Exam 2
Which clients will the nurse monitor most closely for respiratory failure? A. A 30 year old with a C-5 spinal cord injury B. A 55 year old with a brainstem tumor C. A 50 year old experiencing cocaine intoxication D. A 65 year old with COVID-19 pneumonia E. A 35 year old using client-controlled analgesia F. A 40 year old with acute pancreatitis
A. A 30 year old with a C-5 spinal cord injury B. A 55 year old with a brainstem tumor D. A 65 year old with COVID-19 pneumonia E. A 35 year old using client-controlled analgesia F. A 40 year old with acute pancreatitis
What action by perioperative nurse is most important to prevent surgical wound infection in a patient having a THA? A. Administer preoperative AB as ordered B. Assess the patient's white blood cell count C. Instruct the patient to shower the night before D. Monitor the patient's temperature postoperatively
A. Administer preoperative AB as ordered
Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)? A. Anticoagulants B. Antihypertensives C. Antidysrhythmics D. Antibiotics
A. Anticoagulants
Post THA pt's surgical leg is shorter than the other one & pt reports extreme pain. What action by the nurse is best? A. Assess neurovascular status in both legs B. Elevate the affected leg and apply ice C. Prepare to administer pain medication D. Try to place the affected leg in abduction
A. Assess neurovascular status in both legs
Nurse caring for pt day 4 post- kidney transplantation. When assessing for rejection, what is priority? A. Assessment of the quantity of the client's urine output B. Assessment of the client's incision C. Assessment of the client's abdominal girth D. Assessment for flank or abdominal pain
A. Assessment of the quantity of the client's urine output
Nursing interventions for Mr. Johnston prior to surgery include monitoring for shock and bleeding. Which parameters should the nurse check? Select all that apply. A. Blood pressure B. Thigh girth C. Respiratory rate D. Peripheral sensation E. Heart rate
A. Blood pressure B. Thigh girth C. Respiratory rate E. Heart rate
What is the safest initial management of a person with a suspected hip fracture? A. Call for ambulance assistance and do not attempt to move the person. B. Roll victim on to unaffected side and pull shoulders to move. C. Move victim by grabbing shoulders and legs and lifting as a unit. D. Put a pressure dressing over the bleeding area and splint legs together with tape.
A. Call for ambulance assistance and do not attempt to move the person.
The nurse is caring for a patient who has just returned to the postsurgical unit following renal surgery. When assessing the client's output from surgical drains, the nurse should assess what parameters? Select all that apply. A. Color of the output B. pH of the output C. Odor of the output D. Quantity of output E. Visible characteristics of the output
A. Color of the output D. Quantity of output E. Visible characteristics of the output
What type of percussion note or sound will the nurse expect on the affected chest side of a client who has a hemothorax? A. Dull B. Hyperresonant C. Crackling D. Hypertympanic
A. Dull
Why is it important to auscultate Mr. Johnston's lung sounds frequently? A. He has a history of CHF. B. Because of the history of hypertension, he is at risk for a heart attack. C. Older hip fracture patients are at risk for osteoprosis. D. He may be at risk for infection.
