shower. 3. Install an elevated toilet seat in the bathroom. 4. Plan for the client's bed to be in a main floor room. 6. Remove scatter rugs and secure electrical cords against baseboards.

The nurse is assessing the client diagnosed with a left femoral neck fracture. Which findings should the nurse expect? Select all that apply. 1. Left leg is in an abducted position. 2. Left leg is externally rotated. 3. Left leg is shorter than the right. 4. Pain is in the lateral left knee. 5. Pain is in the groin area.

2. Left leg is externally rotated. 3. Left leg is shorter than the right. 5. Pain is in the groin area.

Which of the following fractures puts the client at risk for a fat embolism? Select all that apply 1. Radial compound fracture 2. Pelvic fracture 3. Ulnar spiral fracture 4. Compression fracture of the femur 5. Greenstick fracture of the fibula

2. Pelvic fracture 4. Compression fracture of the femur

Which of the following describes the function of wound dressings? Select all that apply. 1. To dry out the incision 2. Protects surgical incision from infection 3. Absorbs excess drainage 4. Creates a sterile field for the incision 5. Allows for wound friction

2. Protects surgical incision from infection 3. Absorbs excess drainage 4. Creates a sterile field for the incision

The nurse must administer a medication using the Z-track method. Which option describes the nurse's action? 1. Massage the site following removal of the needle. 2. Pull the skin down or to one side before inserting the needle. 3. Insert the needle at a 60-75 degree angle. 4. Aspirate before injecting the medication

2. Pull the skin down or to one side before inserting the needle.

A client's JP drain has been producing a small amount of serous exudate. The nurse checks the client and finds a large amount of sanguineous exudate on the dressing and in the drain. What assessment findings does the nurse expect? Select all that apply. 1. Elevated blood pressure 2. Rapid, thready pulse 3. Pallor 4. Clammy skin 5. Restlessness 6. Bradypnea

2. Rapid, thready pulse 3. Pallor 4. Clammy skin 5. Restlessness

Which of the following anticoagulants has a lower risk of bleeding? 1. Warfarin 2. Rivaroxaban 3. Heparin 4. Dabigatran

2. Rivaroxaban

While changing the client's dressing, the nurse observes the wound's drainage is pale red/pinkish. What does the nurse describe the drainage as? 1. Serous 2. Serosanguineous 3. Sanguineous 4. Purulent

2. Serosanguineous

A client has been hospitalized for 10 days in the intensive care unit on the ventilator and has been NPO. The nurse is giving the client a bath and notices skin breakdown on the sacrum exposing the dermis. When documenting in the medical record, what stage pressure injury will the nurse record? 1. Stage 1 pressure injury. 2. Stage 2 pressure injury. 3. Stage 3 pressure injury. 4. Stage 4 pressure injury.

2. Stage 2 pressure injury.

A client will receive a 2-mL injection of ceftriaxone. Which sites are appropriate for the nurse to administer this medication? Select all that apply. 1. Deltoid 2. Ventrogluteal 3. Abdomen, 2-inches from the umbilicus 4. Dorsogluteal 5. Anterior adipose tissue on thighs 6. Vastus lateralis

2. Ventrogluteal 6. Vastus lateralis

Which of the following is correct regarding rheumatoid arthritis (RA) and osteoarthritis (OA) symptoms? 1. "RA sufferers get pain relief from periods of rest and inactivity." 2. "Persons with OA need a vigorous exercise regimen to maintain flexibility." 3. "Individuals with RA have more pain when they are inactive." 4. "Morning joint stiffness lasting more than one hour is typical of OA."

3. "Individuals with RA have more pain when they are inactive."

A client learning how to self-administer insulin tells the nurse, "I'm not sure I can do this." Which response is the most therapeutic? 1. "Don't worry; everyone is unsure at first." 2. "You'll be fine once you get used to giving yourself shots." 3. "Please share with me your concerns about giving yourself insulin." 4. "I understand, but it's not hard to learn how to do this."

3. "Please share with me your concerns about giving yourself insulin."

