Exam 4

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client has had intermaxillary fixation to repair and stabilize the fracture. The nurse should recognize that the most important goal in the immediate postoperative period is to do which of the following? Prevent aspiration. Ensure adequate nutrition. Promote oral hygiene. Relieve the client's pain.

Prevent aspiration.

​A nurse is completing a neurovascular check of a client's lower extremity after surgery to reduce a fracture. Which of the following parameters should the nurse include as a part of evaluating the neurovascular status of the injured leg? (Select all that apply.) ​Color ​Temperature ​Ecchymosis ​Skin integrity ​Sensation

​Color ​Temperature ​Sensation

​A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following is the appropriate action by the nurse? ​Explore the client's feelings. ​Discuss the competency of the surgeon. ​Review another individual's similar surgical experience. ​Talk with the client's partner.

​Explore the client's feelings.

A nurse is caring for a client hospitalized for an open reduction of a fractured femur and application of a cast. The most important nursing action for the care of this client is to: medicate the client for pain. use the palms of the hands when moving an extremity with a wet cast. perform neurovascular checks of the extremities. petal the edges of the cast to provide smooth edges.

perform neurovascular checks of the extremities.

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Pass a stress test Get out of bed without assistance Be able to self-toilet Ambulate the length of the client's house Be able to drive to the grocery

Get out of bed without assistance Be able to self-toilet Ambulate the length of the client's house

A nurse is providing an educational presentation addressing the topic of "Protecting Your Skin." When discussing the anatomy of the skin with this group, the nurse should state that what cells are responsible for producing the pigmentation of the skin?Melanocytes Squamous cells Islets of Langerhans T cells

Melanocytes

A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply. Discharge planning is minimal because the stay is so short. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past. The client will leave the hospital sooner than in the past. Home care and other referrals are unlikely because same-day surgeries are usually minor.

Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past. The client will leave the hospital sooner than in the past.

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply. Sufficient oxygen saturation Absence of pain Stable blood pressure Ability to tolerate oral fluids Adequate respiratory function

Sufficient oxygen saturation Stable blood pressure Adequate respiratory function

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following should the nurse include? Treatment includes washing the affected area with hot water Treatment focuses on pain management Treatment includes teaching clients about coal tar preparations Treatment includes daily application of warm moist compresses

Treatment includes teaching clients about coal tar preparations

A nurse is assessing a client who is postoperative following abdominal surgery. Which of the following findings should make the nurse suspect deep-vein thrombosis (DVT)? ​Coolness of the leg ​Decreased pedal pulses ​Pain in the ankle and foot ​Unilateral leg edema

Unilateral leg edema

During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action? No action is needed, because the client takes warfarin on a continuing basis. Tell the client to inform the circulating nurse before the anesthesia is administered. Put a note on the preoperative checklist before sending the client into surgery. Notify the surgeon that the client took warfarin the day before surgery.

Notify the surgeon that the client took warfarin the day before surgery.

A nurse is caring for a client who is postoperative from a total hip arthroplasty. The nurse assists the client into a supine position. Which of the following actions is appropriate to prevent external rotation of the lower extremity? Place a wedge pillow between the legs. Place a sandbag to the lateral calf. Place a trochanter roll against the thigh. Place a footboard on the bed.

Place a trochanter roll against the thigh.

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is appropriate regarding the postoperative placement of a prosthesis? "The prosthesis will be in place immediately following surgery to improve your ability to ambulate sooner." decrease the chance of phantom limb pain." decrease the frequency of dressing changes." improve the fit of the prosthesis."

improve your ability to ambulate sooner."

​A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds an evisceration. Which of the following interventions is appropriate? ​Have the client lie flat in bed. ​Use sterile gauze to place gentle pressure on the exposed organs. ​Cover the area with saline-soaked sterile dressings. ​Apply an abdominal binder.

​Cover the area with saline-soaked sterile dressings.

​A nurse is obtaining informed consent from a client prior to surgery. Which of the following is necessary for informed consent to be valid? (Select all that apply.) ​A client's ability to pay for the consented surgical procedure. ​A client's ability to read the consent form. ​Disclosure of the treatment is provided. ​Client understands the surgical procedure. ​Voluntary consent is given.

​Disclosure of the treatment is provided. ​Client understands the surgical procedure. ​Voluntary consent is given.

A nurse is planning care for a client following surgery who is having headaches due to receiving spinal anesthetic. Which of the following is included in the plan of care? ​Encourage increased intake of fluids ​Encourage increased physical activity ​Maintain the client in high Fowler's position ​Apply an ice bag at the injection site of the spinal anesthetic

​Encourage increased intake of fluids

​A nurse is assessing a client who is postoperative and has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings? ​Fatigue ​Respiratory depression ​Bradycardia ​Muscle cramps

​Fatigue

​A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following client findings indicates to the nurse that peristalsis is returning? ​Hypoactive bowel sounds in two quadrants ​Request for a cup of tea and some toast ​Passage of flatus ​Abdominal distention

​Passage of flatus

nurse is teaching a client about the risk factors of skin cancer. Which of the following statements indicates the client understands the teaching? "Because I'm dark-complected, I won't have to worry about skin cancer." "I really need to use sunscreen—even in winter." "I used to lie in the sun all the time but now I just go to the tanning bed." "My father was treated for melanoma, but skin cancer isn't related to genetics."

"I really need to use sunscreen—even in winter."

