MS Final
Know tuberculosis: Mantoux test (PPD) interpretation. After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered: A) Not significant B) Significant C) Nonreactive D) Negative
B) Significant
Know nursing interventions to reduce risk of atelectasis and pneumonia in immobilized patients. A nurse is caring for a patient receiving skeletal traction. Due to the patients severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A) Perform chest physiotherapy once per shift and as needed. B) Teach the patient to perform deep breathing and coughing exercises. C) Administer prophylactic antibiotics as ordered. D) Administer nebulized bronchodilators and corticosteroids as ordered.
B) Teach the patient to perform deep breathing and coughing exercises. To prevent these complications, the nurse should educate the patient about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. Antibiotics, bronchodilators, and steroids are not used on a preventative basis and chest physiotherapy is unnecessary and implausible for a patient in traction.
Know osteoarthritis: Risk factors. A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? A) The patient has a 30 pack-year smoking history. B) The patients body mass index is 34 (obese). C) The patient has primary hypertension. D) The patient is 58 years old.
B) The patients body mass index is 34 (obese). Risk factors for osteoarthritis include obesity and previous joint damage. Risk factors of OA do not include smoking or hypertension. Incidence increases with age, but a patient who is 58 would not yet face a significantly heightened risk. Risk factors 1. Age 2. Obesity 3. Estrogen reduction at menopause 4. Injury 5. Frequent kneeling and stooping
Know burns: Emergent Phase - assessment of effectiveness of fluid resuscitation. The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply.
• Blood pressure • Heart rate • Urine output
Know burns: Priority question - Patient to be assessed first A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire
A) A 4-year-old scald victim burned over 24% of the body Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.
Know burns: Emergent Phase - Findings and management. (THREE QUESTIONS) An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells
A) Administer IV fluids
Know osteoporosis: Complications. An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? A) Bone fracture B) Loss of estrogen C) Negative calcium balance D) Dowagers hump
A) Bone fracture Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause, not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance is not a complication of osteoporosis. Dowagers hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.
Know burns: CO intoxication - S/S at the different percentages of CO in the blood. An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patients face is a cherry-red color. What should the nurse suspect? A) Carbon monoxide poisoning B) Anemia C) Jaundice D) Uremia
A) Carbon monoxide poisoning Carbon monoxide poisoning causes a bright cherry red color in the face and upper torso in light-skinned persons. In dark-skinned persons, there will be a cherry red color to nail beds, lips, and oral mucosa. When anemia occurs in light-skinned persons, the skin has generalized pallor. Anemia in dark-skinned persons manifests as a yellow-brown coloration. Jaundice appears as a yellow coloration of the sclerae. Uremia gives a yellow-orange tinge to the skin.
Know burns: Bacterial translocation in the gut - How to prevent it. A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation? A) Early enteral feeding B) Administration of prophylactic antibiotic C) Bowel cleansing procedures D) Administration of stool softeners
A) Early enteral feeding If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.
Know nursing intervention to prevent flexion contracture of the hip after a below-the-knee amputation (BKA) A nurse is caring for a patient 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. Which of the following measures will best achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day
A) Encouraging the patient to turn from side to side and to assume a prone position The nurse encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor muscles and to prevent flexion contracture of the hip. Postoperative ROM exercises are started early, because contracture deformities develop rapidly. ROM exercises include hip and knee exercises for patients with BKAs. The nurse also discourages sitting for prolonged periods of time.
Know burns: Electrolyte imbalance and Hematocrit and Hemoglobin disturbances during the emergent phase. A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis
Know burns: Emergent Phase - assessment of effectiveness of fluid resuscitation. A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.
Know burns: Medications - Sulfamylon - Adverse systemic reaction. The burn client is receiving treatments of Mafenide Acetate (Sulfamylon) to site of injury. Nurse monitors client knowing that which of the following indicates a systemic effect has occurred A) Hyperventilation B) Elevated blood pressure C) Local pain at burn site D)Local rash at burn site
A) Hyperventilation Carbonic Anhydrase inhibitor can suppress renal excretion of acid and can cause acidosis, monitor for signs of acid- base imbalance (hyperventilation). If occurs med discontinued for 1-2 days.