A. He has a history of CHF.
Which of the following lab and testing parameters may indicate bleeding? Select All That Apply A. Hemoglobin B. Hematocrit C. Platelets D. Pulse Oximetry E. Respiratory Rate. F. Skin color G. Diaphoresis H. SOB (shortness of breath) I. Urine ouput
A. Hemoglobin B. Hematocrit C. Platelets D. Pulse Oximetry E. Respiratory Rate. F. Skin color G. Diaphoresis H. SOB (shortness of breath) I. Urine ouput
Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction? A. Hemoptysis and shortness of breath B. Fever and tracheal deviation C. Audible wheezing on inhalation and exhalation D. Paradoxical chest movements
A. Hemoptysis and shortness of breath
Nurse plans care of pt undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions? A. Improving the client's level of function B. Helping the client come to terms with limitations C. Administering medications safely D. Improving the client's adherence to treatment
A. Improving the client's level of function
A nurse is caring for a client who is postop day 1 right THA. How should the nurse position the pt? A. Keep the client's hips in abduction at all times B. Keep hips flexed at no less than 90 degrees C. Elevate the head of the bed to high fowler's D. Seat the client in a low chair as soon as possible
A. Keep the client's hips in abduction at all times
Nurse caring for pt who had THA. Which of the following interventions should the nurse use to prevent dislocation? A. Maintain foam wedge between legs B. Encourage use of elastic stockings C. Monitor for shortening of the affected leg D. Avoid flexing of the hips more than 60
A. Maintain foam wedge between legs
The pt is receiving RT THA after fall. In immediate postoperative period, what health education the nurse emphasize? A. Make sure you don't bring your knees close together B. Try to lie as still as possible for the fist few days C. Try to avoid bending your knees until next week D. Keep your legs higher than your chest whenever you can
A. Make sure you don't bring your knees close together
Postop THA pt is in supine position. Which nursing action is appropriate to prevent dislocation of the hip? A. Place a wedge pillow between the legs B. Elevate the head of the bed to a fowler's position C. Position the legs in alignment with the spine D. Place a footboard on the bed
A. Place a wedge pillow between the legs
The nurse is caring for a client who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A. Protect the affected leg from internal rotation B. Keep the hip flexed by placing pillows under the client's knee C. Have the client reposition himself independently D. Keep the affected leg in a position of adduction
A. Protect the affected leg from internal rotation
What type of acid-base problem will the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a pH of 7.29? A. Respiratory acidosis with an acid excess B. Metabolic acidosis with an acid excess C. Respiratory acidosis with a base deficit D. Metabolic acidosis with a base deficit
A. Respiratory acidosis with an acid excess
Which of the following is correct positioning when caring for pts post pneumonectomy? A. Turned every hour from the back to the operative side B. Turned every hour from the back to the unoperated side C. Turned every hour from to back or either side D. Shouldn't be turned onto the operative side
A. Turned every hour from the back to the operative side
Nurse caring for preoperative elderly pt scheduled for TKA should notify the surgeon of which of the following results? A. WBC count 20,000 B. Hematocrit 40% C. Creatinine 0.9 D. Potassium 3.8
A. WBC count 20,000
Nurse works in renal transplant unit. To reduce infection risk in a client with a transplanted kidney, the nurse should A. Wash hands carefully and frequently B. Ensure immediate function of the donated kidney C. Instruct the client to wear a face mask D. Bar visitors from the client's room
A. Wash hands carefully and frequently
The nurse is caring for a patient post kidney transplant surgery. To reduce the risk of infection in a client with a transplanted kidney, it is imperative for the nurse to do what? A. Wash hands carefully and frequently. B. Ensure immediate function of the donated kidney. C. Bar visitors from the client's room. D. Instruct the client to wear a face mask.
