unit 3 questions

Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? a. An 80-year-old man who has benign prostatic hyperplasia b. A 62-year-old woman with a known allergy to contrast media c. A 48-year-old woman with established urinary incontinence d. A 45-year-old man receiving oral and intravenous fluid therapy

A

a client with diabetes has the following assessment changes after a percutaneous nephrolithotomy procedure. Which changes requires immediate nursing interventions? A. difficulty breathing and an O2 sat of 88% on 2 L NC B. a point of care BG of 150 and client report of thirst C. a deceased hematocrit by 1% (compared with pre-op values and hematuria) D. an oral temp of 101 and cloudiness of urine draining from the nephrostomy tube after IV administration of a broad-spectrum antibiotic

A

which client will the nurse assess most frequently for indications of venous thromboembolism? (VTE) A. 25 year old weightlifter with a fracture of the right femur B. 45 year old with metastatic cancer and a spinal compression fracture C. 55 year old car crash victim with multiple facial fractures D. 65 year old with a broken elbow and HTN

A VTE is the most common complication of lower extremity fracture resulting from trauma. Immobilization of the limb also contributes to the risk

what is the most common symptom that prompts clients to seek medical attention for problems with the kidneys or urinary tract? A. pain in flank or abdomen, or pain when urinating B. change in the frequency or amount of urination C. exposure to one or more nephrotoxic substances D. change in color, clarity, or odor of the urine

A the onset of pain in the flank, int eh lower abdomen or pelvic region, or in the perineal region causes concern and usually prompts the client tot seek medical care. the nurse asks about the onset, intensity, and duration of the pain ; its location, precipitating and relieving factors, and its association with any activity or event. Painful urination also leads clients to seek medical care

a client experiences a seizure that is observed by the nurse. what will the nurse document in the clients medical record? SATA A. time that seizure began and ended B. whether the seizure was preceded by an aura C. what the client does after the seizure D. how long it takes for the client to return to preseizure status E. the drugs that are administered during the seizure

A, B, C, D

a client has a new synthetic leg cast for a right fractured tibia. What health teaching will the nurse include before discharge to home? SATA A. "elevate your right leg as often as possible to reduce swelling" B. "report increased pain or burning sensation under your cast" C. "use ice on the affected leg for the first 24-36 hours" D. "do not bear weight on the affected leg until instructed to do so" E. "do not cover the cast when you are in bed; keep it open to air dry"

A, B, C, D

which does the nurse recognize as cardinal symptoms for a client with Parkinsons disease? SATA A. tremors B. muscle rigidity C. postural instability D. bradykinesia or akinesia E. choreiform movements D. seizure activity

A, B, C, D parkinsons is a progressive neuro-degenerative disease. It is a debilitating disease affecting mobility and is characterized by four cardinal symptoms: tremor muscle rigidity postural instability bradykinesia or akinesia (slow movement/no movement) postural instability

which important points does the nurse teach a client after an anterior cervical discectomy with suction (ACDF) and prior to discharge? SATA A. information about all prescribed medications B. how long to care for the surgical incision C. a care provider must be with the client for a few days after surgery D. home restriction for lifting and activity E. wear brace or collar as prescribed F. deriving is permitted after 3 days

A, B, C, D, E important points the nurse will include with discharge teaching include: be sure that someone stays with the client for the first few days after surgery; review drug therapy; teach care of the incision; review activity restrictions including no heavy lifting; no driving until surgeon gives permission; no strenuous activities; walk every day; call PCP if symptoms of pain, numbness, and tingling worsen or if swallowing becomes difficult; and wear a brace or collar per PCP prescription

which actions will the nurse include in post procedural care for a client who had a cystoscopy with general anesthesia? SATA A. monitor for airway latency and breathing B. provide frequent VS checks including temperature C. record and monitor for any changes in urine output D. report pink-tinged urine to the urology care provider immediately E. irrigate the urinary catheter with sterile saline if prescribed F. encourage the client to take oral fluids to increase urine output

A, B, C, E, F pink tinged urine is expected after this procedure. However, gross bleeding is not and should be reported. Also notify HCP for obvious blood clots and a decrease or absence of urine output. Irrigate the Foley catheter with sterile saline, if prescribed by the urologist.

which actions are appropriate for the nurse to perform when caring for a client who is placed in Bucks traction after a hip fracture? SATA A. ensuring that the weights never rest on the floor B. removing the boot or belt every 8 hours to assess skin integrity C. comparing the amount of weight applied with the amount prescribed D. removing the weights every 8 hours for 30 minutes to prevent muscle spasms E. assessing the circulation distal to the traction device every hour for the first 24 hours F. instructing all personnel and visitors to not touch or change the position of the weights

A, B, C, E, F traction weights are prescribed at a specific weight and are not removed without an order. They are not to be lifted manually, allowed to rest on the floor, and must hang freely at all times. The belt or boot used for skin traction is removed every 8 hours to inspect skin under. The clients circulation is monitored every hour for the first 24 hours after traction's applied and at least every 4 hours thereafter.

clients with which problems or factors will the nurse assess most frequently for development of acute compartment syndrome? SATA A. lower legs caught between the bumpers of two cars B. massive infiltration of IV fluid into the FA C. bivalve cast on the lower leg D. multiple insect bites to the lower legs E. daily use of oral corticosteroids F. severe burns to the upper extremities

A, B, D, F acute compartment syndrome is a serious limb-threatening condition in which increased pressure within one or more compartments (that contain muscle, blood vessels, and nerves) REDUCES circulation to a lower leg or forearm. Common health problems leading to this condition include: crush injuries to extremities, extravasations and infiltration of IV fluids, and severe inflammatory responses with excessive swelling in an extremity; such as burn injuries or release of toxins from multiple insect stings or bites

which tasks will the nurse delegate to the assistive personal when caring for a client with stage 3 moderate Parkinsons disease? SATA A. assist client to the bathroom B. record accurate intake and output C. teach the client about safety precautions D. assist client with activities of daily living as needed E. assess clients gait and posture F. check and record clients VS every 4 hours

A, B, D, F to correctly respond to this question, the nurse must be familiar with the AP scope of practice which includes assisting clients with ambulation, activities of daily living, recording I&O, and checking as well as recording VS. Assessment and teaching for clients require the additional training and skills of a professional RN

A client is on a 24-hour urine collection. At midpoint during the collection, the client tells the nurse that some of the urine was discarded. What action will the nurse take? SATA A. No action is required. B. Reinforce client education. C. Notify the laboratory staff. D. Restart the urine collection. E. Document the discarded urine. F. Notify the health care provider.

