Homework Assignment 8: Module 4 Practice

A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching? -"Eat more yogurt and broccoli." -"This drug will dissolve any clots you may still have." -"If you miss a dose, double the next dose." -"Don't take aspirin while you're taking warfarin."

"Don't take aspirin while you're taking warfarin."

A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response? -"The risk of transmission of HIV is so low, there's no need to worry." -"Blood typing is more important than testing for infection." -"There is no need for testing unless you have a history of a transfusion reaction." -"Every unit of donated blood is typed and tested for antibodies to infections."

"Every unit of donated blood is typed and tested for antibodies to infections."

The nurse is caring for a client who had a surgical amputation of the left leg related to complication from diabetes. The client asks the nurse, "If my leg is really gone, then why am I having such bad pain?" What is the best response by the nurse? -"You are only imagining that you are having pain." -"It is called phantom pain and may come and go." -"You will continue to have this pain, and you will have to learn to ignore it." -"This is called false pain and is a brain dysfunction."

"It is called phantom pain and may come and go."

A client has a plaster cast applied to the left leg. Which comment by the client following the procedure should the nurse address first? -"My toes are stiff." -"My toes are pink." -"My cast is still wet." -"My pain is a 3."

"My toes are stiff."

The nurse is presenting health education to a 48-year-old man who was just diagnosed with type 2 diabetes. The client has a BMI of 35 and leads a sedentary lifestyle. The nurse gives the client information on the risk factors for his diagnosis and begins talking with him about changing behaviors around diet and exercise. The nurse knows that further client teaching is necessary when the client tells you what? -"I need to start slow on an exercise program approved by my doctor." -"I know there's a chance I could have avoided this if I'd always eaten better and exercised more." -"There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented." -"I want to have a plan in place before I start making a lot of changes to my lifestyle."

"There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented."

The nurse is teaching the client to instill eye drops. Which statement is correct? -"Wash your hands before and after instilling eye drops and do not touch the tip of the bottle." -"Eye drops are to be administered after eye ointments." -"Wait 10 minutes between administering different eye ointments; you do not need to wait between administering different eye drops." -"Eye drops may be administered with contact lenses in place."

"Wash your hands before and after instilling eye drops and do not touch the tip of the bottle."

A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed? -2:00 pm -3:00 pm -4:00 pm -6:00 pm

4:00 pm

Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first? -A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter -A 56-year-old male, who had an arthroscopy of his left knee 3 hours ago, who is asking to be discharged -A 60-year-old female, who is in traction to manage chronic muscle spasms, who is requesting assistance to order her evening meal -The order doesn't matter; all clients are of equal priority

A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter

A client has been involved in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. Other than the bone, what physical structures could be affected by this injury? -All options are correct. -muscles -nerves -blood vessels

All options are correct.

The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery? -Antidysrhythmic therapy -Antianginal therapy -Antineoplastic therapy -Anticoagulation therapy

Anticoagulation therapy

The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate? -A burning sensation and the sensation of an object in the eye -Blurred or cloudy vision -Inability to produce sufficient tears -A swollen lacrimal caruncle

Blurred or cloudy vision

The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client's lungs and, when moving the gown, observes petechial hemorrhages on the skin of the chest. What is the first action by the nurse? -Call the physician to inform them of the findings. -Administer pain medication. -Request an antihistamine for the allergic reaction. -Increase the intravenous fluids for hemorrhage.

Call the physician to inform them of the findings.

Which nursing assessment finding would be indicative of compartment syndrome in the client with a cast applied to the left forearm 3 hours earlier? -Fingers pink and warm and move freely -Capillary refill of left fingers greater than 3 seconds -Radial pulses palpable and +2 bilaterally -Absence of numbness and tingling

Capillary refill of left fingers greater than 3 seconds

A client who underwent an anterior colporrhaphy 6 hours ago has not voided. She reports some discomfort in her suprapubic area. Which of the following would the nurse expect to do? -Administer a stool softener. -Catheterize the client. -Obtain an order for an analgesic. -Apply ice to the area.

Catheterize the client.

A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client? -Assisting with range-of-motion and isometric exercises. -Changing the client's position within prescribed limits. -Administering prescribed analgesics. -Applying warm compresses.