A nurse is providing teaching for a client who is to have a myelogram. Which of the following statements indicates the client understands the teaching? "I will need to keep my head elevated after the procedure." "I will have a radioactive substance injected during the procedure." "I will not be allowed to drink much liquid for 12 hours after the procedure." "I can expect to have some itching during the procedure."

"I will need to keep my head elevated after the procedure."

A client has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery? "The client was tachycardic, had progressive weight loss, and experienced bouts of insomnia as a result of hyperthyroidism." "The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident." "The client had epigastric abdominal pain, an elevated white blood count, and vomiting for 1 day." "The client had severe pain and a laceration to the face with minimal bleeding after being attacked by a dog 1 hour ago."

"The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident."

The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response? "No one has ever died from the procedure you are having." "What family support do you have after the surgery?" "What are your concerns?" "You have nothing to worry about; you have the best surgical team."

"What are your concerns?"

A nurse is teaching a client who has herpes zoster about the order of occurrence of findings associated with this disorder. The nurse should identify the typical occurrence of findings in which order? (Identify the occurrence of findings in the appropriate order of appearance. All findings must be used.)

1. Paresthesia 2. Redness and swelling 3. Vesicles 4. Weeping blisters 5. Crusted lesions 6. Postherpetic neuralgia

A nurse in a provider's office is talking with a client about risk factors for osteoarthritis. Which of the following factors should the nurse include? (Select all that apply.) Bacteria Diuretics Aging Obesity Smoking

Aging Obesity Smoking

A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture. Which of the following is the nurse's priority? Pain control Airway management Oral hygiene Nutritional support

Airway management

A nurse is talking with a client who has gout. The nurse should teach the client not to drink which of the following beverages? Alcohol Orange juice Milk Coffee

Alcohol

A nurse is providing care to a patient who is receiving chemotherapy. The nurse notes that the patient has lost most of the hair on her head. The nurse documents this finding as which of the following? Jaundice Photosensitivity Alopecia Hypopigmentation

Alopecia

A nurse is assessing a client who has Paget's disease of the bone. Which of the following findings should the nurse expect? (Select all that apply.) Cranial enlargement Skeletal pain Waddling gait Cold extremities Vision deficits

Cranial enlargement Skeletal pain Waddling gait

A nurse is caring for a client who has cellulitis of the leg. Which of the following interventions should be included in the nurse's care plan for the client? Enforce strict bedrest for 3 days. Apply fresh ice packs every 4 hr. Elevate the left leg on two pillows. Apply antibiotic ointment to the wound with dressing changes.

Elevate the left leg on two pillows.

nurse is caring for a client who is admitted with widespread psoriasis. The nurse should plan to prepare the client for which of the following treatments? Radiation therapy Exposure to photochemotherapy Topical application of corticosteroids Administration of fluorouracil (Carac)

Exposure to photochemotherapy

Pressure ulcers are caused by:

Extrinsic factors

nurse is formulating a teaching plan for the client who has psoriasis. Which of the following is appropriate to include? Maintain occlusive dressings on the lesions throughout the day. Eliminate the use of products containing salicylic acid. Avoid friction over scaly lesions while bathing. Identify effective stress reduction techniques.

Identify effective stress reduction techniques.

A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. It is 0830 and the client will begin physical therapy (PT) at 0900. Which of the following is an appropriate nursing intervention for this client at this time? Assist the client out of bed into the wheelchair. Identify the client's pain level and medicate if needed. Teach the client which positions to avoid during PT. Complete the client's usual morning care.

Identify the client's pain level and medicate if needed.

A client comes to the clinic reporting shoulder pain. When obtaining the client's history, the nurse suspects a rotator cuff injury. When assessing the client, the nurse expects to find which of the following? Alteration in the contour of the joint Inability to abduct the arm at the shoulder A negative drop arm test A positive Tinel's sign

Inability to abduct the arm at the shoulder

An 82-year-old client is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the client's course of treatment? Increased time required for wound healing Increased vascular supply to superficial skin layers Increased thickness of the subcutaneous skin layer Changes in the character and quantity of bacterial skin flora

Increased time required for wound healing

A nurse is talking with a client who has a new diagnosis of acute bursitis in her right shoulder. Which of the following self-care strategies should the nurse recommend? Range-of-motion exercise Intermittent ice and heat Elevation of the right arm Corticosteroid therapy

Intermittent ice and heat

A nurse is developing a plan of care for a client to achieve the outcome of functional healing of a fracture. Which of the following nursing interventions is the highest priority to assist in meeting this outcome? Maintain immobilization and alignment. Provide optimal nutrition and hydration. Promote independence in activities of daily living. Provide relief from pain and discomfort.

Maintain immobilization and alignment.

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight? Change in temperature of the toes. Pallor of the toes. Edema of the toes. Inability to move toes.

Pallor of the toes.

A nurse is preparing to perform the physical assessment of a newly admitted client. During which of the following components of the assessment should the nurse wear gloves? Select all that apply. Palpation of a rash on the client's trunk Palpation of the client's upper extremities Palpation of the client's fingers Palpation of a lesion on the client's upper back Palpation of the client's scalp

Palpation of a rash on the client's trunk Palpation of a lesion on the client's upper back

What is the major purpose of withholding food and fluid before surgery? Decrease urine output Decrease risk of constipation Prevent overhydration Prevent aspiration

Prevent aspiration

Inspection of the skin is an important part of nursing assessment. Interpretation of abnormalities is based on an understanding of structure and function. The nurse is aware that the epidermis, especially the stratum cornea, has many vital functions. What are some of these functions? Select all that apply. Provides the elasticity of the skin's foundation Secretes fibroblast cells that help repair the skin Produces keratin, the hardening ingredient of the nails Provides an effective barrier to water loss Contains lipids that resist penetration by microbes Contains the nerve receptors for pain perception

Produces keratin, the hardening ingredient of the nails Provides an effective barrier to water loss Contains lipids that resist penetration by microbes

A nurse is formulating a teaching plan for a client who has herpes zoster. The nurse should include which of the following? Inform the client that herpes zoster is only contagious to others who have had chickenpox. Inform the client that they are contagious only if the lesions are draining. Recurrence of infection can be triggered by stress and fatigue. With recurrence of infection, vesicles will appear before the pain begins.