The nurse will administer subcutaneous heparin to a client. Which needle should the nurse select for this injection? 1. 18 gauge, 1 1/2 inch 2. 20 gauge, 1 inch 3. 25 gauge, 5/8 inch 4. 30 gauge, 3/16 inch

3. 25 gauge, 5/8 inch

Which symptom would cause the nurse to suspect a fat embolism in the client with a fractured left femur? 1. Client reports leg pain as 9/10 2. Pedal edema +2 in left leg 3. Client restless and trying to get out of bed 4. Swelling and bruising noted on left thigh

3. Client restless and trying to get out of bed

The client is undergoing a 24-hour urine specimen collection. Twenty hours into the collection period, a single voided urine is accidentally discarded. What is the nurse's best action? 1. Resume the urine collection and collect one additional voided specimen. 2. Discard the urine collected and begin a new urine collection immediately. 3. Complete the urine collection and send all urine collected to the laboratory. 4. Dispose of the urine collected and reschedule the test to begin the next morning.

3. Complete the urine collection and send all urine collected to the laboratory.

The nurse assesses that the client has some finger swelling of a newly casted right arm fracture with no other abnormal findings. Which is the nurse's priority action? 1. Notify the HCP immediately. 2. Split the cast to prevent constriction. 3. Elevate the casted arm on pillows. 4. Document the degree of finger swelling.

3. Elevate the casted arm on pillows.

What should the nurse do first when preparing to identify the left ventrogluteal site for an intramuscular (IM) injection? 1. Place the palm of the left hand over the left greater trochanter 2. Locate the left lateral femoral condyle and greater trochanter 3. Place the palm of the right hand over the left greater trochanter 4. Locate the right posterior superior iliac spine and the greater trochanter

3. Place the palm of the right hand over the left greater trochanter

Which clinical presentation is most often identified with hypocalcemia? Select all that apply. 1. constipation 2. muscle weakness 3. Positive Trousseau sign 4. Positive Chvostek sign 5. tetany

3. Positive Trousseau sign 4. Positive Chvostek sign 5. tetany

The client reports pain in the right leg even though it was amputated. Which complementary therapy should the nurse use to control the phantom pain associated with the client's amputation? 1. A small dose of alprazolam at 8-hour intervals in addition to prescribed oxycodone and acetaminophen q6h prn 2. A high-fiber diet and 2000 mL fluid intake in 24 hours while taking hydromorphone at 4- to 6-hour intervals prn 3. Progressive relaxation exercises three times daily in addition to use of a transdermal patch of fentanyl 4. A local anesthetic as a nerve block in addition to prescribed long-acting oxycodone

3. Progressive relaxation exercises three times daily in addition to use of a transdermal patch of fentanyl

The nurse is teaching the client with carpal tunnel syndrome how best to utilize a wrist splint. Which statement is most appropriate for the nurse to include in the teaching? 1. Leave the splint in place even when bathing. 2. Wear the splint as tight as can be tolerated. 3. Remove the splint intermittently throughout the day. 4. Only wear the splint when doing work that stresses the fingers.

3. Remove the splint intermittently throughout the day.

The experienced nurse observes the new nurse caring for the client who is in skeletal traction to stabilize a proximal femur fracture prior to surgery. Which observation by the experienced nurse indicates the new nurse needs additional orientation? 1. Positions the client so the client's feet stay clear of the bottom of the bed 2. Checks ropes so that they are positioned in the wheel groves of the pulleys 3. Removes weights from ropes until the weights hang free of the bed frame 4. Performs pin site care with chlorhexidine solution once during the 8-hour shift

3. Removes weights from ropes until the weights hang free of the bed frame

The nursing student is caring for the client who had a right TKR 1 day ago. Which action by the student requires the nurse to intervene? 1. Hands the client the control for the continuous passive motion (CPM) machine 2. Offers the client an analgesic when pain is rated at 3 on a 0 to 10 scale 3. Repositions the leg to insert an abductor pillow between the client's legs 4. Places an ice pack wrapped within a towel on the client's operative knee

3. Repositions the leg to insert an abductor pillow between the client's legs

The older adult client wishes to be discharged home after a kyphoplasty. The client has a history of emphysema requiring oxygen at home. To ensure discharge to home is appropriate, which information is most important for the nurse to assess? 1. Home care resources 2. Pain management plan 3. Self-care deficits 4. Medication regime

3. Self-care deficits

The nurse is assessing the client who is to have a closed reduction for a right elbow dislocation. Which should be the nurse's priority? 1. Presence of bruising to the right elbow 2. Pain level rating on a 0 to 10 scale 3. Sensation and pulse of the right forearm 4. Left-handed or right-handed

3. Sensation and pulse of the right forearm

The client has a calcium lab value of 12 mg/dL and the healthcare provider recognizes this can be related to which medical condition? Select all that apply. 1. renal disease 2. hypoparathyroidism 3. hyperparathyroidism 4. vitamin D toxicity 5. presence of cancer