Changing the client's position within prescribed limits.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? -Nonproductive cough and abdominal pain -Hypertension and lack of fever -Bradypnea and bradycardia -Chest pain and dyspnea

Chest pain and dyspnea

A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. The nurse should identify the warning signs of what complication? -Subcutaneous emphysema -Skin breakdown -Compartment syndrome -Disuse syndrome

Compartment syndrome

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client? -Disseminated intravascular coagulation -Compartment syndrome -Carpal tunnel syndrome -Fat embolism syndrome

Compartment syndrome

Which condition is a downward displacement of the bladder toward the vaginal orifice? -Rectocele -Cystocele -Vulvodynia -Fistula

Cystocele

After undergoing surgery the previous day for a total knee replacement, a client states, "I am not ready to ambulate yet." What should the nurse do? -Tell the client that this noncompliance will be reported to the health care provider. -Discuss the complications that the client may experience if there is lack of cooperation with the care plan. -Do nothing because the client has the ultimate right to determine the degree of participation. -Document the client's refusal to ambulate.

Discuss the complications that the client may experience if there is lack of cooperation with the care plan.

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? -Irrigate the ostomy to clear a possible obstruction. -Contact the primary care provider to report this finding. -Document that the stoma appears healthy and well perfused. -Document a nursing diagnosis of Impaired Skin Integrity.

Document that the stoma appears healthy and well perfused.

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? -Contact the care provider to have the client's hemoglobin and hematocrit measured. -Document these expected assessment findings. -Apply barrier ointment to the stoma as prescribed. -Cleanse the stoma with alcohol or chlorhexidine.

Document these expected assessment findings.

A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain? -Elevate the affected extremity and use cold applications. -Breathe deeply and cough every 2 hours until ambulation is possible. -Do ROM exercises as indicated. -Apply antiembolism stockings as indicated.

Elevate the affected extremity and use cold applications.

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. -Encouraging a liberal fluid intake -Instructing the client to move the legs in a "pumping" exercise -Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day -Using elastic stockings, especially when decreased mobility would promote venous stasis -Applying a sequential compression device

Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Using elastic stockings, especially when decreased mobility would promote venous stasis Applying a sequential compression device

An older female client who had a total hip replacement is to be discharged because her healing is almost complete. What would be most important for this client? -Advising the client to avoid red meat. -Urging her to keep the affected limb in an elevated position. -Educating the client about the effects of menopause. -Exploring factors related to the client's home environment.

Exploring factors related to the client's home environment.

Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure? -Fasciotomy -Osteotomy -Arthroplasty -Arthrodesis

Fasciotomy

A nurse is caring for a client with a cast on the left arm after sustaining a fracture. Which assessment finding is most significant for this client? -Fingers on the left hand are swollen and cool -Presence of a normal popliteal pulse -Cast edges are rough, with skin irritation present -Minimal pain in the left arm

Fingers on the left hand are swollen and cool

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? -Cutting the faceplate opening no more than 2 inches larger than the stoma -Gently washing the area surrounding the stoma using a facecloth and mild soap -Scrubbing fecal material from the skin surrounding the stoma -Maintaining wrinkles in the faceplate so it doesn't irritate the skin

Gently washing the area surrounding the stoma using a facecloth and mild soap

After withdrawing the needle from blood donor's arm, the site begins to bleed excessively. What is the nurse's first action? -Apply a tourniquet above the antecubital fossa. -Lower the arm below the level of the heart. -Assist the client into an erect position. -Hold firm pressure on the venipuncture site.

Hold firm pressure on the venipuncture site.

The client with a fractured femur is upset and agitated that skeletal traction will be necessary for 6 to 8 weeks. The client states, "How can I stay like this for weeks? I can't even move!" Based on these statements, the nurse would identify which of the following as the most appropriate nursing diagnosis? -Ineffective Coping related to prolonged immobility -Impaired Physical Mobility related to traction -Deficient Diversional Activity related to prolonged hospitalization -Activity Intolerance related to impaired mobility

Ineffective Coping related to prolonged immobility

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? -Excess fluid volume -Acute pain -Ineffective breathing pattern -Activity intolerance

Ineffective breathing pattern

A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? -Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. -Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. -A laparoscopic approach allows for the removal of the entire gallbladder. -A laparoscopic approach can be performed under conscious sedation.

Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.

A nurse is caring for a client who recently underwent a total hip replacement. What is the best action by the nurse for client care? -Ease the client onto a low toilet seat. -Allow the client's legs to be crossed at the knees when out of bed. -Use soft chairs when the client is sitting out of bed. -Limit hip flexion of the client's hip when the client sits up.

Limit hip flexion of the client's hip when the client sits up.

A client has undergone an external fixation. Which actions would be the priority for this client? -Maintaining pin care. -Planning the client's diet. -Monitoring the client's urine output. -Monitoring the client's blood pressure.