A, C, D

what equipment will the nurse ensure is in the room of a client being admitted on seizure precautions to prevent harm? SATA A. oxygen equipment B. padding for side rails C. suctioning equipment D. saline lock insertion equipment E. padded tongue blade F. neurological assessment flow sheet

A, C, D seizure precautions include ensuring that O2 and suctioning equipment with an airway are readily available. If the client does not have IV access, a saline lock should be inserted, especially if the client is at a significant risk for generalized tonic clonic seizures. the saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded side rails may be embarrassing to the client and family. padded tongue blades do NOT belong at the bedside and should NEVER be inserted into the clients mouth because the jaw may clench down as soon as the seizure begins. Forcing a tongue blade or airway into the mouth is more likely to chip the teeth and increase the risk for aspirating tooth fragments than prevent the client from biting the tongue. improper placement of a padded tongue blade can also obstruct the airway. The seizure must be documented but a neurological assessment flow sheet is not necessary.

the nurse is preparing to teach a client who has been prescribed a levodopa-carbidopa preparation for Parkinsons disease. What health teaching will the nurse include for the client and family? SATA A. "move slowly when changing position from sitting to standing" B. "take tour medication after meals to prevent nausea" C. "report any hallucinations that the client may have" D. "note any changes in mental or emotional status" E. "pay attention to whether your tremors improve or worsen"

A, C, D, E

which lab values will the nurse monitor as specific indicators of a clients kidney functions? SATA A. Creatinine B. BUN C. Cystatin-C D. blood osmolarity E. BUN/Creatinine ratio F. WBC

A, C, D, E

which information will the nurse include when teaching a client self-care measures after shock wave lithotripsy for kidney stones? SATA A. finish the entire prescription of antibiotics to prevent infections B. pain in the region the kidneys or bladder is to be expected C. balance regular exercise with adequate sleep and rest D. drink at the very least 3 liters of fluids every day E. your urine may appear bloody for a few days after the procedure F. watch for and immediately report any bruising to the urologist

A, C, D, E A, C, D, and E include important content for the nurse to teach a client self management after lithotripsy.

which priority teaching points will the nurse include when teaching a client how to prevent low back pain and injury? SATA A. use good posture when sitting, standing, and walking B. participate in a regular exercise program that includes daily aerobic workouts C. do not wear high-heeled shoes D. avoid prolonged sitting or standing E. ensure adequate calcium and vitamin D intake F. keep weight within 30% of ideal body weight

A, C, D, E important teaching points by the nurse for a client to prevent low back pain and injury include; use safe manual handling practices, with specific attention to bending, lifting, and sitting; assess the need for assistance with household chores and other activities; participate in a regular exercise program that promotes back strengthening, such as swimming and walking; do NOT wear high heeled shoes; use good posture when sitting, standing, and walking; avoid prolonged sitting or standing; use a footstool and ergonimic chairs and tables to lessen back strain; be sure that equipment in the workplace is ergonomically designed to prevent injury ; keep weight within 10% of ideal body weight; ensure adequate calcium intake and consider vitamin D supplementation if serum level are low; and stop smoking (if not able to stop, cut down on the number of cigarettes or decrease the use of other forms of tobacco) aerobic exercise is NOT a recommendation for prevention of LBP

which actions will the nurse expect when a client with Parkinsons disease develops drug toxicity or tolerance? SATA A. a reduction in drug dosage B. complete cessation of all drugs used to treat PD symptoms C. a change of drug or in the frequency of admin D. a drug holiday (particularly levodopa therapy) E. prescription of additional drugs to help relieve symptoms associated with the disease F. implementation of exercise therapy to maintain functional abilties

A, C, D, E when drug tolerance is reached, the drugs effects do not last as long. The tx of PD drug toxicity or tolerance includes; a reduction in drug dosage; a change of drug or in the frequency of admin; and a drug holiday during a drug holiday, which can last up to 10 days, the client receives NO drug therapy for PD and the nurse would carefully monitor the client for symptoms of PD and document assessment findings. many clients are on additional drugs to help relieve symptoms associated with the disease (muscle spasms may be relived by baclofen, drooling can be minimized by sublingual atropine sulfate, and insomnia may require a sleeping aid such as zolpidem tartrate)

which aspect will the nurse include when assessing the neuromuscular status of a clients right limb after diagnosis arthroscopy 1 hour ago? SATA A. presence of pain B. gait and balance C. distal pulses D. cap refill E. sensation F. skin temperature

A, C, D, E, F after arthroscopy for either diagnosis or surgical interventions purposes, the nurse assesses the neurovascular status on a regular basis to prevent harm from poor circulation in the extremity or any possibly nerve damage assessment includes monitoring distal pulses, warm, color, cap refill, pain, movement, and sensation of the affected extremity. Neurovascular assessment does not include gait and balance

which assessments are a priority for the nurse to perform to prevent harm on a client who was hit by a motorcycle and has a suspected pelvic fracture? SATA A. checking VS B. asking about opioid use C. examining urine for presence of blood D. asking the client to rate his/her pain E. determining the LOC F. performing neurovascular checks of the lower limbs

A, C, E injuries that cause pelvic fractures often also cause significant damage to the ABDOMEN and can cause INTERNAL HEMORRHAGE as well as damage to the BLADDER. assessing VS and LOC have the highest priority to rule out whether hemorrhage and shock are present. Assessing for bladder injury is also a priority. although the other assessments are important, they are not the immediate priority.

which nursing actions will the nurse take to provide care and prevent harm for an older client experiencing increased nocturia? SATA A. ensure adequate lighting and a hazard free environment B. use caution administering nephrotoxic drugs C. ensure the availability of a bedside toilet, bedpan, or urinal if needed D. encourage the client to sue the toilet, bedpan, or urinal at least every 2 hours E. discourage excessive fluid intake for 2-4 hours before client goes to bed F. respond as soon as possible the clients indication of the need to void