3. hyperparathyroidism 4. vitamin D toxicity 5. presence of cancer

What action by the graduate nurse (GN) when administering insulin lispro will the registered nurse (RN) recognize as a need for intervention? 1. verifies the blood glucose level prior to administering the insulin 2. clarifies the order for the insulin lispro prior to administering the insulin 3. instructs the client to eat the scheduled meal within the next 30 minutes 4. injects the insulin in the right portion of the abdomen 1 inch from the umbilicus

3. instructs the client to eat the scheduled meal within the next 30 minutes

The client is hospitalized following surgical repair of a hip fracture. The client informs the nurse about wishing to observe Ramadan, which is occurring now. Which statement by the nurse demonstrates an understanding of Ramadan? 1. "I'm going to uncover your hip and leg now to check the incision and your pulses." 2. "A dietitian helps to plan your meals so that meat and dairy products are not together.? 3. "I've asked that physical therapy be postponed until around 3 p.m., when Ramadan ends." 4. "I should let the care team know not to bring food or beverages from sunrise to sunset?"

4. "I should let the care team know not to bring food or beverages from sunrise to sunset?"

The clinic nurse completed teaching the client with a rotator cuff tear who is being treated conservatively. Which client statement indicates that further teaching is needed? 1. "I received a corticosteroid injection in my shoulder to reduce the inflammation and pain." 2. "Now that the pain is controlled, I can do progressive stretching and strengthening exercises." 3. "I will continue to take ibuprofen for pain control, but I should take it with food." 4. "I will need an open arthroplasty to repair the torn cuff after the swelling is reduced."

4. "I will need an open arthroplasty to repair the torn cuff after the swelling is reduced."

The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress? 1. "This will alter tissue sensitivity by producing numbness." 2. "This will decrease the metabolic needs of the involved tissues." 3. "This will stop the local release of histamine in the tissues." 4. "This will increase blood flow and accelerate tissue healing."

4. "This will increase blood flow and accelerate tissue healing."

The nurse is tasked with giving a client 4 ml of an antibiotic before leaving. Where and how should the injection be given? 1. In the deltoid using a 1 in 22 gauge needle 2. 1ml in the left deltoid, 3ml in the left vastus lateralis 3. In the vastus lateralis using a 1½ in 20 gauge 4. 2 ml in the left ventrogluteal, 2 ml in the right ventrogluteal

4. 2 ml in the left ventrogluteal, 2 ml in the right ventrogluteal

A preceptor observes a novice nurse caring for a post-mastectomy client with two JP drains. Which action by the novice requires intervention by the preceptor? 1. Selects packaged pre-split 4×4 gauzes for the dressing change 2. Uses aseptic techniques when closing the cap after emptying the drain 3. Places the device in a dependent position 4. Combines the output of both drains into a cylinder and measures amount

4. Combines the output of both drains into a cylinder and measures amount

The nurse is caring for a client who has severe osteoarthritis. What primary joint problems will the nurse expect the client to report? A. Crepitus B. Effusions C. Pain D. Deformities

C. The primary assessment finding typically reported by clients with osteoarthritis is joint pain, although all the others may also occur.

After a total knee arthroplasty, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the skin of both legs is pale pink, warm, and dry, but the client is unable to dorsiflex or plantarflex the surgical foot. What action would the nurse take next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client's bladder or perform a bladder scan.

C. With the femoral nerve block, the client would still be able to dorsiflex and plantarflex the affected surgical foot. Since this is an abnormal finding, the nurse would notify the surgeon or the anesthesiologist immediately.

A nurse teaches a client who is at risk for carpal tunnel syndrome. Which health promotion activities would the nurse include in the health teaching? (Select all that apply.) a. "Frequently assesses the ergonomics of the equipment being used." b. "Take breaks to stretch fingers and wrists during working hours." c. "Do not participate in activities that require repetitive actions." d. "Take ibuprofen to decrease pain and swelling in wrists." e. "Adjust chair height to allow for good posture."

a. "Frequently assesses the ergonomics of the equipment being used." b. "Take breaks to stretch fingers and wrists during working hours." e. "Adjust chair height to allow for good posture."