A. Wash hands carefully and frequently.
Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion? A. Assessing gums daily for indications of bleeding B. Monitoring the platelet count daily C. Assessing breath sounds D. Comparing pedal pulses bilaterally
B. Monitoring the platelet count daily
A pt undergoing THA concerned about bed rest for several days post surgery. How nurse explain activity expectations? A. Pts are only on bed rest for 2-3 days before they begin walking B. PT will help you get up using a walker the day after surgery C. Goal will be to have you walking normally within 5 days of your surgery D. For the first 2 weeks you can use a wheelchair to meet your mobility needs
B. PT will help you get up using a walker the day after surgery
Nurse is planning care for pt postop THA. Which interventions should the nurse include in the plan of care? A. Instruct the client to avoid movement of the affected leg B. Prevent hip flexion of the affected extremity C. Position the lower extremities so that they are touching D. Ensure that client's heels are touching the bed
B. Prevent hip flexion of the affected extremity
Pt is day 1 post kidney transplantation from a living donor. Assessment revealed copious quantities of dilute urine. A. Assess the client for further signs or symptoms of rejection B. Recognize this as an expected finding C. Inform the primary provider of this finding D. Administer exogenous antidiuretic hormone as prescribed
B. Recognize this as an expected finding
A nurse is discharging ot after a THA. What statement by the patient indicates good potential for self-management? A. I can bend down to pick something up B. I no longer need to do my exercises C. I will not sit with my legs crossed D. I won't wash my incision to keep it dry
C. I will not sit with my legs crossed
Nurse reviews lab values of pt returned from kidney transplantation 12 hrs ago. What initial intervention is expected Na 136 Potassium 5 BUN 44 Creatinine A. Start hemodialysis immediately B. Discuss the need for peritoneal dialysis C. Increase the dose of immunosuppression D. Return the patient to surgery for exploration
C. Increase the dose of immunosuppression
The nurse should assign the highest priority for which ng diagnosis for pt post laryngectomy? A. Anxiety related to diagnosis of cancer B. Altered nutrition related to swallowing difficulties C. Ineffective airway clearance related to airway alterations D. Impaired verbal communication related to removal of the larynx
C. Ineffective airway clearance related to airway alterations
A client is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The client is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A. "The physical therapist will likely help you get up using a walker the day after your surgery." B. "Actually, clients are only on bed rest for 2 to 3 days before they begin walking with assistance." C. "Our goal will actually be to have you walking normally within 5 days of your surgery." D. "For the first 2 weeks after the surgery, you can use a wheelchair to meet your mobility needs."
A. "The physical therapist will likely help you get up using a walker the day after your surgery."
When assessing a post TKR client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A. Increased warmth of the calf B. Decreased circumference of the calf C. Loss of sensation to the calf D. Pale-appearing calf
A. Increased warmth of the calf
Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probably presence of a PE? (Select all that apply.) A. Inspiratory chest pain B. Dizziness and syncope C. Pink, frothy sputum D. Worsening dyspnea for 3 days E. Tachycardia F. Productive cough
A. Inspiratory chest pain B. Dizziness and syncope E. Tachycardia
The nurse recognizes that aspiration is a potential complication of a laryngectomy. How'd nurse best manage this risk? A. Facilitate the total parenteral nutrition (TPN) B. Keep a complete suction setup at the bedside C. Feed the client several small meals daily D. Refer the client for occupational therapy
B. Keep a complete suction setup at the bedside
The nurse is caring for a 66-year-old client with end-stage kidney disease. The client was informed by a physician that it is time to consider hemodialysis until a transplant can be found. The client tells the nurse she is not sure she wants to undergo a kidney transplant. What would be an appropriate response for the nurse to make? A. "The decision is certainly yours to make, but be sure not to make a mistake." B. "Have you talked this over with your family?" C. "Kidney transplants in clients your age are as successful as they are in younger clients." D. "I understand your hesitancy to commit to a transplant surgery. Success is comparatively rare."
C. "Kidney transplants in clients your age are as successful as they are in younger clients."
A nurse cares for a patient who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery A. Assess airway patency, breathing, and circulation B. Administer prescribed intravenous pain medications C. Assist the patient to choose a communication method D. Ambulate the patient in the hallway to assess gait
C. Assist the patient to choose a communication method
A client is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? A. Postoperative blood salvage B. Use of a cardiopulmonary bypass machine C. Autologous blood donation D. Prophylactic blood transfusion
C. Autologous blood donation
When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? A. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94%. B. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs. C. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachy-cardia. D. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain.
C. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachy-cardia.