A, C, E, F A, C, E, and F are all appropriate for preventing harm associated with falls related to frequent nocturia. Option B is an appropriate action for client with decreased GFR. Option D is an appropriate action for client with decreased bladder capacity. Option F is appropriate for a decreased bladder capacity, but also appropriate for a client with nocturia to prevent falls

which assessment findings on a client being prepared for a vertebroplasty for a compression fracture of the lumbar vertebrae will the nurse report immediately to the orthopedic surgeon? SATA A. platelet count is 40,000 B. WBC is 9000 C. client reports taking the prescribed dose of an antihypertensive this morning D. client reports taking the prescribed dose of rivaroxaban this morning E. pain rating is an 8 on a 0 - 10 scale F. sensation to pinprick stimulation is reduced on the right leg

A, D although a vertebroplasty is considered a type of minimally invasive surgery, there is a danger of bleeding into the spinal area. Contraindications of the procedure are a platelet count lower than 100,000 and/or having taken an anticoagulant drug, such as rivaroxaban within 48 hrs. the other assessment findings are either normal or expected as a response to spinal compression fractures

a nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report the PCP? A. purulent drainage from the pine sites on the clients forehead B. painful pressure injury under the collar C. inability to move legs or feet D. oxygen sat of 95% on RA

A.

what is the nurses best response when client who had a long leg plaster cast applied an hour ago reports that the cast feels "hot"? A. "plaster gives off heat as it dries, and the heat does not mean anything is wrong" B. "it is likely that you have an infection and will need to be started on antibiotics immediately." C. "this means you are having an allergic reaction and this cast will have to be removed immediately" D. "don't worry. this heat is normal and I will apply a cooling blanket over it for your comfort."

A. Plaster is applied as a wet and easily deformed substance. as plaster dries, it gives off heart as part of this normal chemical reaction. the clients reassured that the HEAT IS NORMAL. Because plaster is easily deformed, it cannot be covered with a cooling blanket

which essential nursing intervention will the nurse implement when a client returns from having shock wave lithotripsy? A. strain the urine to monitor for the passage of stone fragments B. report bruising on the affected side immediately to the urologist C. apply a local anesthetic cream to the clients skin on the affected side D. continuously monitor the clients heart pattern for dysrhythmias

A. after lithotripsy the nurse implements straining the urine to monitor the passage of stone fragments. Bruising on the affected side is expected after this procedure. Anesthetic cream is not needed after the procedure, not is cardiac monitoring

which is the nurses best response when a client who is scheduled for an ultrasound to identify whether osteomyelitis is present states that she is afraid of the pain the procedure will cause? A. "this procedure does not involve needles or incisions and is usually painless" B. "there would only be pain with this procedure if you don't remain perfectly still" C. "a small amount of numbing medicine will be applied to the skin before the procedure" D. "the same medication your dentist uses will be injected 10 minutes before the needle is inserted"

A. ultrasonography is noninvasive and involves rolling a probe on the skin over the area to be imaged. Ultrasound jelly is applied to the skin over the site to be examined to reduce the friction of the probe and make movement smoother. Although clients report a cold sensation, pain is not expected, and no special preparation necessary.

which issue does the nurse consider a priority when caring for a client dx with atonic (akinetic) seizures? A. possibility of injury related to falls B. limited mobility related to lack of tonicity of muscles C. confusion related to postictal period D. organ ischemia related to decreased perfusion

A. with an atonic (akinetic) seizure, the client has a sudden loss of muscle tone, lasting for seconds, following by postictal (after the seizure) confusion. In most cases, these seizures cause the client to fall, which may result in injury.

which priority teaching will the nurse provide to prevent harm for a client after a renal biopsy? A. avoid lifting heavy objects for 1-2 weeks after the procedure B. do not go up or down stairs for at least 10 days C. avoid light house work including cooking and washing dishes D. stay out of the sun until after your f/u appt

A. If no bleeding occurs, the nurse teaches the client that he or she can resume general activities after 24 hours (light housework, such as cooking or washing dishes) The client is instructed to avoid lifting heavy objects, exercising, or performing other strenuous activities for 1-2 weeks after biopsy procedure. Driving may also be restricted

when the nurse is taking a history of an adult client who reports acute low back pain (LBP), which question is most likely to identify a causative factor? A. "have you recently fallen or been lifting heavy objects?" B. "are you having pain that radiates down your arm?" C. "do you have a family history of neurologic disorders?" D. "are you having trouble with waling or maintaining your balance?"

A. LBP is most prevalent during the third to sixth decades of life but can occur at any time. Acute and subacute back pain usually result form an injury or trauma such as during a fall, vehicular crash, or lifting a heavy object. Options B, C, and D are important questions but do not provide information that helps to identify the cause of the LBP

a client who had a plaster splint applied to the ankle at 7 a.m. and received pain medication at 9 a.m. now at 11 a.m. reports that the pain is getting worse, not better. What is the nurses best first action to prevent harm? A. assessing the pulses and skin temp distal to the splint B. loosening the splint and reassessing the clients pain in 15 mins C. requesting a prescription to administer the pain medication IV D. repositioning the extremity on a pillow and placing an ice pack

A. the ankle could be swelling under the cast and impinging on circulation, leading to increased pain from tissue hypoxia or anoxia. The nurse best first action is performing neurovascular assessment to determine if a circulatory problem is present. If circulation is compromised, the nurse would then loosen the splint and notify the HCP

a nurse is performing a musculoskeletal assessment on an older adult. What normal physiologic changes of aging does the nurse expect? SATA A. muscle atrophy B. slowed movement C. kyphosis D. arthritis E. widened gait F. decreased joint range of motion

ALL

the nurse is preparing to teach a client about how to promote musculoskeletal health. Which statements will the nurse include in the teaching plan? SATA A. "if you smoke, you need a smoking cessation plan" B. "avoid drinking excessive alcohol" C. "avoid high risk activities that could cause an accident" D. "include weight bearing exercise like walking on a regular basis" E. "be sure to take in enough calcium and vitamin D"