Recurrence of infection can be triggered by stress and fatigue.

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe? Small, localized blackened area of skin Cold, red skin Painful skin that is swollen and pale in color Red, swollen skin with inflammation spreading to surrounding tissues

Red, swollen skin with inflammation spreading to surrounding tissues

A nurse is teaching about possible treatments for a client who has psoriasis. Which of the following should the nurse include in the teaching? (Select all that apply.) Tar preparations. Corticosteroids. Ultraviolet light therapy. Laser therapy. topical antibiotics.

Tar preparations. Corticosteroids. Ultraviolet light therapy.

​A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins promote wound healing and should be included in the teaching? (Select all that apply.) ​Vitamin A ​Vitamin B12 ​Vitamin C ​Vitamin D ​Vitamin E

Vitamin A ​Vitamin C

A nurse assigns an assistive personnel to apply a footplate to the bed of a client who has his left leg in Buck's traction. The nurse correctly explains that the purpose of this action is to anchor the traction. prevent foot drop. keep the client from sliding down in bed. prevent pressure areas on the foot.

prevent foot drop.

In the immediate postoperative period, vital signs are taken at least every 30 minutes. 15 minutes. 60 minutes. 45 minutes.

15 minutes

A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse should anticipate that the provider will first prescribe, and the client will require teaching about, which of the following medications? Acetaminophen (Tylenol) Celecoxib (Celebrex) Cyclobenzaprine (Flexeril) Ibuprofen (Advil, Motrin)

Acetaminophen (Tylenol)

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. Because this is often the first sign of a serious complication of fractures, the nurse should suspect which of the following? Fat embolism syndrome Acute compartment syndrome Pulmonary embolism Osteomyelitis

Acute compartment syndrome

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the technician to take x-rays, which of the following are appropriate nursing interventions? (Select all that apply.) Apply ice to the ankle. Encourage range of motion of the foot. Provide the client with a light snack. Apply a compression bandage. Elevate the foot.

Apply ice to the ankle. Apply a compression bandage. Elevate the foot.

The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply. Consent must be freely given. Signature must be witnessed by a professional staff member. Consent must normally be obtained by a physician. Consent must be signed on the day of surgery. Consent must be notarized.

Consent must be freely given. Signature must be witnessed by a professional staff member. Consent must normally be obtained by a physician.

During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications does this finding indicate? Poor circulation Pressure from the cast Uneven cast drying Infection

Infection

A nurse is caring for a client who has a fractured femur. Which of the following techniques should the nurse use when performing a assessment of circulatory status? Ask the client to cough and deep-breathe. Observe the client's ability to turn himself in bed. Assist the client in performing biceps exercises. Instruct the client to wiggle his toes.

Instruct the client to wiggle his toes.

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area? Administer medications and fluids. Inspect surgical site. Assess pain level. Maintain patient safety.

Maintain patient safety.

What intervention by the nurse is most effective for reducing hospital-acquired infections? Aseptic wound care Control of upper respiratory tract infections Administration of prophylactic antibiotics Proper hand-washing techniques

Proper hand-washing techniques

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? Maintain bed rest Instruct the client to cross the legs or prop a pillow under the knees Reinforce the need to perform leg exercises every hour when awake Massage the calves or thighs

Reinforce the need to perform leg exercises every hour when awake

A nurse in an urgent care center is caring for a client who has an ankle sprain. Which of the following interventions are appropriate? (Select all that apply.) rest movement heat application compression Elevation

Rest Compression Elevation

A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. Which of the following findings indicates the client is experiencing a complication? A palpable lump in the buttock. change in urinary output. lient reports onset of thirst. lient reports a change in taste.

change in urinary output.

A term used to describe a partial or complete separation of wound edges is erythema. hemorrhage. dehiscence. evisceration.

dehiscence.

nurse in a clinic is teaching a postmenopausal client about prevention of osteoporosis. Which of the following statements by the client requires clarification of the teaching? "I will exclude excessive amounts of protein in my diet." I will select foods which have high fiber content." I will limit my intake of soft drinks." "I will include vitamin E rich foods in my diet."

"I will include vitamin E rich foods in my diet."

​A nurse is providing preoperative teaching for a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following is an appropriate nursing response? ​"They'll protect your legs and heels from skin breakdown." ​"They'll help keep you warm immediately after your surgery." ​"They'll improve your circulation to keep blood from pooling in your legs." ​"They'll make it easier for you to do leg exercises after your surgery."

"They'll improve your circulation to keep blood from pooling in your legs"

The nurse is starting preoperative teaching. What is the best response by the nurse when the client states, "I'm so nervous about my surgery"? "Would you like to discuss the concerns that you have?" "If you are nervous, would you like to revoke your consent?" "We can discuss your concerns and then your nervousness will stop." "Relax. Let's focus on a good outcome."