Which of the following prescriptions should the nurse caring for a THA pt verify with the provider? A. Administer enoxaparin 30 mg subcutaneous every 12 hr B. Place a wedge or pillow between the client's legs when turning C. Instruct the client to restrict flexion of the hip past 120 D. Encourage the client to perform foot and calf exercises every 2 hr
C. Instruct the client to restrict flexion of the hip past 120
ICU nurse is precepting new nurse caring for a pt with tracheostomy. What action' d the critical care nurse recommend? A. Deflate the cuff overnight to prevent tracheal tissue trauma B. Inflate the cuff to the highest possible pressure in order to prevent aspiration C. Monitor the pressure in the cuff at least every 8 hours D. Keep the tracheostomy tube plugged at all times
C. Monitor the pressure in the cuff at least every 8 hours
A pt underwent THA yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A. Keep the affected leg in a position of adduction B. Have the client reposition himself independently C. Protect the affected leg from internal rotation D. Keep the hip flexed by placing pillows under the client's knee
C. Protect the affected leg from internal rotation
Case Study Q 1: Which of these findings are cause for concern? A. BP 128/84 mmHg B. Heart rate 114 (sinus tachycardia) C. RR 24 and labored with O2 saturation: 91% on 40% O2 D. Temperature 99.4 F (axillary)
C. RR 24 and labored with O2 saturation: 91% on 40% O2
Q 4: Student nurse is to perform tracheostomy care under the RN's supervision. Which instructions RN give the student? A. Create a clean field B. Clean the inner cannula with full-strength hydrogen peroxide C. Remove old dressings and excess secretions D. Suction the tracheostomy tube after the trach care
C. Remove old dressings and excess secretions
A 91 yrs pt is having orthopedic surgery. What intervention is most justified in the care of this client? A. Administration of prophylactic antibiotics B. Total parenteral nutrition (TPN) C. Use of a pressure-relieving mattress D. Use of a foley catheter until discharge
C. Use of a pressure-relieving mattress
A 91-year-old client is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A. Total parenteral nutrition (TPN) B. Use of a Foley catheter until discharge C. Use of a pressure-relieving mattress D. Administration of prophylactic antibiotics
C. Use of a pressure-relieving mattress
Nurse caring for a pt postop RT THA. Nurse should maintain the right leg in which of the following positions? A. Adduction B. External rotation C. Internal rotation D. Abduction
D. Abduction
Nurse caring for pt postop TKA and has a continuous passive motion. Which of the following actions should the nurse take? A. Store the CPM machine on the floor when not in use B. Use a special pillow to rotate the affected knee internally C. Set the CPM to fully flex the knee joint D. Apply ice to the operative knee
D. Apply ice to the operative knee
1-day post THA pt receiving morphine for pain control. Pt reports nausea and vomiting. Which action' d the nurse take? A. Insert a nasogastric tube B. Administer an antiemetic C. Encourage use of the incentive spirometer D. Auscultate bowel sounds
D. Auscultate bowel sounds
The risk of blood loss in pt undergoing THA is the indication for which of the following actions? A. Use of a cardiopulmonary bypass machine B. Postoperative blood salvage C. Prophylactic blood transfusion D. Autologous blood donation
D. Autologous blood donation
Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax? A. Left chest caves in on inspiration and "puffs out" on expiration. B. The left lung field is dull to percussion and crackles are present on auscultation. C. The client has bloody sputum and wheezes. D. Chest is asymmetrical and trachea deviates toward the right side.
D. Chest is asymmetrical and trachea deviates toward the right side.
A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A. Client is able to weight-bear equally on both legs. B. Client is able to demonstrate full ROM of the affected hip. C. Client is able to perform ADLs independently. D. Client is able to perform transfers safely.
D. Client is able to perform transfers safely.
In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)? A. Administering sodium bicarbonate B. Having the client breathe rapidly and deeply into a paper bag C. Assessing for the presence of adventitious lung sounds D. Increasing the oxygen flow rate
D. Increasing the oxygen flow rate
Volume in post orthopedic surgery pt closed suction drainage is within expected parameters but drainage has a foul odor. A. Aspirate a small amount of drainage for culturing B. Advance the drain 1 to 1.5 cm C. Irrigate the drain with normal saline D. Inform the surgeon of this finding
D. Inform the surgeon of this finding
A nurse is caring for a client who is postoperative day 1 right hip replacement. How should the nurse position the client? A. Elevate the head of the bed to high Fowler's B. Keep hips flexed at no less than 90 degrees C. Seat the client in a low chair as soon as possible D. Keep the client's hips in abduction at all times
D. Keep the client's hips in abduction at all times
Nurse assesses post orthopedic surgery pt frequently for S&S of infection as pt is at high risk for which complication? A. Cellulitis B. Septic arthritis C. Sepsis D. Osteomyelitis
D. Osteomyelitis
There are reasons for and against the addition of potassium to the IV solution administered to Mr. Johnston. For the statement below, choose "For" or "Against": Mr. Johnston took his diuretic this morning, which may cause hypokalemia.