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse respond? a. "Skeletal traction will assist in realigning your fractured bone." b. "This treatment will prevent future complications and back pain." c. "Traction decreases muscle spasms that occur with a fracture." d. "This type of traction minimizes damage as a result of fracture treatment."

a. "Skeletal traction will assist in realigning your fractured bone."

A nursing student studying the musculoskeletal system learns about important related hormones. What information does the student learn? (Select all that apply.) a. A lack of vitamin D can lead to rickets. b. Calcitonin increases serum calcium levels. c. Estrogens stimulate osteoblastic activity. d. Parathyroid hormone stimulates osteoclastic activity. e. Thyroxine stimulates estrogen release.

a. A lack of vitamin D can lead to rickets. c. Estrogens stimulate osteoblastic activity. d. Parathyroid hormone stimulates osteoclastic activity.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowlers position. c. Increase the intravenous flow rate. d. Assess response to pain medications.

a. Administer oxygen via nasal cannula.

A nurse cares for a client who has a deep wound that is being treated with a wet-to-damp dressing. Which intervention should the nurse include in this clients plan of care? a. Change the dressing every 6 hours. b. Assess the wound bed once a day. c. Change the dressing when it is saturated. d. Contact the provider when the dressing leaks.

a. Change the dressing every 6 hours.

A nurse manages wound care for clients on a medical-surgical unit. Which client wounds are paired with the appropriate treatments? (Select all that apply.) a. Client with a left heel ulcer with slight necrosis Whirlpool treatments b. Client with an eschar-covered sacral ulcer Surgical dbridement c. Client with a sunburn and erythema Soaking in warm water for 20 minutes d. Client with urticaria Wet-to-dry dressing changes every 6 hours e. Client with a sacral ulcer with purulent drainage Transparent film dressing

a. Client with a left heel ulcer with slight necrosis Whirlpool treatments b. Client with an eschar-covered sacral ulcer Surgical dbridement

A nurse is planning postoperative care for a client following a total hip arthroplasty. What nursing interventions would help prevent venous thromboembolism for this client? (Select all that apply.) a. Early ambulation b. Fluid restriction c. Quadriceps-setting exercises d. Compression stockings/devices e. Anticoagulant drug therapy

a. Early ambulation c. Quadriceps-setting exercises d. Compression stockings/devices e. Anticoagulant drug therapy

A nurse assesses a client with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.) a. Edema Increased capillary permeability b. Pallor Increased blood blow to the area c. Unequal pulses Increased production of lactic acid d. Cyanosis Anaerobic metabolism e. Tingling A release of histamine

a. Edema Increased capillary permeability c. Unequal pulses Increased production of lactic acid d. Cyanosis Anaerobic metabolism

A nurse plans care for a client who is recovering from open reduction and internal fixation (ORIF) surgery for a right hip fracture. Which interventions would the nurse include in this client's plan of care? (Select all that apply.) a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. c. Push the client's patient-controlled analgesia button. d. Re-position the client every 2 hours. e. Use pillows to encourage subluxation of the hip.

a. Elevate heels off the bed with a pillow. b. Ambulate the client on the first postoperative day. d. Re-position the client every 2 hours.

A nurse teaches a client with a fractured tibia about external fixation. Which advantages of external fixation for the immobilization of fractures would the nurse share with the client? (Select all that apply.) a. It leads to minimal blood loss. b. It allows for early ambulation. c. It decreases the risk of infection. d. It increases blood supply to tissues. e. It promotes healing.

a. It leads to minimal blood loss. b. It allows for early ambulation. e. It promotes healing.

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this clients plan of care to prevent pressure sores? (Select all that apply.) a. Place a small pillow between bony surfaces. b. Elevate the head of the bed to 45 degrees. c. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. e. Re-position the client who is in a chair every 2 hours. f. Keep the clients heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

a. Place a small pillow between bony surfaces. d. Use a lift sheet to assist with re-positioning. f. Keep the clients heels off the bed surfaces.

A home health nurse assesses a client with diabetes who has a new cast on the arm. The nurse notes the clients fingers are pale, cool, and slightly swollen. Which action should the nurse take first? a. Raise the arm above the level of the heart. b. Encourage range of motion. c. Apply heat to the affected hand. d. Bivalve the cast to decrease pressure.

a. Raise the arm above the level of the heart.