"Would you like to discuss the concerns that you have?"

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority? Monitoring vital signs Applying a sterile, moist dressing Inserting a nasogastric (NG) tube Putting the client on nothing-by-mouth (NPO) status

Applying a sterile, moist dressing

A client who has undergone a right below-the-knee amputation due to trauma now has a prosthetic limb. When teaching the client about prosthesis and stump care, the nurse should include which of the following instructions? Keep the prosthesis in direct contact with the residual limb. Apply a moisturizing lotion or oil to the stump daily. Dry the prosthesis socket completely before applying it to the limb. Expect some skin irritation from the prosthesis.

Dry the prosthesis socket completely before applying it to the limb.

​A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? ​Positive Kernig's sign ​Positive Homan's sign ​Dull, aching calf pain ​Soft, pliable calf muscle

Dull, aching calf pain

In which instance may a surgeon operate without informed consent? Invasive procedures Radiologic procedures Emergency situations Procedures requiring sedation

Emergency situations

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the affected arm? A bounding distal pulse Acute pain Ecchymosis of the surrounding skin Increasing edema

Increasing edema

An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate wound healing and prevent poor outcomes for this client? Select all that apply. Nutritional status Quality of food ingested Caloric intake The amount of carbohydrates the client ingests The client's ability to perform his or her own wound care

Nutritional status Quality of food ingested Caloric intake

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client will be in which of the following positions? upine and both legs extended ith the right leg flat on the bed Semi-Fowler's with the legs elevated to 10° With the right leg at a 20°angle

With the right leg at a 20°angle

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding? "Skeletal traction has less risk for infection than skin traction." "Clients with skin traction have more mobility than those with skeletal traction." "Skeletal traction is more appropriate than skin traction for reducing a fracture. " "Clients with skin traction have more discomfort than those with skeletal traction."

"Skeletal traction is more appropriate than skin traction for reducing a fracture. "

The triage nurse in the ED is assessing a client who reports pain and swelling in her right lower leg. The client's pain became much worse last night and appeared along with fever, chills, and sweating. The client states, "I hit my leg on the car door 4 or 5 days ago and it has been sore ever since." The client has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this client? Warfarin to treat arterial insufficiency Antibiotics to treat cellulitis Platelet transfusion to treat thrombocytopenia Heparin IV to treat VTE

Antibiotics to treat cellulitis

A nurse is caring for a client following arthroscopic knee surgery. To prevent postoperative complications, the nurse should have the client do which of the following? Remain on bedrest for the first 24 hr. Keep the leg in a dependent position. Apply ice to the affected area. Begin active range of motion.

Apply ice to the affected area.

A nurse is assisting a client who is postoperative following abdominal surgery with morning care and identifies a loop of bowel through an opening in the surgical incision. After calling for help, which of the following actions should the nurse take first? heck vital signs. Provide reassurance to the client. Apply moistened sterile gauze to the site. Position the client supine with knees and hips bent.

Apply moistened sterile gauze to the site.

A charge nurse is asked to witness a surgical consent form. Upon entering the room, the client asks "Are there other options besides surgery?" Which of the following responses by the nurse is appropriate? "The provider discussed all of your options with you earlier. It is time to sign the consent so your treatment may begin." "I would not have this type of surgery. Studies have shown that the survival rate is better with medical management." "Several treatment options are available for your disease. Have you discussed this with your provider?" "You have the right to have other treatments. I can inform the surgeon you do not want the surgery."

"several treatment options are available for your disease. Have you discussed this with your provider?"

​A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray? ​Lemon sherbet ​Plain yogurt ​Cranberry juice ​Carrot juice

Cranberry juice

Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply. Causative Diagnostic Cosmetic Normative Palliative

Cosmetic Diagnostic Palliative

​A nurse is caring for a client on the second day following abdominal surgery and observes wound evisceration. Which of the following is the first action by the nurse? ​Raise the head of the bed 15 to 20-degrees ​Place the client supine with knees bent ​Assess for manifestations of shock ​Cover the area with a sterile dressing, moistened with saline

Cover the area with a sterile dressing, moistened with saline

A nurse is explaining the importance of sunlight on the skin to a woman with decreased mobility who rarely leaves her house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?

D

A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections? Chronic obstructive pulmonary disease Gout Diabetes Rheumatoid arthritis

Diabetes

​A nurse is assessing a client who will undergo abdominal surgery in 2 hr. The nurse finds that the client has mild anxiety about the surgery, last had food and fluids at 2330 the previous evening, and signed the surgical consent 2 days ago. Which of the following is an appropriate nursing action regarding these findings? ​Call the anesthesiologist to sedate the client. ​Notify the surgeon of the client's food and fluid consumption. ​Witness the surgical consent. ​Document the findings in the client's medical record.

Document the findings in the client's medical record.

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. Watching television Changing position Listening to music An epidural infusion An On-Q pump

Watching television Changing position Listening to music

The nurse is preparing to send a client to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the client to surgery? Select all that apply. Dietitian's assessment Verification form Nurses' notes Social work assessment Laboratory reports

Laboratory reports Nurses' notes Verification form

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock? Pooling of secretions in the lungs Weak and rapid pulse rate Warm, dry skin Obstructed airway

Weak and rapid pulse rate

A nurse is caring for a client who has urinary incontinence following surgery. Findings include the leakage of small amounts of urine frequently during the day and night, along with urinating frequently in small amounts. Her bladder is often distended and palpable upon examination. The nurse identifies these findings as associated with which of the following types of incontinence? ​Stress incontinence. ​Urge incontinence. ​Overflow incontinence. ​Reflex incontinence.