ALL

which actions will the nurse take to ensure that a clients 24 hour urine collection is completed appropriately? SATA A. teach the client that a 24 hour collection of urine is necessary to quantify or calculate the rate of clearance of a particular substance B. check with the lab or procedure manual for proper technique to manta the 24 hour collection C. do not remove urine from the collection container for other specimens during the 24 hour period D. on initiation of the collection, asks the client to void, discard the urine, and note the time, then begin collection E. twenty four hours after initiation, ask the client to empty the bladder 24 hours after initiation and add that urine to the container. F. place signs appropriately, then inform all personnel or family caregivers that the test is in progress

ALL

which points and actions will the nurse include when teaching a client and family after a BKA about care of the residual limb? SATA A. demonstrating how to apply a figure 8 elastic wrap B. reviewing the signs and symptoms of wound infection C. reminding the client and family to rewrap the limb several times each day D. obtaining a return demonstration of the elastic wrap application E. reviewing positioning and exercises for prevention of flexion contractures F. informing the client that after the incision is healed, it can be cleaned during bathing or showering with soap and water

ALL all of the listed points and actions are appropriate for the nurse to include when teaching a client and family about care of the residual limb

which priority teaching points will the nurse provide for a client with a spinal cord injury who is treated with a halo fixation with vest? SATA A. be careful when leaning forward or backward because the weight of the halo device alters balance B. wear loose clothing, preferably with large openings for head and arms C. wash under the liner of the vest to prevent rashes or sores D. support your head with a small pillow when sleeping to prevent unnecessary pressure and discomfort E. do not drive because you can't turn your head from side to side so peripheral vision is impaired. F. increase fluids and fiber in the diet to prevent constipation

ALL of them. all of these are important teaching points for a client with a spinal cord injury who is being treated with a halo fixation with vest. the client cannot turn his/her head to check for blind spots, to peripheral vision is limited and it is not safe to drive.

the nurse is assigned to care for a post op client who had an open reduction, internal fixation of the right tibia yesterday. The client reports increased right leg pain, numbness, and tingling. What would be the nurses first action at this time? A. elevate the surgical leg on a pillow B. perform a neurovascular check C. administer pain medications D. call the HCP

B

which client assessment data is essential for the nurse to report to the health care provider before a renal scan is performed? A. pink tinged urine B. reports pregnancy C. reports claustrophobia D. history of an aneurism clip

B

which assessment finding on a client who has a closed fracture of the lower femur with extensive swelling and bruising best indicates to the nurse that perfusion in the affected limb is adequate? A. pulse ox on the R forefinger is 98% B. pedal pulse of the affected limb is easily palpated and strong C. femoral pulse of the affected limb is easily palpated and strong D. cap refill on great toe of the affected limb is about 4 seconds

B measures of the perfusion adequacy in the affected limb must be made on the affected limb, distal to the injury. Although cap refill can provide an indication of perfusion adequacy, it is not as reliable as a pedal pulse

the nurse is admitting a client undergoing a CT scan with contrast. Which finding does the nurse report as a possibly immediate hypersensitivity reaction? SATA A. Nausea B. pruritus C. urticaria D. laryngeal stridor E. flushing of the skin

B, C, D, E

the nurse is caring for a client who was admitted to the ED with a report of left knee pain and swelling after playing baseball with friends. which nursing actions are appropriate when caring for the client? SATA A. apply heat to the affected area B. assess the severity and quality of pain C. perform a neurovascular check D. elevate the affected extremity E. immobilize the injured knee joint

B, C, D, E

which priority preoperative teaching about post op concerns does the nurse provide for a client scheduled for lumbar surgery? SATA A. bedrest restriction for at leat 48 hours B. techniques for getting into and out of bed C. limitations and restrictions for home activities D. expectations for turning and moving in bed E. immediate reporting of any numbness or tingling F. dietary restrictions for sodium and fats

B, C, D, E nurse teaches client preoperatively about post op expectations because many clients are discharged to home within 23-48 hours after surgery. priority teaching includes: techniques to get into and out of bed; expectations for turning and moving in bed; reporting immediately any new sensory perceptions, such as numbness and tingling; or now motor impairment that may occur in the affected leg or in both legs; home care activities or restrictions because of the short hospital stay, the nurse teaches family members and other caregivers how to assist the client and what restrictions the client must follow at home because the surgery occurs

a client had an open reduction internal fixation (ORIF) of the right wrist. What health teaching is appropriate for the nurse to provide for the client before returning home? SATA A. "keep your arm below the level of your heart as often as possible" B. "use an ice pack for the first 24 hours to decrease tissue swelling" C. "report coolness or discoloration of your right hand to your doctor" D. "don't place any device under the cat to scratch the skin if it itches" E. "move the fingers of the right hand frequently to promote blood flow"

B, C, E

which assessment findings in a client with a complete and displaced fracture of the femur indicates tot he nurse possible fat embolism syndrome? SATA A. increased swelling over the fracture site B. petechiae on the neck and chest C. decreased platelet count D. dry mucous membranes E. sudden onset confusion F. PaO2=72

B, C, E , F decreased arterioal oxygen level, acute confusion, and a. decreased platelet count are common indicators of FES. although the presence of a petechial rash is a late manifestation, it s a classic finding of FES. swelling over the fracture site and dry mucous membranes are NOT symptoms of FES

which clients with fractions will the nurse recognize as being at increased risk for delayed or slow bone healing? SATA A. 28 year old male with multiple long bone fractures B. 35 year old female with diet induced osteopenia C. 45 year old female semiprofessional tennis player D. 58 year old female taking corticosteroids daily for an autoimmune disorder E. 65 year old male with arteriosclerosis F. 75 year old male COPD

B, D, E, F risk factors for delayed or slow bone healing after a fracture include; age older than 70; presence of bone density loss, such as osteopenia or chronic use of corticosteroids, and poor circulation such as arteriosclerosis unless there are complications, multiple fracture do not increased delayed healing risk

what instructions would the nurse give an AP about the proper handling of a clients routine urinalysis specimen? SATA A. leave the specimen in the bathroom B. ensure the container is tightly covered C. place the sample in a sterile container D. take the sample to the lab within 1 hr E. put the sample in a plastic sample bag F. refrigerate a sample that cannot be taken to the lab right away

