Adult 1 - Exam 1

After teaching a patient who is recovering from a vertebroplasty, the nurse assesses the patient's understanding. Which statement by the patient indicates a need for additional teaching?

"I can drive myself home after the procedure."

A nurse is discharging a patient after a total hip replacement. What statement by the patient indicates good potential for self-management?

"I will not sit with my legs crossed."

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

"Primary osteoporosis occurs in postmenopausal women due to lack of estrogen."

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?

Inform the surgeon that the sterile field has been broken.

A nurse assesses a patient with a fracture who is being treated with skeletal traction. Which assessment would alert the nurse to urgently contact the health provider?

Traction weights are resting on the floor.

An older patient has returned to the surgical unit after a total hip replacement. The patient is confused and restless. What intervention by the nurse is most important to prevent injury?

Use an abduction pillow.

The post-anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative patients. Which patient would the nurse assess first?

Patient with a respiratory rate of 6 breaths/min.

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

A patient in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?

Give the patient a bedpan or urinal to use.

A patient has arrived in the postoperative unit. What action by the circulating nurse takes priority?

Participating in hand-off report.

The nurse on the postoperative inpatient unit assesses a patient after a total hip replacement. The patient's surgical leg is visibly shorter than the other one and the patient reports extreme pain. While a coworker calls the surgeon, what action by the nurse is best?

Assess neurovascular status in both legs.

A nurse is monitoring a patient after moderate sedation. The provider has prewritten discharged orders and the patient's spouse is asking if they can leave. What action by the nurse is best?

Assess the patient using the modified Aldrete scale.

A postoperative patient vomited. After cleaning and comforting the patient, which action by the nurse is most important?

Auscultate lung sounds.

A postoperative patient has just been admitted to the post-anesthesia care unit (PACU). What assessment by the PACU nurse takes priority?

Airway

The postoperative nurse is caring for a patient who reports feeling "something popped" after vomiting. What action by the nurse is a priority?

Apply a sterile nonadherent dressing

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

Arrange a home safety evaluation.

A nurse working in the preoperative holding area performs which functions to ensure patient safety? (Select all that apply.)

Check that consent is on the chart. Ensure that the patient has an armband on. Have the patient help mark the surgical site. Allow the patient to use the toilet before giving sedation.

A patient has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?

Demonstrate how to splint the incision.

An inpatient nurse brings an informed consent form to a patient for an operation scheduled for tomorrow. The patient asks about possible complications from the operation. What response by the nurse is best?

Do not have the patient sign the consent and call the surgeon.

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication?

Fat embolism syndrome

Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture?

Greenstick

A nurse is caring for a patient on an epidural patient-controlled analgesia (PCA) pump. Which action by the nurse is most important to ensure patient safety?

Have another nurse double-check the pump settings.

A patient with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?

Ice packs

A client has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication?

Inadequate immobilization

A nurse works in the rheumatology clinic and sees patients with rheumatoid arthritis (RA). Which patient would the nurse see first?

Patient with a red, hot, swollen right wrist

A nurse on the postoperative inpatient unit receives a hand-off report on four patients using patient-controlled analgesia (PCA) pumps. Which patient would the nurse see first?

Patient with a respiratory rate of 8 breaths/min

A client was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the client tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?

Prepare the client for opening or bivalving of the cast

A circulating nurse wishes to provide emotional support to a patient who was just transferred to the operating room. What action by the nurse would be best?

Remain with the patient.

A hospitalized patient uses a transdermal fentanyl (Duragesic) patch for chronic pain. Which action by the nurse is most important for patient safety?

Remove the old patch when applying the new one.

The nurse is teaching a patient with gout dietary strategies to prevent exacerbations of other problems. Which statement by the nurse is most appropriate?

"Drink 1 to 2 L of water each day."

A nurse assesses a patient with a cast for potential compartment syndrome. Which clinical manifestations are correctly paired with the physiologic changes of compartment syndrome? (Select all that apply.)

Edema—increased capillary permeability Unequal pulses—increased production of lactic acid Cyanosis—anaerobic metabolism

A postoperative patient is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the patient? (Select all that apply.)

"Check all over-the-counter medications for acetaminophen." Do not take more pills each day than you are prescribed." "Eat a diet that is high in fiber and drink lots of water." "You shouldn't drive while you are taking this medication."

A nurse is caring for a patient who is recovering from an above-the-knee amputation. The patient reports pain in the limb that was removed. How would the nurse respond?

"How would you describe the pain that you are feeling?"

A student nurse asks why several patients are getting more than one type of pain medication instead of very high doses of one medication. Which response by the registered nurse is best?

"Pain is so complex it takes different approaches to control it."

A nurse cares for a patient placed in skeletal traction. The patient asks, "What is the primary purpose of this type of traction?" How would the nurse respond?

"Skeletal traction will assist in realigning your fractured bone."

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

"Wash your hands before touching the drain or dressing."

The nurse is assessing a patient's pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. Which question by the nurse would be best to ask the patient for completing a comprehensive pain assessment?

"What pain rating would be acceptable to you?"

An emergency department nurse cares for a patient who sustained a crush injury to the right lower leg. The patient reports numbness and tingling in the affected leg. Which action would the nurse take first?

Assess the pedal pulses.

A patient is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance patient safety related to this anesthesia? (Select all that apply.)

Assessing distal circulation to the operative arm after positioning Padding the patient's shoulder and arm on the operating table

A patient is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. Which finding in the patient's health history would lead the nurse to consult with the provider over the choice of medication? 25-pack-year smoking history

Drinking 3 to 5 beers a day.

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals?

Encouraging the client to turn from side to side and to assume a prone position

A patient comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the patient for Heberden's nodules. What assessment technique is correct?

Inspect the patient's distal finger joints.

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.)

Liver biopsy: diagnostic Total shoulder replacement: restorative

After teaching a patient with a fractured humerus, the nurse assesses the patient's understanding. Which dietary choice demonstrates that the patient correctly understands the nutrition needed to assist in healing the fracture?

Roast beef with low-fat milk and a vitamin C supplement

A patient who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. Which intervention for pain management does the nurse include in the patient's care plan?

Round-the-clock analgesia with PRN analgesics.

A nurse plans care for a patient who is prescribed skeletal traction. Which intervention would the nurse include in this plan of care to decrease the patient's risk for infection?

Schedule for pin care to be provided every shift.

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

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

A preoperative nurse is assessing a patient prior to surgery. Which information would be most important for the nurse to relay to the surgical team?

Use of multiple herbs and supplements