Prep U #2

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 at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? "Getting the flu can complicate pneumonia." "Influenza vaccine will prevent typical pneumonias." "Influenza is the major cause of death in the United States." "Viruses like influenza are the most common cause of pneumonia."

"Viruses like influenza are the most common cause of pneumonia."

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia? A client with a history of smoking two packs of cigarettes per day until quitting 2 years ago A client who ambulates in the hallway every 4 hours A client with a nasogastric tube A client who is receiving acetaminophen (Tylenol) for pain

A client with a nasogastric tube

Which is one of the most common causes of death in clients diagnosed with fat emboli syndrome? Myocardial infarction Stroke Acute respiratory distress syndrome Pulmonary embolism

Acute respiratory distress syndrome

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP? Administration of prophylactic antibiotics Administration of pneumococcal vaccine to vulnerable individuals Obtaining culture and sensitivity swabs from all newly admitted clients Administration of antiretroviral medications to clients over age 65

Administration of pneumococcal vaccine to vulnerable individuals

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer? An inhaled beta2-adrenergic agonist An inhaled corticosteroid An I.V. beta2-adrenergic agonist An oral corticosteroid

An inhaled beta2-adrenergic agonist

Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery? Instruct about using client-controlled analgesia, if prescribed Instruct about exercise, as prescribed Apply antiembolism stockings Apply cold packs

Apply antiembolism stockings

Which is a potential complication of a low pressure in the endotracheal tube cuff? Tracheal bleeding Aspiration pneumonia Tracheal ischemia Pressure necrosis

Aspiration pneumonia

A client has a Fiberglass cast on the right arm. Which action should the nurse include in the care plan? Keeping the casted arm warm by covering it with a light blanket Avoiding handling the cast for 24 hours or until it is dry Evaluating pedal and posterior tibial pulses every 2 hours Assessing movement and sensation in the fingers of the right hand

Assessing movement and sensation in the fingers of the right hand

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 nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize? Smoking up to three cigarettes weekly is generally allowable. Chronic inhalation of indoor toxins can cause lung damage. Minor respiratory infections are considered to be self-limited and are not treated with medication. Activities of daily living (ADLs) should be clustered in the early morning hours.

Chronic inhalation of indoor toxins can cause lung damage.

What is the best action by the nurse to achieve optimal outcomes when caring for a client with a musculoskeletal disorder who is using a cast? Educate the client on cast care and complications Prepare the client for cast application Assess for neurovascular compromise Provide effective pain control

Educate the client on cast care and complications

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 patient sustained an open fracture of the femur 24 hours ago. While assessing the patient, the nurse observes the patient is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand is likely occurring with this patient? Spontaneous pneumothorax Cardiac tamponade Pneumonia Fat emboli

Fat emboli

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 has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client Has wheezes in the right lung lobes Has a respiratory rate of 28 breaths/minute Reports shortness of breath Cannot perform activities of daily living

Has wheezes in the right lung lobes

A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan? Removing the weights once every shift Maintaining the bed in the knee gatch position Keeping the client in semi-Fowler's position Maintaining correct body alignment

Maintaining correct body alignment

An unresponsive client had a plaster cast applied to the right lower leg 8 hours ago. When moving the client, the nurse notices an indentation on the posterior lower portion of the cast. What is the best action by the nurse? Document the findings. Notify the physician. Remove the cast immediately. Assess for pedal pulse and mobility of toes.

Notify the physician.

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.

The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment? Providing sufficient oxygen to improve oxygenation Avoiding the use of oxygen to decrease the hypoxic drive Monitoring the pulse oximetry to assess need for early intervention when PCO2 levels rise Increasing pH

Providing sufficient oxygen to improve oxygenation

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 caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? Keeping the head of the bed at 15 degrees or less Turning the client every 4 hours to prevent fatigue Using strict hand hygiene Providing oral hygiene daily

Using strict hand hygiene

The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene? Body aligned opposite to line of traction pull Weights hanging and touching the floor Pulleys without evidence of the obstruction Ropes freely moving over pulleys