Know osteoporosis: Medications An older adult women current medication regimen includes alendronate (Fosamax). What outcome would indicate successful therapy? A) Increased bone mass B) Resolution of infection C) Relief of bone pain D) Absence of tumor spread
A) Increased bone mass Bisphosphonates such as Fosamax increase bone mass and decrease bone loss by inhibiting osteoclast function. These drugs do not treat infection, pain, or tumors.
Know risk for DVT for patients in traction: S/S The nurse assesses the patient in traction frequently. What signs or symptoms would the nurse assess for when assessing for a DVT in a traction patient? 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 Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.
Know cast care and compartment syndrome development - Prevention/Assessment. (TWO QUESTIONS) A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A) Prepare the patient for opening or bivalving of the cast. B) Obtain an order for a different analgesic. C) Encourage the patient to wiggle and move the fingers. D) Petal the edges of the patients cast.
A) Prepare the patient for opening or bivalving of the cast. Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure. Ordering different analgesics does not address the underlying problem. Encouraging the patient to move the fingers or perform range-of-motion exercises will not treat or prevent compartment syndrome. Petaling the edges of a cast with tape prevents abrasions and skin breakdown, not compartment syndrome.
Know burns: Emergent Phase - Findings and management. (THREE QUESTIONS) A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit B) Decreased prothrombin time (PT) C) Potassium deficit D) Decreased hematocrit
A) Sodium deficit Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, base-bicarbonate deficit, and elevated hematocrit. PT does not typically decrease.
Know osteomyelitis: Most common causative pathogen. A patient presents to a clinic complaining of a leg ulcer that isnt healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what? A) Staphylococcus aureus B) Proteus C) Pseudomonas D) Escherichia coli
A) Staphylococcus aureus S. aureus causes over 50% of bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent.
Know Psoriasis: Nursing education for patients receiving UV therapy with methoxsalen. A patient who has psoriasis is taking methoxsalen (Oxsoralen) to treat the condition along with receiving therapeutic ultraviolet A. The nurse notes burning and blistering of the patient's skin. Which action will the nurse take? A. Ask the patient about any recent exposure to sunlight. B. Explain to the patient that these signs mean the treatment is working. C. Report spread of the psoriasis to the patient's provider. D. Tell the patient to take the methoxsalen after the ultraviolet A treatment.
A. Ask the patient about any recent exposure to sunlight. Patients taking methoxsalen can develop burning and blistering with exposure to sunlight. These signs do not indicate efficacy of the treatment and do not mean the psoriasis is worsening. There is no indication for taking the drug after the UVA exposure.
Parkland formula/Rule of nine/ Math calculation question (TWO QUESTIONS). An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will give during the first 8 hours?
ANS- 600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr
Know Psoriasis: Findings (ALL THAT APPLY). MOST common areas for plaque psoriasis is? select all that apply A. Elbows B. Knees C. Trunk D. Genitals E. Nails
ANS- A,B A. Elbows B. Knees
Know Osteoporosis: Nutrients intake recommended to prevent it (ALL THAT APPLY). The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. The nurse should question the patient about her intake of what nutrients? Select all that apply. A) Calcium B) Simple carbohydrates C) Vitamin D D) Protein E) Soluble fiber
ANS- A,C A) Calcium C) Vitamin D A patients risk for osteoporosis is strongly influenced by vitamin D and calcium intake. Carbohydrate, protein, and fiber intake do not have direct effect on the development of osteoporosis.
Know Back Pain: Diagnostic assessments (ALL THAT APPLY). A nurse is caring for a patient who is being assessed following complaints of severe and persistent low back pain. The patient is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? that apply. A) Computed tomography (CT) B) Angiography C) Magnetic resonance imaging (MRI) D) Ultrasound E) X-ray
ANS- A,C,D,E A) Computed tomography (CT) C) Magnetic resonance imaging (MRI) D) Ultrasound E) X-ray A variety of diagnostic tests can be used to address lower back pain, including CT, MRI, ultrasound, and X-rays. Angiography is not related to the etiology of back pain.
