Unit 6 - EAQ Quiz

A client who had a right total hip replacement three days ago reports extreme tenderness in the right calf. On examination the nurse identifies a warm area occurring on the back of the leg, extending into the popliteal space. The physical therapist has just arrived to assist the client with ambulation and exercise. What should the nurse do to best meet this client's needs? 1. Assist the therapist in ambulating the client. 2. Administer the client's prescribed analgesic. 3. Reassure the client that pain can be expected after surgery. 4. Notify the health care provider regarding the client's status.

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A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's blood studies indicate pH 7.30, Po2 60 mm Hg, Pco2 55 mm Hg, and HCO3 23 mEq/L. The nurse concludes that the client is experiencing: 1. Hypocapnia 2. Hyperkalemia 3. Generalized anemia 4. Respiratory acidosis

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A nurse notes the weights attached to a 7-year-old child in traction are touching the floor. What action should the nurse take? 1. Raising the foot of the bed 2. Lengthening the traction rope 3. Notifying the health care provider 4. Moving the child toward the head of the bed

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Which statement by a female client with a non-weight-bearing long leg cast indicates the need for the nurse to reinforce discharge teaching? 1. "The cast can be wrapped in plastic when I take a shower." 2. "I called my office to let them know I will be back at work next week." 3. "The physical therapist is going to teach me how to walk with crutches." 4. "I am going to give myself a pedicure with red nail polish when I get home."

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A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? 1. Relieve muscle spasm and pain 2. Prevent contractures from developing 3. Keep the client from turning and moving in bed 4. Maintain the limb in a position of external rotation

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An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

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What nursing action will limit hypoxia when suctioning a client's airway? 1. Apply suction only after catheter is inserted. 2. Limit suctioning with catheter to half a minute. 3. Lubricate the catheter with saline before insertion. 4. Use a sterile suction catheter for each suctioning episode.

1

A client is fitted for and receives a prosthesis after an above-the-knee amputation. A week later the client states, "I feel so much better." What is the reason why most clients report an improved self-image after using a prosthesis? 1. Their improved functional abilities 2. Their belief that they look more whole 3. The acceptance they receive from others 4. The fact that something is being done to help

1

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take? 1. Instruct the client to splint the wound with a pillow when coughing 2. Place the client in the supine position and inspect the site of the incision 3. Assess the intensity of the pain and administer the prescribed analgesic 4. Call the health care provider immediately and then check for wound dehiscence

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The practitioner prescribes no weight bearing on a leg that has been casted because of a fracture of the femur. How should the nurse determine the appropriate length of the crutches for this child? (Select all that apply.) 1. The crutches should reach 2 inches below the axillae. 2. The crutches' tips should rest 6 inches outside the feet. 3. There should be a snug fit under the axillae when the child walks. 4. There should be a slight stoop of the shoulders when the child walks. 5. The elbows should be extended when the crutches are held at the crossbar.

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A client appears anxious, exhibiting 40 shallow respirations per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. The nurse concludes that the client's complaints probably are related to: 1. Eupnea 2. Hyperventilation 3. Kussmaul's respirations 4. Carbon dioxide intoxication

2

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the applying of a/an: 1. Binder 2. Ice bag 3. Elastic bandage 4. Warm compress

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A nurse addresses the needs of a client who is hyperventilating to prevent what complication? 1. Cardiac arrest 2. Carbonic acid deficit 3. Reduction in serum pH 4. Excess oxygen saturation

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A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? 1. Supine 2. Orthopneic 3. Low-Fowler 4. Semi-Fowler

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A nurse teaches self-care to a client who had a cast applied for a fracture of the right ulna and radius. The nurse instructs the client to notify the primary health care provider immediately if the client experiences: 1. Slight stiffness of the fingers 2. Increasing pain at the injury site 3. Small amount of bloody drainage on the cast 4. Bounding radial pulse in the affected extremity

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After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement? 1. Postural drainage 2. Turning and positioning 3. Administration of an expectorant 4. Percussion and vibration techniques

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In the postanesthesia care unit after a below-the-knee amputation, a client begins crying after feeling for the affected lower leg. How should the nurse respond? 1. Administer medication to induce sleep. 2. Allow the client to ventilate feelings of loss. 3. Provide time for privacy by leaving the room. 4. Do not address the behavior until the client is more alert.

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The nurse is caring for a client four hours after the client's hip replacement surgery. When assisting the client out of bed, the nurse should: 1. Tell the client that both legs must have equal weight bearing 2. Advise the client that the legs must continually be kept wide apart 3. Sit the client in a straight-back chair so that the hips are kept flexed 4. Transfer the client using a mechanical lift because weight bearing on the leg is not allowed

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The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: 1. Respiratory acidosis 2. Respiratory alkalosis 3. Respiratory compensation 4. Respiratory decompensation

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The nurse is caring for two clients. The first client had a below-the-knee amputation as a result of an accident. The second client had a below-the-knee amputation because of chronic decreased arterial perfusion. The nurse anticipates that the postoperative courses of these two clients may differ because the: 1. First client probably will adjust more quickly 2. Second client's incision will take longer to heal 3. Second client is more likely to have phantom limb sensations 4. First and second clients have different occupations

2

Which nursing intervention is most appropriate for a client in skeletal traction? 1. Add and remove weights as the client desires. 2. Assess the pin sites at least every shift and as needed. 3. Ensure that the knots in the rope are tied to the pulley. 4. Perform range of motion to joints proximal and distal to the fracture at least once a day.

2

A toddler has just had a cast applied for a fractured wrist. The wrist and elbow are immobilized. What information should the nurse include in the home care instructions before discharge? (Select all that apply.) 1. Resume usual activities. 2. Report swelling of fingers. 3. Keep the affected shoulder immobilized. 4. Elevate casted arm when the child is standing. 5. Lower the casted arm when the child is lying down.

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Clients who have casts applied to the lower extremities must be monitored for complications. Which finding during assessment of the extremities of these clients is indicative of a complication? (Select all that apply.) 1. Warmth 2. Numbness 3. Skin desquamation 4. Generalized discomfort 5. Prolonged capillary refill

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A client has a fracture of the tibia and a cast is applied. When caring for the client, the nurse should: 1. Cover the cast with plastic wrap until dry 2. Assist with weight bearing when the client ambulates 3. Elevate the affected leg above the level of the heart 4. Insert a finger inside the edges of the cast to check for skin abrasions

3

A health care provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens? 1. After activity 2. Before meals 3. On awakening 4. Before a respiratory treatment

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A nurse is assisting a client with a full leg cast to use crutches. Which clinical manifestations alert the nurse that the client can no longer tolerate the physical exertion of crutch walking? 1. Pulse of 100 and deep respirations 2. Flushed skin and slowed respirations 3. Profuse diaphoresis and rapid respirations 4. Blood pressure of 150/88 mm Hg and shallow respirations

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A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

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A nurse is planning care for a school-aged child after the application of a spica cast. What should the nurse include in the plan of care for the child? 1. Using the crossbar to turn the child 2. Log-rolling the child until the cast is dry 3. Evaluating neurovascular status of the legs 4. Drying the cast with a hair dryer on the cool setting

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What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh? 1. Palpate the femoral artery of the affected leg. 2. Assess for a positive Homan sign of the affected leg. 3. Compress and release the toenails of the affected foot. 4. Instruct the client to flex and extend the knee of the affected leg.

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A nurse is caring for a client in respiratory distress. The health care provider prescribes oxygen via a non-rebreather mask. Which mask should the nurse use to implement the oxygen prescription? 1. Simple face mask 2. Venturi mask 3. Face tent 4. Nonrebreathing mask

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