Weights hanging and touching the floor

Which type of fracture produces several bone fragments? Comminuted Open Oblique Incomplete

comminuted

A client has a fractured femur and is being seen in the emergency department. The nurse assessing the area notices there is a grating sound that is suspected to be bone ends moving over one another. This sound is called: crepitus. false motion. spasm. deformity.

crepitus

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

The client has suffered a comminuted fracture. Which image best depicts this type of fracture?

first pic--> cracked with fragments

Which term refers to a fracture in which one side of a bone is broken and the other side is bent? Spiral Greenstick Avulsion Oblique

greenstick

Which factor may contribute to compartment syndrome? Hemorrhage Macular lesion Venous thromboembolus Disuse syndrome

hemorrhage

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

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 is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: level of consciousness (LOC). extremities for signs of cyanosis. oxygen saturation level. hemoglobin, hematocrit, and red blood cell levels.

oxygen saturation level.

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Oxygen-induced hypoventilation Oxygen toxicity Oxygen-induced atelectasis Hypoxia

oxygen toxicity

A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? Risk for infection Risk for ineffective role performance Risk for perioperative positioning injury Risk for powerlessness

risk for infection

A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate? "Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury." "You may discuss your prescriptions with your physician at your follow-up appointment." "If your temperature is normal for 48 hours, you may discontinue the medication." "The antibiotics will help the bone to heal."

"Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury."

Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse? "CPM increases range of motion of the joint." "CPM strengthens the muscles of the leg." "CPM delivers analgesic agents directly into the joint." "CPM prevents injury by limiting flexion of the knee."

"CPM increases range of motion of the joint."

A nurse has just completed teaching with a client who has been prescribed a meter-dosed inhaler for the first time. Which statement if made by the client would indicate to the nurse that further teaching and follow-up care is necessary? "I will make sure to take a slow, deep breath as I push on my inhaler." "After I breathe in, I will hold my breath for 10 seconds." "I do not need to rinse my mouth with this type of inhaler." "If I use the spacer, I know I am only supposed to push on the inhaler once."

"I do not need to rinse my mouth with this type of inhaler."

A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide in client cast care? "Cover the cast with a blanket until the cast dries." "Keep your right leg elevated above heart level." "Use a knitting needle to scratch itches inside the cast." "A foul smell from the cast is normal."

"Keep your right leg elevated above heart level."

A client diagnosed with a right ulnar fracture asks why the cast needs to go all the way up the arm. What is the best response by the nurse? "This allows for the strength in the arm to remain consistent." "The joint above the fracture and below the fracture must be immobilized." "When a spica cast is ordered, the arm must be immobilized." "The method allows for the fastest healing time and the greatest mobility."

"The joint above the fracture and below the fracture must be immobilized."

The nurse is providing instructions to the client following application of a fiberglass cast. Which statement by the client indicates further education is needed? "Under no circumstances should I get my cast wet." "The cast should not come in contact with other plastics." "I should avoid touching the cast while it is wet." "The cast will be hot while it is drying."

"Under no circumstances should I get my cast wet."

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

A client returns to the nursing unit following an open reduction with internal fixation of the right hip. Which nursing interventions would be appropriate for the prophylactic treatment of deep vein thrombosis? Select all that apply. Increasing fluid intake Maintaining antiembolic stockings Administering enoxaparin Encouraging coughing exercises Increasing fiber intake

Increasing fluid intake Maintaining antiembolic stockings Administering enoxaparin

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 nursing student is taking a pathophysiology examination. Which of the following factors would the student correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease (COPD)? Choose all that apply. Inflamed airways that obstruct airflow Mucus secretions that block airways Overinflated alveoli that impair gas exchange Dry airways that obstruct airflow Decreased numbers of goblet cells

Inflamed airways that obstruct airflow Mucus secretions that block airways Overinflated alveoli that impair gas exchange

The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for? Atelectasis Hypovolemia Pulmonary embolism Urinary tract infection

Pulmonary embolism

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? Cough Hemoptysis Syncope Tachypnea

Tachypnea

A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing? Gradually increase levels of physical exertion. Change filters on heaters and air conditioners frequently. Take prescribed medications as scheduled. Avoid goose-down pillows.

Take prescribed medications as scheduled.

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.