B, D, E, F the nurse teaches the AP that urine specimens become more alkaline when left standing unrefrigerated for more than 1 hr, when bacteria are present, or when a specimen is left uncovered. alkaline urine increases cell breakdown. So, the presence of RBC may be missed on analysis. The AP ensures that urine specimens are covered and delivered to the lab promptly. A plastic bag protects against contact with urine that may be on the outside of the cup. Urine specimen delayed 2 or more Horus require refrigeration or other specific storage and transport precautions to ensure the integrity of the urine specimen. This is a routine urinalysis and does NOT need to be sterile. The sample should NOT be left in the bathroom

a client expressed concern over the presence of external pins and external devises used to manage her fracture and says she wishes it al could have been placed internally so it wouldn't be visible. What advantages will the nurse tell the client that external fixation has over internal fixation of fractures? SATA A. the risk for infection is reduced B. you lost less blood than you would have with an internal fixation C. this device allows you to move and walk earlier than an internal device D. you will not need surgery to remove these devices after healing is complete E. most people have less pain with the external devices with internal devices F. this devices replaces the need for the use of any other device, such as a cast or a boot later

B,C, D, E the use of external fixation devices results in less blood loss and less pain than internal fixation devices. Moving, walking, and exercising can occur much earlier. The infection risk with external fixation devices is GREATER than with internal devices because there is a continuing disruption of skin integrity with the presence of pins. Other devices may still be needed after fractures are stabilized with external fixation devices

which client will the nurse determine requires the most assistance with performance of ADLs? A. 28 year old with bilateral BKA B. 40 year old with amputation of dominant hand C. 50 year old with AKA D. 70 year old with amputation of all the toes on the left foot

B. clients who have any part of an upper extremity amputated, especially of the dominant hand are much more likely to come less independent in ADLs. A 70 year old client who has been independent in ADLs is likely to remain independent after amputation of all toes on the left foot, although balance and mobility may be changed

to prevent harm. which prescribed drug would the nurse question for an older client with Parkinsons disease? A. Bromocriptine mesylate B. Benztropine C. Amantadine D. Levedopa-Carbidopa

B. for severe motor symptoms such as tremors and rigidity, one of the older anticholinergic drugs may be prescribed, but they are rarely used as primary drugs for PD. examples: Benztropine, trihexyphenidyl HCl, and procyclidine. These drugs should be avoiding in older adults because they can cause acute confusion, urinary retention, constipation, dry mouth, and blurred vision. the nurse would be sure to clarify if a prescription for this drug written for an older adult with PD.

what is the nurses best response to a client with a lower limb amputation who says "I think I am going crazy. I know my foot is gone but I still feel my big toe burning and itching"? A. "are you sure you were awake? sometimes people dream this pain as part of hoping that the missing part will grow back" B. "you are not crazy; many people continue to feel pain and other sensation in a limb that was amputated. How severe is this pain?" C. "this complication is usually seen in a person who has not accepted the fact that the limb is gone. a psychologist can help you cope with this" D. "this problem is very common and although nothing can be done about it, we can give you pain medication for the pain you feel at the surgical site"

B. phantom limb pain is a real physiologic problem for many people after amputation. The pain is real and requires appropriate management. Telling the client that the limb cannot be hurting because it is missing is NOT therapeutic and will NOT reduce the clients expressed concern that he may be "crazy" Drug therapy for this varies with the type of sensation felt as well as the intensity Although some clients may need a mental HCP to assist with coping, immediate pain management is the priority for this client, along with allaying his anxiety.

what is the nurses best response to a young adult client who says "How will I ever walk on that?" after seeing his pale and thin leg after removal of a long leg cast that has been in place for 7 weeks? A. "fractures can heal but the bones are never as strong as they were before the break" B. "the leg will be weak at first, but will regain muscle strength and size as you exercise" C. "the bone will thicken as healing continues and make this leg as large as your other one" D. "the color changed because the poster in the cast rubbed off on it and will improve when you are able to shower"

B. with immobilization in a cast, leg muscle atrophy and become thin. Skin becomes pale, dry, and flaky from lack of exposure to air and water. Both of these conditions improve when the cast is off. How much strength returns to the leg depends on the degree of exercise and use it gets, not on the thickness of the bone

which technique does the nurse use to assess a clients report of paresthesia in the lower extremities? A. use a doppler to locate the pedal pulse, the dorsals pedis pulse, and the popliteal pulse B. ask the client to identify sharp and dull sensations using a paper clip and a cotton ball C. use a reflex hammer to test for deep tendon reflexes D. ask the client to walk across the room and observe for gait and equilibrium

B. The nurse asks whether paresthesia (tingling sensation) or numbness is present in the involved leg. Both extremities are checked for sensory perception but using a cotton ball and a paper clip for comparison of light or dull and sharp touch. The client may feel sensation in both legs but may experience a stronger sensation on the unaffected side.

which is the priority action for the nurse to perform when caring for a pt who just had a needle bone biopsy under local anesthesia? A. administering pain medications B. assessing for bleeding C. checking the gag reflex D. assessing the distal pulse

B. bone is very vascular and can bleed excessively after a biopsy. Although pain management is also important, the medication ca be administered after first assessing whether excessive bleeding is present. The gag reflex is not affected by local anesthesia. Pulses distal to the biopsy area are not likely to be affected by the procedure. They should be assessed but not as first or priority action.

which assessment finding in a client who has a fracture of the right wrist alerts the nurse to a possible early indication of a complication? A. wiggling fingers causes pain B. client reports numbness and tingling C. fingers are cold and pale; pulses are impalpable D. pain is severe and seems out of proportion to injury

B. numbness and tingling are early indications of nerve entrapment or impingement. Moving the fingers below a wrist injury is expected to cause some pain. Cold, pale fingers in which pulses cannot be palpated is a LATE indication of a complication, as is pain that grows worse out of proportion to the injury

which post op assessment finding, for a client who underwent a laminectomy, does the nurse report immediately to the surgeon? A. refusal of the client to cough and deep breathe B. swelling or bulging at the operative site C. pain along the operative incision site D. serosanguineous drainage on the dressing

B. the nurse will immediately report bulging at the incision site. This may be due to a CSF leak or a hematoma, both of which should be reported to the surgeon immediately. CSF may be visible as a "halo" around the outer edges of the dressing. The loss of large amount of CSF may cause the client to report having a "sudden headache"

the nurse teaches a UAP how to position a client who had an AKA last week. Which statement by the UAP indicated understanding of teaching? A. "we should keep the surgical leg elevated on two pillows at all times" B. "we should keep the client in a sitting position as long as possible" C. "we should keep the surgical leg as flat on the bed as possible" D. "we should keep the client in a prone position most of the day"