Overflow incontinence

​The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications? ​Dietary imbalance ​Fecal impaction ​Paralytic ileus ​Prolapsed incision

Paralytic ileus

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? Sepsis Pulmonary embolism Hematoma Infection

Pulmonary embolism

A nurse in a provider's office is talking with a client for whom the provider is considering arthroplasty. When the client asks the nurse what this procedure will do for him, the nurse should explain that the purpose of the procedure is to do which of the following? Assess the extent of joint damage. Fuse a joint and reduce pain. Prevent further joint damage. Replace the joint and improve function.

Replace the joint and improve function.

A client who has a fracture of the right tibia has had a fiberglass cast applied. To teach the client how to observe and manage his casted extremity at home, the nurse should include which of the following instructions? Use a blow dryer on a moderate heat setting to dry the cast after showering. Use a cotton swab to relieve itching under the cast. Report any worsening or unrelieved pain. Avoid moving the affected leg.

Report any worsening or unrelieved pain.

A nurse in a provider's office is talking with a client about risk factors for osteoporosis. Which of the following factors should the nurse include? (Select all that apply.) Sedentary lifestyle Obesity Aging Caffeine intake Secondhand smoke

Sedentary lifestyle caffeine intake aging Secondhand smoke

​A nurse is caring for a client who is one week postoperative following abdominal surgery. While changing the client's abdominal dressing the nurse notes the presence of serosanguineous drainage. The nurse should recognize which of the following? ​Serosanguineous drainage at this time is expected after abdominal surgery. ​Serosanguineous drainage at this time is a manifestation of possible dehiscence. ​Serosanguineous drainage at this time is a manifestation of hemorrhage. ​Serosanguineous drainage at this time is a manifestation of infection.

Serosanguineous drainage at this time is a manifestation of possible dehiscence.

When planning the skin care of a client with decreased mobility, the nurse is aware of the varying thickness of the epidermis. At what location is the epidermal layer thickest? The elbows The knees The scalp The palms of the hands

The palms of the hands

The nurse is caring for a client who has paraplegia following a hunting accident. The nurse knows to assess regularly for the development of pressure ulcers on this client. What rationale should the nurse cite for this nursing action? The risk for pressure ulcers is related to what caused the immobility. The risk for pressure ulcers is directly related to the duration of immobility. The client likely has a decreased level of consciousness. The client may not be motivated to prevent pressure ulcers.

The risk for pressure ulcers is directly related to the duration of immobility.

A client who has just had abdominal surgery returns to the unit from the postanesthesia care unit with an IV fluid infusion and an NG tube in place. Which of the following is the assessment priority for the nurse who is caring for the client? ​The IV catheter insertion site ​The level of the client's pain ​The surgical dressing ​The patency of the NG tube

The surgical dressing

The nurse is aware that which of the following nutrients promotes normal blood clotting? Zinc Vitamin K Magnesium Vitamin C

Vitamin K

A nurse is caring for a client who had abdominal surgery two days ago. Which of the following findings by the nurse requires immediate attention? Blood pressure reading was 102/66. Urinary drainage bag is full of straw-colored urine. Wound has thick yellow-green drainage. Respirations are shallow at a rate of 24 breaths per minute.

Wound has thick yellow-green drainage.

The nurse documenting an acute open wound should include which characteristic(s)? Select all that apply. Pattern of eruption Wound size Wound bed Periwound skin

Wound size Periwound skin Wound bed

A nurse is caring for a client following a right total hip arthroplasty. Postoperatively the nurse should maintain the right leg in a position of adduction. external rotation. internal rotation. abduction.

abduction.

A nurse is caring for a client who has a femur fracture and, 8 hr after the injury, reports a sudden onset of dyspnea and severe chest pain. Which action should the nurse take first? administer oxygen. prepare for an ICU transfer. increase the IV fluid infusion rate. Administer pain medication.

administer oxygen.

A nurse in a clinic is caring for a client who requires a hysterectomy and states that she "has decided to delay having this surgery for several months". Which of the following is an appropriate statement by the nurse? ​"This type of surgery is very easy and should not cause a major disruption in your activities." ​"Most women don't have any problems during their recovery." ​"Can you elaborate on your reasons for delaying the surgery?" ​"If this happened to one of my family members, I would tell them to go ahead and not wait."

​"Can you elaborate on your reasons for delaying the surgery?"

​A nurse is teaching a client who is preoperative how to do deep breathing exercises and cough effectively after surgery. Which client statement indicates to the nurse that the teaching has been effective? ​"I'll splint my incision with a pillow to cough." ​"I'll ask for pain medication after I do the exercises." ​"I'll use the incentive spirometer when I can get out of bed." ​"I'll breathe deeply and cough every 4 hours."

​"I'll splint my incision with a pillow to cough."

A nurse is caring for a client with a compression fracture of a spinal vertebra. Just prior to an hour-long transport to the hospital, the client was medicated with intravenous morphine sulfate (Duramorph). On arrival, the neurosurgeon determines that urgent surgical intervention is indicated for the fracture. The nurse realizes that consent for the surgery must be obtained from a relative of the client. can be inferred since the client consented to the transport. should be obtained from the client immediately. will be delayed until the morphine is metabolized.

must be obtained from a relative of the client.