Know acute respiratory failure: Assessment parameters to monitor (ALL THAT APPLY). A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply. A) Coping B) Level of consciousness C) Oral intake D) Arterial blood gases E) Vital signs
ANS- B,D,E B) Level of consciousness D) Arterial blood gases E) Vital signs Patients are usually treated in the ICU. The nurse assesses the patients respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.
Know fractures: complications. A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
ANS- C,D,E C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and CRPS are later complications of fractures
Know Osteoporosis: Nutrients intake recommended to prevent it (ALL THAT APPLY). A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrients? Select all that apply. A) Vitamin B12 B) Potassium C) Calcitonin D) Calcium E) Vitamin D
ANS- D,E D) Calcium E) Vitamin D A diet rich in calcium and vitamin D protects against skeletal demineralization. Intake of vitamin B12and potassium does not directly influence the risk for osteoporosis. Calcitonin is not considered to be a dietary nutrient.
Know equivalency of retained fluid and weight gained. The nurse caring for a patient with suspected renal dysfunction calculates that the patients weight has increased by 5 pounds in the past 24 hours. The nurse estimates that the patient has retained approximately how much fluid? A) 1,300 mL of fluid in 24 hours B) 2,300 mL of fluid in 24 hours C) 3,100 mL of fluid in 24 hours D) 5,000 mL of fluid in 24 hours
B) 2,300 mL of fluid in 24 hours An increase in body weight commonly accompanies edema. To calculate the approximate weight gain from fluid retention, remember that 1 kg of weight gain equals approximately 1,000 mL of fluid. Five lbs = 2.27 kg = 2,270 mL.
Know amputations: Rationale for the need of a pressure dressing on the end of the residual limb. The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patient's room and finds him resting in bed with his residual limb supported on a pillow. What is the nurse's most appropriate action? A) Inform the surgeon of this finding. B) Explain the risks of flexion contracture to the patient. C) Transfer the patient to a sitting position. D) Encourage the patient to perform active ROM exercises with the residual limb.
B) Explain the risks of flexion contracture to the patient.
Know asthma management: Peak flow meter - Green zone meaning/management, yellow zone meaning/management, red zone meaning/management. An asthma educator is teaching a patient newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the patient that a peak flow meter measures what value? A) Highest airflow during a forced inspiration B) Highest airflow during a forced expiration C) Airflow during a normal inspiration D) Airflow during a normal expiration
B) Highest airflow during a forced expiration
Know osteomyelitis: Associated diseases. A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis? A) Increase calcium and vitamin intake. B) Perform meticulous foot care. C) Exercise 3 to 4 times weekly for at least 30 minutes. D) Take corticosteroids as ordered.
B) Perform meticulous foot care. Diabetic foot ulcers have a high potential for progressing to osteomyelitis. Meticulous foot care can help mitigate this risk. Corticosteroids can exacerbate the risk of osteomyelitis. Increased intake of calcium and vitamins as well as regular exercise are beneficial health promotion exercises, but they do not directly reduce the risk of osteomyelitis.
Know burns: Management phases - Priority goals of each phase A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A) Monitoring fluid and electrolyte imbalances B) Providing education to the patient and family C) Treating infection D) Promoting thermoregulation
B) Providing education to the patient and family Patient and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the patient is still in the acute phase of burn recovery.
Know burns: Mechanical debridement - extent of the intervention The nurse is preparing the patient for mechanical dbridement and informs the patient that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from the viable tissue B) Removal of eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound
B) Removal of eschar until the point of pain and bleeding occurs Mechanical dbridementcan be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical dbridement can also be accomplished through the use of topical enzymatic dbridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural dbridement. Shaving the burned skin layers and early wound closure are examples of surgical dbridement.
Know hip replacement arthroplasty: Nursing care. A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient 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) Actually, patients are only on bed rest for 2 to 3 days before they begin walking with assistance. B) The physical therapist will likely help you get up using a walker the day after your surgery. C) Our goal will actually be to have you walking normally within 5 days of your surgery. D) For the first two weeks after the surgery, you can use a wheelchair to meet your mobility needs.
B) The physical therapist will likely help you get up using a walker the day after your surgery.