For
There are reasons for and against the addition of potassium to the IV solution administered to Mr. Johnston.For the statement below, choose "For" or "Against": Mr. Johnston received extra fluids in the ED, which may increase urine output and potassium loss.
For
There are reasons for and against the addition of potassium to the IV solution administered to Mr. Johnston.For the statement below, choose "For" or "Against": Mr. Johnston takes digoxin. Hypokalemia may promote digoxin toxicity.
For
30 m after giving analgesics to post THA pt , pt pain is unrelieved. That is a warning sign of which complication? A. Subcutaneous emphysema B. Skin breakdown C. Compartment syndrome D. Disuse syndrome
C. Compartment syndrome
Post kidney transplant pt appears anxious and tearful "My body is going to reject the kidney; I know I'm going to die." A. You've waited years for this transplant, you need to think positively. B. I understand your concerns, let's talk about them C. Don't think like that; I'm certain you will be fine D. If your body rejects kidney, you can have dialysis
B. I understand your concerns, let's talk about them
Which of the following is a risk for an older patient who is taking Vicodin and plain Tylenol frequently? A. The codeine will cause diarrhea. B. It is recommended that Tylenol not exceed 4 grams in 24 hours or liver problems may occur. C. Pain medication such as Tylenol is more effective than Vicodin. D. The patient should not need so much pain medication.
B. It is recommended that Tylenol not exceed 4 grams in 24 hours or liver problems may occur.
The patient asks what the Lovenox is for and why he needs it every day. What do you think the nurse should tell the patient? A. "Lovenox is given every day into your abdomen to prevent ulcer formation." B. "Lovenox is like synthetic heparin, which will prevent blood clots from developing in your legs." C. "Lovenox prevents red blood cell formation, which could cause clots in your veins." D. "This drug increases your platelets, which are important in helping your body fight infection."
B. "Lovenox is like synthetic heparin, which will prevent blood clots from developing in your legs."
With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)? A. A 50 year old with type 2 diabetes mellitus and cellulitis of the leg B. A 36 year old who had open reduction and internal fixation of the tibia C. A 25 year old receiving IV antibiotics through a peripheral line D. A 72 year old with dehydration and hypokalemia taking oral potassium supplements
B. A 36 year old who had open reduction and internal fixation of the tibia
The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 60 year old who was recently extubated and reports a sore throat. B. A 50 year old being mechanically ventilated who has tracheal deviation. C. A 30 year old receiving continuous positive airway pressure (CPAP) and has intermittent wheezing. D. A 40 year old receiving oxygen facemask and whose respiratory rate is 24 breaths/min.