A nurse is caring for a preoperative client who is sedated and awaiting surgery. While reviewing the client's preoperative forms, the nurse notes that the consent form has been signed by the client but has not been witnessed. The nurse should proceed with client preparation because the signed form is valid without a witness. ask the client to resign the form so that the nurse can sign as the witness. sign as a witness after verifying the client's signature with the client. notify the nurse manager and the provider.

notify the nurse manager and the provider.

The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing: anxiety acute pain orthostatic hypotension incisional pain

orthostatic hypotension

A nurse in an urgent care center is caring for a child who has a forearm fracture. The parent tells the nurse that the provider said it was a greenstick fracture and asks what that means. The nurse should explain that: the bone cracked lengthwise but didn't break all the way through. fragments of bone have splintered into the surrounding tissue. the bone ends have been forced toward each other. the sharp edge of the bone has broken through the skin.

the bone cracked lengthwise but didn't break all the way through.

The nurse is caring for a client who is getting ready for ambulatory surgery. After the nurse places the IV, the client indicates pain. The nurse should: remove the IV and have another nurse attempt to reinsert an IV into a new site. administer preoperative meds PO. request that a central line is inserted. administer a local anesthetic.

remove the IV and have another nurse attempt to reinsert an IV into a new site. It is possible that the catheter is up against a valve or by a nerve and is causing more pain than is expected for an IV site.

nurse in a clinic is caring for a client with suspected osteoporosis. Which of the following assessment findings is a risk factor for the development of the disease? Drinks one alcoholic beverage per day smokes 1 pack of cigarettes per day Large body stature History of bone fracture during childhood

smokes 1 pack of cigarettes per day

A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. The nurse should advise the client to increase her intake of carrots. spinach. cabbage. potatoes.

spinach.

The epidermis consists of four layers as listed below. Place the layers in the proper order from outermost to innermost.

stratum corneum stratum lucidum stratum granulosum stratum germinatum

A nurse is talking with a client who has a new diagnosis of gout. When the client asks the nurse how she got this disorder, the nurse should explain, in terminology the client can understand, that gout develops when: uric acid levels drop and calcium forms precipitate. tophi form in the kidneys and they impair the excretion of uric acid. the intra-articular deposition of urate crystals causes inflammation. articular cartilage thins, leading to splitting and fragmentation.

the intra-articular deposition of urate crystals causes inflammation.

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to: eat a balanced diet that is high in protein. take medications as prescribed. use the incentive spirometer every 2 hours. limit activity for the first 72 hours.

use the incentive spirometer every 2 hours.

A nurse is preparing a client for surgery. She should begin preoperative teaching by exploring: ​what the client knows about the surgery. ​the client's usual coping mechanisms. ​the client's current home environment. ​which family members will help with postoperative care.

what the client knows about the surgery.

The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is: "Clients are often on bed rest following surgery, and the exercises can help prevent pressure ulcers." "Leg exercises help prevent pneumonia while you are on bed rest." "Leg exercises help prevent blood clots in your legs." "Your intestinal tract slows down following surgery, and the exercises will help restore normal intestinal activity."

"Leg exercises help prevent blood clots in your legs."

​A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first? ​Determine the time the client last received pain medication. ​Measure the client's vital signs, including temperature. ​Ask the client to rate her pain on a scale of 0 to 10. ​Reposition the client and offer her a back rub.

Ask the client to rate her pain on a scale form 0 to 10.

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.) Massaging the legs every 4 hours Assisting the patient with leg exercises Encouraging early ambulation Applying compression stockings only at night Avoiding placement of pillows or blanket rolls under the patient's knees

Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees

A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? Insert a nasogastric tube. Make the client NPO. Encourage use of the incentive spirometer. Auscultate bowel sounds.

Auscultate bowel sounds.

A nurse is educating coworkers about how to minimize back pain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? Avoid prolonged sitting. Apply cold packs frequently. Sleep in a side-lying position with flexed knees. Sleep on a soft mattress. Try shoe insoles.

Avoid prolonged sitting. Sleep in a side-lying position with flexed knees. Try shoe insoles.

The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply. Personnel present Benefits of surgery Explanation of procedure Potential risks Estimated time of procedure Description of alternatives

Benefits of surgery Explanation of procedure Potential risks Description of alternatives

Which diagnostic test would be used if a malignancy is suspected?Patch test Biopsy Skin scraping Tzanck smear

Biopsy

A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?

By protecting older adults against shearing injuries

The nurse is monitoring a presurgical patient for electrolyte imbalance. Which classification of medication may cause electrolyte imbalance? Diuretics Phenothiazines Insulin Corticosteroids

Diuretics

A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect with a hip fracture? Leg lengthening Hip pallor Muscle spasms Leg abduction

Muscle spasms

The nurse has administered preanesthetic medication. What action should the nurse take next? Educate the client on discharge instructions. Obtain the client's signature on the consent form. Place the client on bed rest with the side rails up. Review the client's list of home medications.

Place the client on bed rest with the side rails up.

A nurse is discussing Russell's traction with a newly licensed nurse. Which of the following statements about this form of traction is appropriate? Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction uses a cervical halter to decrease cervical muscle spasms. Russell's traction uses a pelvic girdle belt to decrease lower back pain. Russell's traction uses skeletal pins to stabilize the fracture.

Russell's traction uses a sling under the knee to treat a fracture of the femur.

A nurse is caring for a client who is receiving a transfusion with one unit of packed cells because of blood loss during surgery. Thirty minutes after the unit of blood is hung, the client reports chills and back pain. The client's blood pressure is 80/64 mm Hg. Which of the following is the first action the nurse should take? Stop the infusion of blood. Inform the provider. Obtain a urine specimen. Notify the laboratory.