C

which suggestion will the nurse make to help a client who has complex regional pain syndrome (CRPS) int eh right arm weeks after an open reduction was required to repair a broken elbow and fractured radius to reduce the discomfort? A. take pain mediations around the clock even when the pain is not present B. when the sensations occur, immobilize and ice the limb until they pass C. use a dry wash cloth and rub the skin on the arm several times daily D. wrap the arm in wam, wet compresses as soon at the pain starts

C CRPS is a dysfunction of the central and peripheral nervous system in areas of bone fractures with soft tissue damage that leads to a severe, persistent burning pain, muscle spasms, and changes in skin color, temperature, and sensitivity among other symptoms to facilitate soft tissue healing and prevent CRPS, clients are told to frequently apply a variety of objects with varying surface types directly to the skin to desensitize it. These objects can be rough, smooth, hard, soft, sharp (but not enough to damage the skin), or dull

which circumstance does the nurse recognize as creating the greatest risk of recurrent urolithiasis when client is admitted for an orthopedic procedure? A. providing milk to the client with every meal tray or snack B. insertion of an indwelling urinary catheter for the procedure C. restricting foods and fluids for extended periods of time D. administering an opioid narcotic drug for the severe pain

C the nurse urges clients to drink enough fluids to maintain dilute urine throughout he day and night unless fluid restriction is needed for an other health problem. Some urologist recommend sufficient fluid intake to result in at least 1.5L of urine output or 7-12 voiding daily. Food can provide 20% or more of fluids intake, particularly the intake of fruits and vegetables. Insufficient fluid intake can lead to recurrent urolithiasis. A history of calculi in the urinary tract is also a risk factor for recurrence.

which actions will the nurse take to prevent a flexion contractor in a client who is post op from a AKA low on the femur? SATA A. applying the elastic wraps on the stump distal to the proximal figure 8 pattern B. using aseptic technique when irrigating the wound or changing the dressing C. instructing the client to perform gluteal muscle contraction exercises hourly while awake D. assisting the client to a prone position for 20-30 minutes every 3-4 hours E. keeping the remaining part of the extremity positioned above the level of the heart F. encouraging the client to spend as much time as possible in a chair while awake

C, D gluteal muscles are extensors of the hip joint. Contraction exercises of these buttocks muscle straightens the leg and make the extensor muscles stronger to help prevent flexion contractures. Having the client assume a prone position for 20-30 minutes every 3-4 hours also helps keep the upper leg in an extended position and prevents flexion contractures. Sitting in a chair requires flexion and promotes flexion contractures

which precautions or care information are appropriate for the nurse to include when teaching a client going home with a synthetic forearm cast? A. "be sure to change the stockinette at least once a week" B. "limit movement of the fingers and wrist joints to prevent pain" C. "keep your hand and arm elevated above the level of your heart to reduce swelling" D. "use an ice pack on the cast for the first 6-8 hours, and cover the pack with a towel" E. "when upright, wear the sling so that it distributes over your shoulders and not just your neck" F. "call your HCP immediately if numbness and tingling occur in your hand or fingers"

C, D, E, F a synthetic cast dries quickly and is not deformed by handling it. a fresh fracture is likely to swell and applying ice to the cast, as well as keeping the hands and arms elevated above the heart can help limit the swelling. The swelling can still cause impingement of a nerve, and the client is instructed to report numbness and tingling as soon as possible to prevent harm. Slings, although partially supported by the neck, should have the greater support resting on the shoulders and trunk to prevent damage to the neck. The stockinette is not changed separately from the cast. The client is instructed to move the wrist and fingers to maintain ROM and prevent muscle atrophy or contractures

which actions will the nurse perform first when a client in a body cast reports a painful "hot spot" underneath the cast and an unpleasant odor? A. requesting a cast change B. offering the client a PRN pain medication C. assessing the clients temperature and VS D. elevating the extremity and applying an ice pack over the spot

C. A hot spot coupled with an unpleasant odor are indications of possible infection under the cast. Before notifying the HCP or taking any other action, the nurse will assess the clients temperature and other VS for other indications of infection

what its eh most appropriate action for the nurse to take when assessment on a client with external fixation reveals crusts have formed around the pin sites? A. assessing the clients temperature B. notifying the surgeon immediately C. documenting the findings as the only action D. removing the crusts and culturing the drainage

C. Drainage of clear fluids (weeping) is expected in the first 72 hours around pin sites The drainage forms crusts that are believed to protect the site from infection and are NOT removed

which activity does the nurse ask a client to perform when assessing ROM in the hand? A. gripping the nurses hand as hard as possible B. rapidly rotating the hand from palm up to palm down C. apposing each finger to thumb and then making a fist D. waving the hand from side to side as though waving goodbye

C. a quick way to assess ROM in the hand is by asking the client perform two separate maneuvers. One is making a fist. The other is bringing each fingertip separately to appose the thumb. Gripping is a way to assess strength but NOT ROM. Waving a rotating the hand palm up and palm down assesses some ROM of the wrist but NOT fingers.

which client with a nonhealling fracture of the humerus will the nurse recognize as having a contraindication for the use of electrical bone stimulation? A. 30 year old with a seizure disorder B. 40 year old smoker with HTN C. 50 year old with an implanted cardiac pacemaker D. 60 year old with reduced immunity from corticosteroid use

C. any type of electrical bone stimulation on an arm is contraindicated for clients who have implanted pacemakers

which functional assessment is a priority when the nurse assesses a client with a Parkinsons disease and notes mask like faces? A. ability to sense pain in the facial area B. ability to hear normal voice tones C. ability to chew and swallow D. ability to see in a dim lighted environment

C. changes in facial expression or a mask like face with wide-open, fixed, staring eyes is caused by rigidity of the facial muscles. In late-stage PD, this rigidity can lead to difficulties in chewing & swallowing, particularly if the pharyngeal muscles are involved. as a result, the client may have inadequate nutrition and uncontrolled drooling may occur

which observation indicates to the nurse that a quadriplegic clients spouse understands teaching about performance of assistive coughing (quad cough)? A. spouse assist the client in a wheelchair and coaches deep coughing B. spouse places hands on the clients lateral chest and pushes inward on exhalation C. spouse places hands below the clients diaphragm and pushes upward with exhalation D. spouse assists the client into high-fowlers position and encourage taking a number of deep breaths