Know osteoarthritis: Joint findings During a head-to-toe assessment of a patient with osteoarthritis, you note bony outgrowths on the distal interphalangeal joints. You document these findings as: A. Bouchard's Nodes B. Heberden's Nodes C. Neurofibromatosis D. Dermatofibromas
B. Heberden's Nodes Bony outgrowths found on the DISTAL interphalangeal joint (closest to the fingernail and furthest away from the body) is called Heberden's Node. If the bony outgrowth was found on the PROXIMAL interphalangeal joint (middle joint of the finger...closest to the body) it is called Bouchard's Node.
Know chest tube care: Meanings of no tidaling in the water seal compartment. A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this?* A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.
B. The lung may have re-expanded or there is a kink in the system. You should see fluctuation (tidaling) of the fluid level in the water-seal chamber; if you don't, the system may not be patent or working properly, or the patient's lung may have re-expanded; Look for constant or intermittent bubbling in the water-seal chamber, which indicates leaks in the drainage system.
Know crutch gait for patients with amputations: Three-point gait, four-point gait, swing-through gait. While your patient is ambulating with crutches he moves both crutches forward along with the injured leg and then moves the non-injured forward. When you document you will note that the patient used what type of gait while ambulating with crutches? A. Two-point gait B. Three-point gait C. Four-point gait D. Swing-to-gait
B. Three-point gait
Know osteoporosis: Hormone involved in inhibiting bone resorption and promoting bone formation A nurse is reviewing the pathophysiology that may underlie a patient's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? A) Estrogen B) Parathyroid hormone (PTH) C) Calcitonin D) Progesterone
C) Calcitonin Calcitonin inhibits bone resorption and promotes bone formation, estrogen inhibits bone breakdown, and parathyroid increases bone resorption. Estrogen, which inhibits bone breakdown, decreases with aging. Parathyroid hormone (PTH) increases with aging, increasing bone turnover and resorption. Progesterone is the major naturally occurring human progestogen and plays a role in the female menstrual cycle.
Know cast care and compartment syndrome development - Prevention/Assessment. (TWO QUESTIONS) A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome
C) Compartment syndrome Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.
Know burns: Compressive garment - instructions for the use. A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment.How would the nurse instruct the patient to wear this garment? A) 4 to 6 hours a day for 6 months B) During waking hours for 2 to 3 months after the injury C) Continuously D) At night while sleeping for a year after the injury
C) Continuously
Know DVT: Risk factors Which of the following is the primary risk factor for pulmonary embolism? A)Smoking B)Heart disease C)Deep vein thrombosis D)Malignancy
C) Deep vein thrombosis
Know fractures: Nursing care for patient with cast. Handle the cast gently with an open palm to avoid denting the cast. Once the cast is thoroughly dry, the edges may need to be petaled to avoid skin irritation from rough edges and to prevent plaster of paris debris from falling into the cast and causing irritation or pressure necrosis. A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious. B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil. C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.
C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists. Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose. Several strips (petals) of tape are placed by the health care provider over the rough areas to ensure a smooth cast edge. Pain and discomfort can be minimized through proper alignment and positioning. Carefully observe dressings or casts for any signs of bleeding or drainage. Report a significant increase in size of the drainage area.
Know complications of hip fracture: S/S. A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient 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 patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome
C) Fat embolism syndrome Fat embolism syndrome occurs most frequently in young adults and elderly patients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.
Know complications of hip fracture: S/S. A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable. B) Use supplementary oxygen when transferring or mobilizing. C) Increase fluid intake and perform prescribed foot exercises. D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.
C) Increase fluid intake and perform prescribed foot exercises. Deep vein thrombosis (DVT) is among the most common complications related to a hip fracture. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. The patient should not be told to endure pain; a proactive approach to pain control should be adopted. While respiratory complications commonly include atelectasis and pneumonia, the use of deep-breathing exercises, changes in position at least every 2 hours, and the use of incentive spirometry help prevent the respiratory complications more than using supplementary oxygen. Bed rest may be indicated in the short term, but is not normally required for 14 days.
