MS: 25, 50

A client is admitted with a large draining wound on the leg. What action does the nurse take first?

Obtain cultures of the leg wound.

A nurse cares for a client who is prescribed vancomycin (Vancocin) 500 mg IV every 6 hours for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which action should the nurse take?

Assess the IV site at least every 2 hours for thrombophlebitis.

A client is in the internal medicine clinic reporting bone pain. The client's alkaline phosphatase level is 180 units/L. What action by the nurse is most appropriate?

Assess the client for leg bowing.

A client has scoliosis with a 65-degree curve to the spine. What action by the nurse takes priority?

Assess the client's cardiac and respiratory systems.

A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs?

Assess the client's coping skills and support systems.

A nurse is assessing an older client and discovers back pain with tenderness along T2 and T3. What action by the nurse is best?

Consult with the provider about an x-ray.

A nurse who manages client placements prepares to place four clients on a medical-surgical unit. Which client should be placed in isolation awaiting possible diagnosis of infection with methicillin-resistant Staphylococcus aureus(MRSA)?

Client admitted from a nursing home with furuncles and folliculitis

A nurse sees clients in an osteoporosis clinic. Which client should the nurse see first?

Client taking raloxifene (Evista) who reports unilateral calf swelling

A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education?

"After you bathe, put lotion on before your skin is totally dry."

What information does the nurse teach a women's group about osteoporosis?

"For 5 years after menopause you lose 2% of bone mass yearly."

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions should the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.)

"Have you been under a lot of stress lately?" "Have you recently had any other health problems?" "Have you changed any medications recently?"

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?

"How are you coping with providing this care?"

After teaching a client who has psoriasis, a nurse assesses the client's understanding. Which statement indicates the client needs additional teaching?

"I have to make sure I keep my lesions covered, so I do not spread this to others."

After teaching a client how to care for a furuncle in the axilla, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching?

"I'll cleanse the area prior to applying antibiotic cream."

After educating a caregiver of a home care client, a nurse assesses the caregiver's understanding. Which statement indicates that the caregiver needs additional education?

"If his tailbone is red and tender in the morning, I will massage it with baby oil."

A client has been prescribed denosumab (Prolia). What instruction about this drug is most appropriate?

"Make appointments to come get your shot."

A nurse delegates care for a client who has open skin lesions. Which statements should the nurse include when delegating this client's hygiene care to an unlicensed assistive personnel (UAP)? (Select all that apply.)

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

A nurse assesses a young female client who is prescribed isotretinoin (Accutane). Which question should the nurse ask prior to starting this therapy?

"Which method of contraception are you using?"

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?

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

A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best?

"Your feet have less blood flow, so healing is slower."

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.)

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

The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option?

Client with a spinal cord injury who cannot tolerate sitting up

A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection?

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

A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure ulcer development?

A 65-year-old with hemi-paralysis and incontinence

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.)

Adherence to the antibiotic regimen Eating high-protein and high-carbohydrate foods Proper use of the intravenous equipment

A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.)

Alcohol Caffeine Carbonated beverages Vitamin D

A client is admitted with a bone tumor. The nurse finds the client weak and lethargic with decreased deep tendon reflexes. What actions by the nurse are best? (Select all that apply.)

Assess the daily serum calcium level. Consult the provider about a loop diuretic. Instruct the client to call for help out of bed.

A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first?

Assess the right leg for pulses, skin color, and temperature.

When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next?

Apply a different pressure-relieving device.

A client with Paget's disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Applying a heating pad Providing a massage

A client with osteoporosis is going home, where the client lives alone. What action by the nurse is best?

Arrange a home safety evaluation.

A client has been advised to perform weight-bearing exercises to help minimize osteoporosis. The client admits to not doing the prescribed exercises. What action by the nurse is best?

Ask the client about fear of falling.

A nurse prepares to admit a client who has herpes zoster. Which actions should the nurse take? (Select all that apply.)

Assess staff for a history of or vaccination for chickenpox. Check the admission orders for analgesia. Ensure that gloves are available in the room

The nurse studying osteoporosis learns that which drugs can cause this disorder? (Select all that apply.)

Barbiturates Corticosteroids Loop diuretics

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 client's plan of care?

Change the dressing every 6 hours.

A nurse evaluates the following data in a client's chart: Admission Note Prescriptions Wound Care 78-year-old male with a past medical history of atrial fibrillation is admitted with a chronic leg wound Warfarin sodium (Coumadin) Sotalol (Betapace) Vacuum-assisted wound closure (VAC) treatment to leg wound Based on this information, which action should the nurse take first?

Contact the provider and express concerns related to the wound treatment prescribed.

A nurse cares for a client who reports pain related to eczematous dermatitis. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)

Cool, moist compresses Tepid bath with cornstarch

A client in a nursing home refuses to take medications. She is at high risk for osteomalacia. What action by the nurse is best?

Ensure the client gets 15 minutes of sun exposure daily.

A client is scheduled for a bone biopsy. What action by the nurse takes priority?

Ensuring that informed consent is on the chart

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.)

Draining sinus tracts Presence of foot ulcers

A client is suspected to have muscular dystrophy. About what diagnostic testing does the nurse educate the client? (Select all that apply.)

Electromyography Muscle biopsy Serum aldolase Serum creatinine kinase

A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment?

Fungal infection - Ketoconazole (Nizoral)

A client has a metastatic bone tumor. What action by the nurse takes priority?

Handle the affected extremity with caution.

A hospitalized client is being treated for Ewing's sarcoma. What action by the nurse is most important?

Handling and disposing of chemotherapeutic agents per policy

After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching?

High-protein diet with vitamins and mineral supplements

A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first?

Irregular blue mole with white specks on the lower leg

A nurse plans care for a client who is immobile. Which interventions should the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)

Place a small pillow between bony surfaces. Use a lift sheet to assist with re-positioning. Keep the client's heels off the bed surfaces.

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the fingers and on the wrists. Which action should the nurse take?

Place the client in a single room.

An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38,000/mm3 but the client is afebrile. What action does the nurse take first?

Place the client on contact isolation.

A client has a bone density score of -2.8. What action by the nurse is best?

Planning to teach about bisphosphonates

A nurse is caring for four clients. After the hand-off report, which client does the nurse see first?

Post-microvascular bone transfer client whose distal leg is cool and pale

A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below: Which diagnostic test should the nurse anticipate being ordered for this client?

Punch skin biopsy

A nurse prepares to discharge a client who has a wound and is prescribed home health care. Which information should the nurse include in the hand-off report to the home health nurse?

Recent wound assessment, including size and appearance

A nurse evaluates the following data in a client's chart: Admission Note Laboratory Results Wound Care Note 66-year-old male with a health history of a cerebral vascular accident and left-side paralysis White blood cell count: 8000/mm3 Prealbumin: 15.2 mg/dL Albumin: 4.2 mg/dL Lymphocyte count: 2000/mm3 Sacral ulcer - 4 cm ´ 2 cm ´ 1.5 cm Based on this information, which action should the nurse take?

Request a dietary consult.

A nurse assesses a client who has psoriasis. Which action should the nurse take first?

Shake the client's hand and introduce self.

A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.)

Strengthening exercises are important. Take recommended calcium and vitamin D Walk 30 minutes at least 3 times a week.

A nurse cares for older adult clients in a long-term acute care facility. Which interventions should the nurse implement to prevent skin breakdown in these clients? (Select all that apply.)

Use a lift sheet when moving the client in bed. Avoid tape when applying dressings. Implement pressure-relieving devices.

A client has an ingrown toenail. About what self-management measure does the nurse teach the client?

Warm moist soaks