B. A 50 year old being mechanically ventilated who has tracheal deviation.
Which of the following pieces of furniture should the nurse instruct a post THA pt to sit in at home? A. A reclining chair with an ottoman B. A straight-backed chair with an elevated seat C. A couch with plush cusions D. A rocking chair with a curved back
B. A straight-backed chair with an elevated seat
A client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, the client reports a new onset of pain at the surgical site. What is the nurse's best action? A. Reassure the client that pain is a direct result of increased activity B. Assess the surgical site and the affected extremity C. Administer pain medication as prescribed D. Assess the client for signs and symptoms of systemic infection
B. Assess the surgical site and the affected extremity
On returning to bed after ambulating, a THA pt who will discharge tomorrow, reports a new onset of pain. A. Administer pain meds as prescribed B. Assess the surgical site and the affected extremity C. Reassure the client that pain is a direct result of increased activity D. Assess the client for signs and symptoms of systemic infection
B. Assess the surgical site and the affected extremity
The nurse is caring for a patient who is postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? A. Assessment for flank or abdominal pain B. Assessment of the quantity of the client's urine output C. Assessment of the client's abdominal girth D. Assessment of the client's incision
B. Assessment of the quantity of the client's urine output
Nurse reviews THA pt ADLs prior to discharge. Nurse should identify what activity as posing a risk for hip dislocation? A. Straining during a bowel movement B. Bending down to put on socks C. Lifting items above shoulder level D. Transferring from a sitting to standing position
B. Bending down to put on socks
The nurse caring for pt with tracheostomy should maintain what cuff pressure? A. Between 10 and 15 mmHg B. Between 15 and 20 mmHg C. Between 20 and 25 mmHg D. Between 25 and 30 mmHg
B. Between 15 and 20 mmHg
Nurse caring for older adult who is being discharged post THA. What outcome must be met prior to discharge? A. Client is able to perform ADLs independently B. Client is able to preform transfers safely C. Client is able to weight-bear equally on both legs D. Client is able to demonstrate full ROM of the affected hip
B. Client is able to preform transfers safely
Case Study Q 2: Based on the patient's vital signs, what is the appropriate nursing action? A. Inform the provider of abnormal vital signs B. Complete an assessment of airway and respiratory status C. Provide patient teaching regarding relaxation techniques D. Notify the rapid response team for extra assistance
B. Complete an assessment of airway and respiratory status
After THA, the closed suction device had 320 mL of output in the first 24 hours. How should the nurse best respond? A. Inform the primary provider promptly B. Document this as an expected assessment finding C. Limit the client's fluid intake to 2 L for the next 24 hours D. Administer a loop diuretic as prescribed
B. Document this as an expected assessment finding
When planning preoperative teaching for pt undergoing thoracotomy, what information should the nurse communicate to pt? A. How to milk the chest tubing B. How to splint the incision when coughing C. How to take prophylactic antibiotics correctly D. How to manage the need for fluid restriction
B. How to splint the incision when coughing
The nurse understands that rejection of a transplanted kidney within 24 hour is termed A. Chronic rejection B. Hyperacute rejection C. Acute rejection D. Simple rejection
B. Hyperacute rejection
The ICU nurse is caring for a client who is postoperative day 1 following kidney transplantation from a living donor. The assessment revealed that the client is producing copious quantities of dilute urine. What is the nurse's most appropriate response? A. Administer exogenous antidiuretic hormone as prescribed. B. Recognize this as an expected finding. C. Inform the primary provider of this finding. D. Assess the client for further signs or symptoms of rejection.
B. Recognize this as an expected finding.
In addition to the pulmonary health care provider, which other member of the interprofessional team will the nurse expect to collaborate with most frequently when providing care to a client with a pulmonary embolism (PE)? A. Registered dietitian nutritionist B. Respiratory therapist C. Occupational therapist (OT) D. Pharmacist
B. Respiratory therapist
While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? A. Unilateral Neglect Related to Hematoma B. Risk for Ineffective Peripheral Tissue Perfusion C. Disturbed Kinesthetic Sensory Perception D. Risk for Infection
B. Risk for Ineffective Peripheral Tissue Perfusion
Nurse notes a post TKA pt developed hematoma at surgical site. Affected leg has decreased pedal pulse. Ng diagnosis is? A. Risk for infection B. Risk for ineffective peripheral tissue perfusion C. Unilateral neglect related to hematoma D. Disturbed kinesthetic sensory perception
B. Risk for ineffective peripheral tissue perfusion
An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? A. The presence of internal or external rotation B. Signs of neurovascular compromise C. The client's complaints of pain D. The presence of leg shortening
B. Signs of neurovascular compromise
Pt recovering from kidney transplant. Pt's urine output 1500 mL/12 hr since transplantation. Priority assessment? A. Checking skin turgor B. Taking blood pressure C. Assessing lung sounds D. Weighing the patient
B. Taking blood pressure
Pt undergoing thoracotomy is concerned too much pain to cough. What'd be appropriate nursing intervention for the pt? A. Teach him postural drainage B. Teach him how to perform huffing C. Teach him to use a mini-nebulizer D. Teach him how to use a metered dose inhaler
B. Teach him how to perform huffing
What is the rationale for the doctor's order for ferrous sulfate? A. The iron augments the effects of morphine. B. The medication provides iron, an essential component in the formation of hemoglobin. C. The iron that it contains will help to relieve constipation. D. Normally, digoxin depletes the body of iron; the patient should have been taking this medication before admission.