C. client is taught by the nurse to coordinate his/her cough effort with an assistant. The spouse, or other assistant places his/her hands on the upper abdomen over the diaphragm and below the ribs. The client takes a breath and coughs during expiration (exhalation). The assistant locks his/her elbows and pushes inward & upward as the client coughs. This technique is called assisted coughing, quad cough, or cough assist. Repeating the coordinated effort, with rest, periods as needed, until the airway is clear is important.

what is the priority nursing assessment for a client who has undergone a kidney biopsy? A. monitor for urinary retention B. assess for onset of HTN C. perform frequent checks for hemorrhage D. observe for signs of nephrotoxicity

C. the major risk is bleeding into the kidney or into the tissues external from the kidney at the biopsy site. For 24 hours after the biopsy, the nurse monitors the dressing site, VS (especially fluctuations in BP), urine output, HgB, and hematocrit

for which client will the nurse question the prescription of ziconotide for severe persistent back pain? A. client with sciatic nerve pain B. client using massage and heat for pain relief C. client with severe mental health problems D. clients using NSAIDs and acupuncture for pain relief

C. Zoconotide can be taken with opioid analgesics but should NOT be administered to a client with severe mental health or behavior health problems because it can cause psychosis. If symptoms such as hallucinations and delusions occur, teach client and families to stop the drug immediately and notify their HCP.

which instructions for handling the amputated digit will the nurse provide to a caller to the ED who reports that a friend just sustained an amputation of a finger while cleaning a lawn mower? A. "place the finger in a glass of milk and keep it cold while transporting it" B. "seal the finger in a plastic bag and pack with the cut site up in a cup of ice" C. "wrap the finger in a clean cloth, seal it in a plastic bag, and place the bad in ice water" D. "place the finger back on your friends hand and wrap it tightly with an elastic bandage"

C. current recommended guidelines for maintaining viability of an amputated finger (or other digit) are to wrap the completely severed finger in a dry clean cloth, place the finger in a watertight, sealed plastic bag, and then put the bag in ice water, NEVER directly on ice

which assessment is the priority for the nurse to perform on a client admitted to the ED with multiple rib fractures? A. pulses in all four extremities B. pulse rate and rhythm C. O2 sat D. pain intensity

C. rib fractures are painful and the client may be breathing too shallowly to maintain gas exchange. In addition, if there are sharp edges on the ribs, the lungs can be punctured. After respiratory assessment, cardiac assessment would be the next priority.

which assessment finding on an older client who fell while getting out of bed indicates to the nurse a possible fracture? A. the client is extremely confusion and trying to get up B. the client cries out when the nurse attempts to examine him C. one leg is shorter than the other and has protruding bump on the side D. the skin of both legs is cooler and darker than that of the upper extremities

C. strong indicators of lower limb fracture or joint dislocation is a change in the length (usually short) of the affected limb and abnormal protrusions or obvious deformities. In an older client, the skin of the legs is cooler and darker than that of the arms. Confusion may be a cause of a consequence of the fall but does not indicate a fracture or bone injury Pain is non specific

what is the priority nursing concern for a client with Parkinson disease with right-sided trembling and weakness, as well as dizziness when moving from sitting to standing? A. decreased ability to perform activities of daily living B. feelings of isolation and loneliness C. safety related to possible injury due to falls D. poor nutritional and fluid intake

C. the nurses priority concern for this client with PD is related to safety. The client has right-sided trembling and weakness, as well as experiencing dizziness when first moving from a sitting to a standing position, all of which increases the risk for injuries due to falls.

a client diagnosed with renal colic. What would the nurse do first? A. prepare the client for lithotripsy B. encourage oral intake of fluids C. strain the urine and send for urinalysis D. administer opioids as prescribed

D

a client who had an elected BKA reports pain in the foot that was amputated last week. What is the nurses most appropriate response to the clients pain? A. "the pain will go away after the swelling decreased" B. "that's phantom limb pain, and every amputee has that" C. "your foot has been amputated, so its in your head" D. "on a scale of 0-10, how would you rate your pain?"

D

which serum laboratory finding is of concern for the nurse and should be reported to the HCP? A. calcium= 9 B. phosphorus= 4.5 C. lactate dehydrogenase= 150 D. alkaline phosphatase= 210

D

which statement by the client indicates a need for further teaching by the nurse about preventing back injuries? A. "I need to lose weight because I'm too big" B. "I should not stand or sit for a long period of time" C. "it would be best if I could get ergonomic office furniture" D. "exercise is not going to help my back very much"

D

which precaution or care information will the nurse teach a client prescribed low intensity pulsed ultrasound treatments for a very slow healing fracture of the lower leg specific for this treatment? A. use a reliable form of birth control until treatment is complete B. the treatment cannot be used if you have any types of DM C. the device should not be used in the same room with a microwave oven D. expect to dedicate approximately 20 minutes each day for the treatment

D there are no specific adverse effects or contraindications for the use of this therapy

after ensuring ABCs along with a head to toe, which action will the nurse take next in the emergency care of a client with an extremity fracture? A. checking the neurovascular status of the area distal to the injury: temperature, color, sensation, movement, and vital pulses by comparing the affected and unaffected limbs B. elevating the affected area on pillows, applying an ice pack that is wrapped to protect the skin, and obtaining a prescription for pain medications C. immobilizing the extremity by splinting; include joints above and below the fracture site, followed by rechecking the circulation D. removing or cutting the clients clothing to inspect the affected area above and below the injury

D. Before any appropriate intervention action can be taken, the nurse must first visually inspect the area to adequately assess the trauma. This entails removing or cutting away clothing in the affected area without causing more harm.

which report or manifestation indicates to the nurse that a clients treatment for renal colic has been successful? A. urine is pink tinged B. urine output is 50mL per hour C. bladder scan shows no residual urine D. client reports that pain is relieved

D. Renal colic is the severe pain that occurs with the presence of kidney stones. When tx is successful, the clients pain is relieved

which question is most appropriate for the nurse to ask a client who has been receiving scheduled and PRN opioids for severe pain with multiple fractures who now has a distended abdomen and hypoactive bowel sounds? A. "did you use opioids or other recreational drugs before your injury?" B. "what specific foods have you eaten in the past 2 days?" C. "how would you rate your pain on a 0-10 scale?" D. "when was your last bower movement?"