What happens during plantarflexion? a. The bottom of the foot moves toward the calf, decreasing the angle between those two surfaces, which leaves the toes pointing away from the body b. The top of the foot moves toward the shin, decreasing the angle between those two surfaces, leaving the toes pointing toward the head c. The foot twists to the left d. The foot twists to the right

a. The bottom of the foot moves toward the calf, decreasing the angle between those two surfaces, which leaves the toes pointing away from the body

A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this clients hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.) a. Wash your hands before touching the client. b. Wear gloves when bathing the client. c. Assess skin for breakdown during the bath. d. Apply lotion to lesions while the skin is wet. e. Use a damp cloth to scrub the lesions.

a. Wash your hands before touching the client. b. Wear gloves when bathing the client.

A nurse assesses a client who has a chronic wound. The client states, I do not clean the wound and change the dressing every day because it costs too much for supplies. How should the nurse respond? a. You can use tap water instead of sterile saline to clean your wound. b. If you don't clean the wound properly, you could end up in the hospital. c. Sterile procedure is necessary to keep this wound from getting infected. d. Good hand hygiene is the only thing that really matters with wound care.

a. You can use tap water instead of sterile saline to clean your wound.

A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention would the nurse include in this client's plan of care? a. Place pillows between the client's knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.

b. Encourage range-of-motion exercises.

After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the clients understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Low-fat diet with whole grains and cereals and vitamin supplements b. High-protein diet with vitamins and mineral supplements c. Vegetarian diet with nutritional supplements and fish oil capsules d. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet

b. High-protein diet with vitamins and mineral supplements

A nurse assesses a wife who is caring for her husband. She has a Braden Scale score of 9. Which question should the nurse include in this assessment? a. Do you have a bedpan at home? b. How are you coping with providing this care? c. What are you doing to prevent pediculosis? d. Are you sharing a bed with your husband?

b. How are you coping with providing this care?

What happens during dorsiflexion? a. The bottom of the foot moves toward the calf, decreasing the angle between those two surfaces, which leaves the toes pointing away from the body. b. The top of the foot moves toward the shin, decreasing the angle between those two surfaces, leaving the toes pointing toward the head. c. The foot twists to the left. d. The foot twists to the right.

b. The top of the foot moves toward the shin, decreasing the angle between those two surfaces, leaving the toes pointing toward the head.

The nurse assesses a client who is admitted with a pelvic fracture. Which assessments would the nurse monitor to prevent or detect a complication of this injury? (Select all that apply.) a. Temperature b. Urinary output c. Blood pressure d. Pupil reaction e. Skin color

b. Urinary output c. Blood pressure e. Skin color

A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection? a. Client with blood cultures pending b. Client who has thin, serous wound drainage c. Client with a white blood cell count of 23,000/mm3 d. Client whose wound has decreased in size

c. Client with a white blood cell count of 23,000/mm3

A nurse is caring for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication would the nurse most likely administer? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen

c. Intravenous calcitonin

The nurse is caring for a client who had a closed reduction of the left arm and notes a large wet area of drainage on the cast. What action is the most important? a. Cut off the old cast. b. Document the assessment. c. Notify the primary health care provider. d. Wrap the cast with gauze.

c. Notify the primary health care provider.

A nurse teaches assistive personnel (AP) about providing hygiene for a client in traction. Which statement would the nurse include as part of the teaching about this client's care? a. "Remove the traction when re-positioning the client." b. "Assess the client's skin when performing a bed bath." c. "Provide pin care by using alcohol wipes to clean the sites." d. "Ensure that the weights remain freely hanging at all times."

d. "Ensure that the weights remain freely hanging at all times."

A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year-old female with type 2 diabetes and fractured ribs c. A 55-year-old female prescribed ibuprofen for osteoarthritis d. A 74-year-old male who smokes and has a fractured pelvis

d. A 74-year-old male who smokes and has a fractured pelvis

A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? a. Hypertension b. Diarrhea c. Infection d. Hematuria

d. Hematuria

A nurse cares for a client in skeletal traction. The nurse notes that the skin around the clients pin sites is swollen, red, and crusty with dried drainage. Which action should the nurse take next? a. Request a prescription to decrease the traction weight. b. Apply an antibiotic ointment and a clean dressing. c. Cleanse the area, scrubbing off the crusty areas. d. Obtain a prescription to culture the drainage.

d. Obtain a prescription to culture the drainage.

A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client's risk for infection? a. Washing the frame of the fixator once a day b. Releasing fixator tension for 30 minutes twice a day c. Avoiding moving the extremity by holding the fixator d. Scheduling for pin care to be provided every shift

d. Scheduling for pin care to be provided every shift