B. The medication provides iron, an essential component in the formation of hemoglobin.
Why is it important for Mr. Johnston to cough and use his incentive spirometer? Select All That Apply A. To prevent venous thromboembolism B. To prevent pneumonia C. To prevent pneumothorax D. To prevent atelectasis
B. To prevent pneumonia D. To prevent atelectasis
While caring for a client with a tracheostomy tube, the nurse should normally provide suctioning how often? A. Every 2 hours when the client is awake B. When adventitious breath sounds are auscultated C. When there is a need to prevent the client from coughing D. When the nurse needs to stimulate the cough reflex
B. When adventitious breath sounds are auscultated
Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client's condition is worsening? A. Increasing temperature B. Abdominal cramping C. Hand tremors D. Distended neck veins in the high-Fowler position
D. Distended neck veins in the high-Fowler position
Nurse is reviewing pt education prior to discharge of THA pt. Which pt statement indicates need for further pt teaching? A. I'll need to keep several pillows between my legs at night B. I need to remember not to cross my legs. It's such a habit C. Occ. therapist is showing me the use of a "sock puller" to help get dressed D. I'll need my husband to assist me in getting off the low toilet seat
D. I'll need my husband to assist me in getting off the low toilet seat
A nurse is planning the care of a client who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions? A. Administering medications safely B. Improving the client's adherence to treatment C. Helping the client come to terms with limitations D. Improving the client's level of function
D. Improving the client's level of function
What instructions should the nurse give to a pt post thoracotomy regarding activity immediately following discharge? A. Walk 1 mile (1.6 km) 3-4x a week B. Use weights daily to increase arm strength C. Walk on a treadmill 30 minutes daily D. Perform shoulder exercises five times daily
D. Perform shoulder exercises five times daily
What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)? A. Partial bronchial airway obstruction B. Thickened alveolar membranes and poor gas exchange C. Increased oxygen need resulting from a septic clot PE D. Shunting of deoxygenated blood to the left side of the heart
D. Shunting of deoxygenated blood to the left side of the heart
Nurse observes large amount of thick secretions visible in the trach. What is the priority nursing action? A. Add pulmonary toileting to daily interventions B. Instruct the UAP to sit with the patient until she is calmer C. Call the respiratory therapist for a stat bronchodilator treatment D. Suction the artificial airway and remove the secretions
D. Suction the artificial airway and remove the secretions
Nurse caring for pt scheduled for arthroplasty. Which pt statement indicates pt understands the procedure. A. This procedure determines the extent of joint damage B. This procedure will fuse my point to reduce my pain C. The procedure will prevent further joint damage D. This procedure will replace my joint to improve function
D. This procedure will replace my joint to improve function
Nurse preparing pt for a THA. For which of the following reasons should the nurse assess the client's vital signs? A. To prevent postoperative hypotension B. To determine how the client will tolerate the procedure C. To assess the client's pain level D. To establish a baseline for postoperative assessment
D. To establish a baseline for postoperative assessment
A post THA patient is confused and restless. What intervention by the nurse is most important to prevent injury? A. Administer mild sedation B. Keep all four siderails up C. Restrain the patient's hands D. Use an abduction pillow
D. Use an abduction pillow