D. Severe fractures are very painful and usually require opioid pain meds for some time regardless whether the client has ever used any in the pst. A major SE of opioids is decreased peristalsis and constipation. The first question to ask is when did the client last have a bowel movement. The client usually requires a bowel regiment to relieve constipation and prevent a possible paralytic ileus

what is the priority nursing concern when client is admitted with a history of kidney stones an presence with severe flank pain, nausea and vomiting, pallor, and diaphoresis? A. possible hemorrhage B. urinary elimination C. impaired tissue perfusion D. severe pain

D. The major symptoms of stones is severe pain, commonly called renal colic. Drug therapy is needed in the first 24-36 hours when pain is most severe. Opioids are used to control the severe pain caused by stones and may be given IV for rapid pain relief

what is the priority nursing assessment after a client returns from surgery for an anterior cervical discectomy with fusion? (ACDF) A. assess for gag reflex and swallowing ability B. monitor VS and check neurological status C. check for bleeding and drainage at the incision site D. assess for airway latency and respiratory effort

D. The priority for care in the immediate post op period after an ACDF is maintaining an airway and ensuring that the client has no problems with breathing. swelling from the surgery can narrow the trachea, causing a partial obstruction

what is the nurses best action when a client is having a generalized tonic clonic seizure and becomes cyanotic? A. raise the head of the bed and apply oxygen by NC B. suction the client and alert the Rapid Response Team C. call the HCP and obtain intubation equipment D. stay with the client because the cyanosis is usually self-limiting

D. it is not unusual for a client to become cyanotic during a generalized tonic clonic seizure. the cyanosis is generally self-limiting, and no tx is needed so the nurse would remain with the client. some PCP prefer to give a high-risk client (older adult, critically ill, or debilitated client) oxygen by NC or facemark during the postictal (after seizure) phase

what question does the nurse ask to help interpret the result when a health adult clients urinalysis reveals a protein level of 0.9? A. "have you ever been treated for a urinary tract infection?" B. "are you sexually active and if so, do you use condoms?" C. "do you have a family history of cardiac or biliary disease?" D. "have you recently performed any strenuous exercise?"

D. random findings of proteinuria followed by a series of negative findings does not imply kidney disease. Normal values for protein in the urine is 0-8. The nurse asks the client about strenuous exercise because urinary protein levels may be increased with exercise. Other causes of increased protein level include stress, infection, and glomerular disorders

which medication prescription will the nurse clarify before administering it to a client? A. gabapentin for a client who has partial seizures B. diazepam rectal gel for a client with status epilepticus C. carbamazepine for a client with tonic clonic seizures D. warfarin for a client who takes phenytoin for seizures

D. using warfarin together with phenytoin may cause a client to bleed more easily. it may also increase phenytoin levels. Phenytoin feels and PTT or INR should be monitored whenever the dosage is changed or discontinued

which client will the nurse consider to be at highest risk for nonunion after a fracture? A. 40 year old who is 20 lbs overweight and has a Colles fracture of the wrist B. 50 year old female who is commented fracture of the humerus C. 60 year old male with multiple fractured ribs D. 70 year old female with a "tib fib" fracture

D. This client has three major risk factors for nonunion; older age, female, and lower limb fracture

which additional electrolyte change will the nurse expect to find in a client who has hypercalcemia? A. hyponatremia B. hyperkalemia C. hypochloremia D. hypophosphatemia

D. blood calcium and phosphorus levels exist in a balance reciprocal relationship that causes one level to rise as the other one decreased. Elevations of serum calcium levels above normal cause a corresponding decrease in serum phosphorus levels. High levels of serum calcium do not change the serum levels of sodium, potassium or chloride

what priority information does the nurse include when teaching a client with Parkinson disease about the prescribed drug selegiline, a selective monoamine oxidase type B inhibitor? A. take the drug with meals B. avoid driving or operating heavy machinery C. take the medication daily at bedtime D. avoid eating aged cheese or cured meats

D. the nurse would teach clients taking MAOIs about the need to avoid foods, beverages, and drugs that contain tyramine, such as cheese and aged, smoked, or cured foods and sausage. remind them to also avoid red wine and beer to prevent severe headaches and life-threatening HTN. clients are taught to continue these restrictions for 14 days after the drug is discontinued

which action will the nurse perform next when an obese clients popliteal pulse on one side cannot be palpated? A. palpating the popliteal pulse on the opposite side B. attempting to assess the pedal pulse on the same side C. notifying the HCP immediately D. using a doppler to assess blood flow in that popliteal space

D. the popliteal pulse may be difficult to palpate in an obese client. The next best action is to assess this pulse using a doppler device. Although other assessment findings on that limb, such as checking for a pedal pulse, can help determine whether general blood flow is adequate, it does not establish whether or not there is a problem in that specific artery.

what preprocedural instruction will the nurse provide for a client scheduled for an ultrasonography? A. "empty your bladder just before the test begins" B. "stop taking your routine medications 24 hours before the test" C. "you must have nothing to eat or drink after midnight before the test" D. "drink 500 to 1000mL of water 2-3 hours before the test"

D. ultrasonography usually requires a full bladder. The nurse instructions the client NOT to void after drinking the water until the test is complete

which steps will the nurse perform first on a client during assessment of the renal system? A. listen for a bruit over each renal artery B. lightly palpate the abdomen in all four quadrants C. percuss from the lower abdomen toward the umbilicus D. observe the flank region for asymmetry or discoloration

D. with assessment, inspection comes first. The nurse inspects the abdomen and the flank regions with the client in both supine and sitting positions. He/She observes for asymmetry (swelling) or discoloration (bruising or redness) in the flank region, especially yin the area of the costovertebral angle. Auscultation for bruits comes next. Auscultation is completed before percussion and palpation because these activities can alter bowel sounds and obscure abdominal vascular sounds. Palpation and percussion are usually completed by the HCP or NP.