Stop the infusion of blood.

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. Wheezes Afebrile Tachypnea Crackles Chills

Tachypnea Crackles Chills

Following a suicide bombing at a shopping mall, an unidentified, unconscious client is admitted to the emergency department with an acute intra-abdominal hemorrhage. The nurse should recognize that consent for the surgery should be obtained from an officer of the court. must be obtained from a relative of the client. can be inferred since the client is in critical condition. will be delayed until the client is identified.

can be inferred since the client is in critical condition.

A nurse is caring for a bariatric client prior to a surgical procedure. What surgical complications would the nurse monitor the bariatric client for postoperatively? Select all that apply. cardiovascular complications pulmonary complications gastrointestinal complications nervous system complications renal complications

cardiovascular complications pulmonary complications

A client who has been admitted for weakness and taking fluids poorly is unable to move well in the bed and requires assistance. What are this client's risk factors for developing pressure sores? Select all that apply. inactivity immobility vascular disease localized edema dehydration

dehydration immobility inactivity

A nurse is conducting a preoperative interview with a client that is scheduled for surgery. The client states that he takes acetylsalicylic acid (Aspirin) 81 mg by mouth daily. Prior to the client's upcoming surgery, the nurse should instruct the client to do which of the following? ​Decrease the dose in half 2 weeks before surgery. ​Resume the same dose the week of surgery. ​Double the dose the week of surgery. ​Discontinue the dose 2 weeks before surgery.

discontinue the dose 2 weeks before surgery

A nurse is caring for a client who is immediately postoperative following thoracic surgery. The nurse administers a narcotic analgesic to the client frequently for pain. Which of the following should the nurse recognize as the primary reason for this action? It decreases the client's level of anxiety. It facilitates the client's deep breathing. It suppresses the client's cough reflex. It reduces the client's respiratory rate.

it facilitates the client's deep breathing

A nurse is caring for a client following an abdominal surgery. The client has a Penrose drain in place under the surgical dressing. The dressing is to be changed every 4 hr and as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area? Montgomery straps Hypoallergenic tape Large, bulky absorbent pads Hydroactive dressing

montgomery straps

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply. physical condition nutritional status gender health status Ethnicity age

nutritional status age physical condition health status

A nurse is caring for a client who is postoperative following a below-the knee amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time? Wrap the stump with an elastic bandage in a figure-eight configuration. Remove the elastic bandage and re-wrap the stump once a day. Wrap the stump with an elastic bandage in a proximal-to-distal direction. Secure the elastic bandage to the lowest joint.

Wrap the stump with an elastic bandage in a figure-eight configuration.

It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to: avoid dizziness. avoid aspiration. help eliminate inhaled anesthetics. maximize comfort.

avoid aspiration.

​A nurse is caring for an elderly client who is scheduled for surgery. Which of the following should the nurse be aware that the client is at risk for? (Select all that apply.) ​A decrease in the ability to communicate ​A decrease in the skin elasticity ​A decrease in medication efficacy ​An increase in metabolism ​An increase in cardiac output

​A decrease in the ability to communicate ​A decrease in the skin elasticity

A nurse is caring for a client following major spinal surgery. Despite administration of pain medication via a PCA, the client reports severe pain when turned and positioned. The spouse says to the nurse, "I wish I could do something to make my spouse feel better." Which of the following is a therapeutic response for the nurse to give? "It must be very difficult for you to see your spouse in pain." "I wish there was more that I could do to relieve your spouse's pain too." "I'm sure your spouse will begin to feel better soon." "We're doing everything we can to keep your spouse comfortable."

"It must be very difficult for you to see your spouse in pain."

A nurse is admitting a client for a scheduled surgery. The client is anxious. Which of the following responses by the nurse is appropriate? ​"You have nothing to worry about." ​"Other's who have had this procedure have had great results." ​"Tell me more about your concerns." ​"Why are you feeling so anxious?"

"Tell me more about your concerns."

A nurse is talking with a client who has gout. The nurse should teach the client to avoid the use of which of the following types of medication? NSAIDs Salicylates Antihistamines Expectorants

Salicylates

The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways the nurse might help alleviate the client's anxiety? Select all that apply. Ask the client if he would like to speak with a clergyperson. Listen empathetically to the client's concerns about the procedure. Make sure the client understands what will happen during surgery. Review the client's postoperative goals following the procedure. Remind the client that the chances of something going wrong are statistically low. Offer a sedative to help the client relax and feel more comfortable.

Ask the client if he would like to speak with a clergyperson. Listen empathetically to the client's concerns about the procedure. Make sure the client understands what will happen during surgery. Review the client's postoperative goals following the procedure.

A nurse is caring for a client who has a cast in place for a fractured tibia. Of the following, which nursing action is the priority immediately after the provider has applied the cast? Checking capillary refill Discussing cast care Managing pain Performing range of motion

Checking capillary refill

A dark-skinned firefighter is admitted to the emergency room with smoke inhalation. An assessment result indicates possible carbon monoxide poisoning. What is the indicator noted on the assessment? Cherry red color to the nail beds, lips, and oral mucosa Purplish tinge to the hands Ashen gray and dull color to his face Dull or yellow-brown shade to his chest

Cherry red color to the nail beds, lips, and oral mucosa

A young student is brought to the school nurse after falling off a swing. The nurse is documenting that the child has bruising on the lateral aspect of the right arm. What term will the nurse use to describe bruising on the skin in documentation? Urticaria Telangiectasias Purpura Ecchymoses

Ecchymoses

How should the nurse best position a client who has leg ulcers that are venous in origin? Keep the client's knees bent to 45-degree angle and supported with pillows. Keep the client's legs flat and straight. Elevate the client's lower extremities. Dangle the client's legs over the side of the bed.