Know low back pain: Sciatic pain characteristics. A patient presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain? A) Bursitis B) Radiculopathy C) Sciatica D) Tendonitis
C) Sciatica Sciatica nerve pain travels down the back of the thigh to the foot of the affected leg. Bursitis is inflammation of a fluid-filled sac in a joint. Radiculopathy is disease of a nerve root. Tendonitis is inflammation of muscle tendons.
Know osteoporosis: Risk factors. A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe? A) Recurrent infections and prolonged use of NSAIDs B) High alcohol intake and low body mass index C) Small frame, female gender, and Caucasian ethnicity D) Male gender, diabetes, and high protein intake
C) Small frame, female gender, and Caucasian ethnicity Small-framed, nonobese Caucasian women are at greatest risk for osteoporosis. Diabetes, high protein intake, alcohol use, and infections are not among the most salient risk factors for osteoporosis.
Know amputations: Phantom limb pain - cause. Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain? A) Apply intermittent hot compresses to the area of the amputation. B) Avoid activity until the pain subsides. C) Take opioid analgesics as ordered. D) Elevate the level of the amputation site
C) Take opioid analgesics as ordered.
Know COPD (Emphysema and Chronic bronchitis) management - Oxygen administration. A patient diagnosed with chronic obstructive pulmonary disease (COPD) is on oxygen therapy at 3 L per nasal cannula. Which assessment finding should alert the nurse to a potential problem with this patient? a. Respiratory rate of 26 B. Low carbon dioxide levels C. Arterial oxygen saturation level of 99% D. Lower oxygen saturation levels at night than during the day
C. Arterial oxygen saturation level of 99% Clients who have COPD can need 2 to 4 L/min of oxygen via nasal cannula or up to 40% via Venturi mask. Clients who have chronically increased PaCO2 levels usually require 1 to 2 L/min of oxygen via nasal cannula.
Know burns: Curling's ulcers - assessment of effectiveness of the treatment. A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? A. Anemia B. Cardiac arrest C. Gastric ulcers D. Hyperthyroidism
C. Gastric ulcers The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.
Know Osteoarthritis: Joints involved (ALL THAT APPLY) The nurse is teaching a class about the joints commonly affected by osteoarthritis (OA). Which joints should the nurse include? A. Ankles, feet, and spine B. Knees, feet, and spine C. Hands, knees, and hips D. Neck, shoulders, and ankles
C. Hands, knees, and hips Hands, knees, and hips are the most commonly affected joints of OA. Feet, spine, neck, shoulders, and ankles are not the most common locations.
Know crutch gait for patients with amputations: Three-point gait, four-point gait, swing-through gait. While using crutches the patient moves both crutches forward and then moves both legs forward past the placement of the crutches. This is known as the: A. Two-point gait B. Swing-to-gait C. Swing-through-gait D. Three-point gait
C. Swing-through-gait
Know drug considerations: Digoxin and hydrochlorothiazide - possible complication - Assessment. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. take the digoxin if the pulse is below 60 beats/min.
C. notify the health care provider if nausea develops. Nausea is an indication of digoxin toxicity and should be reported so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. The patient will need to include potassium-containing foods in the diet to avoid hypokalemia. Patients should be taught to check their pulse daily before taking the digoxin and if the pulse is less than 60 beats/min, to call their provider before taking the digoxin. Diuretics should be taken early in the day to avoid sleep disruption.
Know burns: Electrical burns - Assessment - Complication - Management (TWO QUESTIONS). Which of the following complications is common for victims of electrical burns? A.) Inhalation injury B.) Hypovolemic shock C.) Infection D.) Cardiac dysrhythmia
D) Cardiac dysrhythmia Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.
Parkland formula/Rule of nine/ Math calculation question (TWO QUESTIONS). A patient arrives in the emergency department after being burned in a house fire. The patients burns cover the face and the left forearm. What extent of burns does the patient most likely have? A) 13% B) 25% C) 9% D) 18%
D) 18% When estimating the percentage of body area or burn surface area that has been burned, the Rule of Nines is used: the face is 9%, and the forearm is 9% for a total of 18% in this patient.
Know burns: Inhalation Injury/CO intoxication - Management. A patient is brought to the ED by paramedics, who report that the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is the priority in the care of a patient who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management
D) Airway management Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.