Maintaining pin care.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? -Auscultate the abdomen for bowel sounds every 4 hours -Measure abdominal girth every shift -Monitor for reports of nausea and vomiting -Measure blood glucose concentration every 4 to 6 hours

Measure blood glucose concentration every 4 to 6 hours

When caring for a client with a fracture, what assessment would take priority? -Neurovascular compromise -Hormonal imbalances -Cardiac problems -Altered kidney function

Neurovascular compromise

The nurse is caring for a client who has had a fracture reduction using a cast. What is most important for the nurse to assess? -Cardiac status -Renal function -Sleep status -Neurovascular status

Neurovascular status

The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery? -Keep the knees together at all times -Never cross the affected leg when seated -Avoid placing a pillow between the legs when sleeping -Bend forward only when seated in a chair

Never cross the affected leg when seated

To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treating inflammatory conditions of the eyes? -Nonsteroidal anti-inflammatory drugs (NSAIDs) -Miotics -Mydriatics -Cycloplegics

Nonsteroidal anti-inflammatory drugs (NSAIDs)

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing? -Scrubbing the drainage from around the pin site -Obtaining a culture -Applying iodine-based solution -Apply ointment to the pin site.

Obtaining a culture

When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis? -Pain in the feet -Inability to dorsiflex -Negative Homan's sign -Pain in the calf

Pain in the calf

A client who is post op bariatric surgery reports diarrhea. What is the most likely cause of the client's symptoms? -Poor dietary choices -Medication side effects -Immobility -Decreased intrinsic factor

Poor dietary choices

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? -Allow the client to gently scratch inside the cast with a pencil. -Give the client a sterile tongue depressor to use for scratching instead of the pencil. -Provide a fan to blow cool air into the cast to relieve itching. -Obtain a prescription for a sedative, such as lorazepam, to prevent the client from scratching.

Provide a fan to blow cool air into the cast to relieve itching.

A nurse is giving instructions to a client who's going home with a leg cast. Which teaching point is most critical? -Using crutches properly -Exercising joints above and below the cast, as ordered -Avoiding walking on a leg cast without the health care provider's permission -Reporting signs of impaired circulation

Reporting signs of impaired circulation

A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session? -Using crutches efficiently -Exercising joints above and below the cast, as prescribed -Removing the cast correctly at the end of the treatment period -Reporting signs of impaired circulation

Reporting signs of impaired circulation

A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following? -Hemorrhage -Bowel incontinence -Respiratory dysfunction -Skin breakdown

Respiratory dysfunction

A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care? -Antioxidant supplements, vitamin C and E, beta-carotene, and selenium -Eyeglasses or magnifying lenses -Corticosteroid eye drops -Surgical intervention

Surgical intervention

A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? -Perform chest physiotherapy once per shift and as needed. -Teach the client to perform deep breathing and coughing exercises. -Administer prophylactic antibiotics as prescribed. -Administer nebulized bronchodilators and corticosteroids as prescribed.

Teach the client to perform deep breathing and coughing exercises.

A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario? -The client has a right to refuse the transfusion. -The health care provider may first call the client's parents if the client refuses. -The client can only refuse the transfusion if the consent form has not been signed. -The health care provider may ask for a court order if the client refuses.

The client has a right to refuse the transfusion.

The nurse is assessing a client who has a chronic pain disorder and who also has class II obesity. What principle should guide the care team's choice of pain treatments for this client? -The client may require higher doses of opioids than clients without obesity. -The client is more likely to experience relief with NSAIDs than with opioids. -The client's renal function must be monitored more closely during pain treatment than in clients without obesity. -Adverse effects of opioids may be more difficult to assess than in clients without obesity.

The client may require higher doses of opioids than clients without obesity.

A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image? -The client closes his or her eyes when the abdomen is exposed. -The client avoids talking about the recent surgery. -The client asks the spouse to leave the room. -The client touches the altered body part.

The client touches the altered body part.

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? -The client is 5' 9" tall and weighs 128 lb (58 kg). -The client has been pregnant four times. -The client usually walks 3 miles a day. -The client will be immobile during and shortly after surgery.

The client will be immobile during and shortly after surgery.

The nurse is caring for a hospitalized client who has class II obesity and who has limited mobility. The nurse should address the client's risk for skin breakdown by: -cleaning and drying regularly within the client's skin folds. -avoiding the use of pillows to position the client. -making a referral to physical therapy. -ensuring the client receives a high-calorie, high-protein diet.

cleaning and drying regularly within the client's skin folds.

A client undergoes an open reduction of a femur fracture, and returns to the orthopedic unit with a cast in place. What is the rationale for frequently assessing the client's pedal pulses? -ensuring adequate circulation to the casted limb -providing typical postoperative nursing management -ensuring surgery was successful -ensuring there wasn't nerve damage during surgery

ensuring adequate circulation to the casted limb

A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma? -immobilization -surgical repair -external rotation -enhancing complications

immobilization

A nurse is working on a surgical floor. The nurse must logroll a client following a: -laminectomy. -thoracotomy. -hemorrhoidectomy. -cystectomy.

laminectomy