Elevate the client's lower extremities.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. Establishing an IV line Verifying the surgical site with the client Taking measures to ensure the client's comfort Applying a grounding device to the client Preparing the medications to be given in the OR

Establishing an IV line Verifying the surgical site with the client Taking measures to ensure the client's comfort

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for this client at this time? Elevate the foot of the bed. Encourage sitting up as much as possible. Elevate the stump on a pillow. Have the client lie prone several times a day.

Have the client lie prone several times a day.

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following? Hypoxia Local trauma Psoriasis Anemia

Hypoxia

The nurse is planning care for a client in the postoperative period. Place the following nursing diagnoses in sequence, from highest to lowest priority.

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection

A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply. -the client's spouse's thoughts about the upcoming surgery -intravenous fluids and other lines and tubes -the surgeon's fee and other hospital charges -postoperative pain control -cough and deep-breathing exercises

Intravenous fluids and other lines and tubes Postoperative pain control Cough and deep-breathing exercises

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. Administer blood products per orders. Maintain a patent airway. Raise the head of the bed 30 degrees. Frequently monitor neurological status. Apply oxygen per orders. Apply a warming blanket.

Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders.

A nurse is caring for a client following a left hip arthroplasty. Which of the following should the nurse implement to prevent dislocation? Maintain foam wedge between legs. Encourage use of elastic stockings. Monitor for shortening of the affected leg. Avoid flexing the hips more than 60°.

Maintain foam wedge between legs.

A nurse is caring for a client who is in Buck's traction. Which of the following nursing interventions is appropriate? (Select all that apply.) Monitor peripheral pulses in the affected extremity. Position weights against the foot of the bed. Adjust the prescribed weights every shift. Examine the skin under the traction splint. Assess the temperature of the affected extremity.

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

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention? Blood pressure of 94/62 mm Hg Urine output of 60 ml/hr Oxygen saturation of 82% Respiratory rate of 12 breaths per minute

Oxygen saturation of 82%

A client is about to undergo electromyography. The nurse should explain to the client that this diagnostic test involves which of the following? Administration of a radioisotope 2 hr before the procedure Injection of a radiopaque contrast agent or air into a joint cavity Use of x-rays or ultrasound to approximate bone mineral density Placement of thin needles into the muscles with recording of responses to stimuli

Placement of thin needles into the muscles with recording of responses to stimuli

A client comes to the clinic reporting wrist pain. When obtaining the client's history, the nurse suspects carpal tunnel syndrome. When assessing the client, the nurse should expect to find which of the following? Decreased radial pulse Positive Chvostek's sign Cool extremities Positive Phalen's sign

Positive Phalen's sign

A nurse in the outpatient clinic is caring for a client who has psoriasis. Which of the following is an expected finding? Abdominal lesions Serous drainage Intense pain Silvery, white scales

Silvery, white scales

Biopsies are performed on which of the following? Select all that apply. Skin nodules Blisters Plaques Ulcers Keloids

Skin nodules Blisters Plaques Ulcers

The nurse is educating a client scheduled for elective surgery. The client currently takes aspirin daily. What education should the nurse provide with regard to this medication? Aspirin should be increased until 3 days before surgery, then it should be discontinued until 3 days after surgery. Continue to take the aspirin as ordered. Take half doses of the aspirin until 1 week after surgery. Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician.

Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician.

A nurse is caring for a client who balanced skeletal traction with a Thomas splint for the treatment of a fracture of the femur. Which of the following interventions is appropriate to prevent pressure points from occurring around the top of the splint? he nurse should apply lotion to the skin around the edges of the splint. The nurse should frequently reposition the client to keep him pulled up in bed. The nurse should pad the top of the splint with washcloths. The nurse should apply a foot plate to the bed.

The nurse should frequently reposition the client to keep him pulled up in bed.

A nurse at an urgent care center cares for four clients with leg or foot injuries. Which of the following client reports should suggest to the nurse that the client has an ankle sprain? Dropping a 10-lb weight on his lower leg at the health club Having ankle pain after running a 10-mile race Twisting his foot while running bases during a baseball game Getting hit by another soccer player on the field

Twisting his foot while running bases during a baseball game

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities? Dermatitis Ulceration Cellulitis Rubor

Ulceration

A nurse is providing medication teaching for a client who has psoriasis and has a new prescription for a topical corticosteroid cream. Which of the following should the nurse include in the teaching? Creams should be applied in a thick layer to completely cover the lesions. Discontinuing the medication will cause hypopigmentation of the area. Rubbing the medication vigorously into the lesions will increase absorption. Wrapping plastic around the site can increase the medication's effectiveness.

Wrapping plastic around the site can increase the medication's effectiveness.

A nurse is caring for a client who has a fractured right hip and a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the purpose of this device is to prevent fluid from accumulating in the wound. prevent bleeding from the surgical site. prevent the development of a wound infection. eliminate the need for wound irrigations.

prevent fluid from accumulating in the wound.

A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should: turn him frequently. perform passive range-of-motion (ROM) exercises. reduce the client's fluid intake. encourage the client to use a footboard.

turn him frequently.