Know cast care and compartment syndrome development - Prevention/Assessment. (TWO QUESTIONS) A patient has had a cast placed for the treatment of a humeral fracture. The nurses most recent assessment shows signs and symptoms of compartment syndrome. What is the nurses most appropriate action? A) Arrange for a STAT assessment of the patients serum calcium levels. B) Perform active range of motion exercises. C) Assess the patients joint function symmetrically. D) Contact the primary care provider immediately.
D) Contact the primary care provider immediately. This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment. Assessment of calcium levels is unnecessary.
Know low back pain: Treatment for patients non responsive to the traditional approach. A nurse is reviewing the care of a patient who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug? A) Calcitonin B) Prednisone C) Aspirin D) Cyclobenzaprine
D) Cyclobenzaprine Short-term prescription muscle relaxants (e.g., cyclobenzaprine [Flexeril]) are effective in relieving acute low back pain. ASA is not normally used for pain control, due to its antiplatelet action and associated risk for bleeding. Calcitonin and corticosteroids are not used in the treatment of lower back pain.
Priority question of patients with hypertension - Know complications - Patient to be assessed first. The home health nurse is caring for a patient who has a comorbidity of hypertension. What assessment question most directly addresses the possibility of worsening hypertension? A) Are you eating less salt in your diet? B) How is your energy level these days? C) Do you ever get chest pain when you exercise? D) Do you ever see spots in front of your eyes?
D) Do you ever see spots in front of your eyes? To identify complications or worsening hypertension, the patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a beneficial lifestyle modification, but nonadherence to this is not necessarily a sign of worsening symptoms.
Know burns: S/S of different type of burns - Know rule of Nine. A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness
D) Full-thickness A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the patient will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn.
Know fractures: open, comminuted, intra articular, and greenstick. Radiographs of a boys 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? A) Impacted B) Compound C) Compression D) Greenstick
D) Greenstick Greenstick fractures are an incomplete fracture that results in the bone being broken on one side, while the other side is bent. This is not characteristic of an impacted, compound, or compression fracture.
Know total hip replacement: patient's teaching. A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patients statements would indicate to the nurse that the patient requires further 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) The occupational therapist is showing me how to use a sock puller to help me get dressed. D) I will need my husband to assist me in getting off the low toilet seat at home.
D) I will need my husband to assist me in getting off the low toilet seat at home. To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.
Know contact dermatitis: Management A patient has developed severe contact dermatitis with burning, itching, cracking, and peeling of the skin on her hands. What should the nurse teach the patient to do? A) Wear powdered latex gloves when in public. B) Wash her hands with antibacterial soap every few hours. C) Maintain room temperature at 75F to 80F whenever possible. D) Keep her hands well-moisturized at all times.
D) Keep her hands well-moisturized at all times. Powdered latex gloves can cause contact dermatitis. Skin should be kept well-hydrated and should be washed with mild soap. Maintaining room temperature at 75F to 80F is not necessary.
Know tuberculosis: Mantoux test (PPD) interpretation. A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result? A) Uncertain B) Positive C) Borderline D) Negative
D) Negative
Know burns: Autograft and grafting management. A nurse is caring for a patient whose chemical injury has necessitated a skin graft to his left hand. The nurse enters the room and observes that the patient is performing active range of motion (ROM) exercises with the affected hand. How should the nurse best respond? A) Liaise with the physical therapist to ensure that the patient is performing exercises safely. B) Validate the patients efforts to increase blood perfusion to the graft site. C) Remind the patient that ROM exercises should be passive, not active. D) Remind the patient of the need to immobilize the graft to facilitate healing.
D) Remind the patient of the need to immobilize the graft to facilitate healing. The nurse should instruct the patient to keep the affected part immobilized as much as possible in order to facilitate healing. Passive ROM exercises can be equally as damaging as active ROM.
Know tuberculosis: Transmission/precautions A patient on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? A) Standard precautions only B) Droplet precautions C) Standard and contact precautions D) Standard and airborne precautions
D) Standard and airborne precautions Airborne precautions are required for proven or suspected pulmonary TB. Standard precaution techniques are used in conjunction with the transmission-based precautions, regardless of the patients diagnosis. Droplet and contact precautions are insufficient.
Know COPD (Emphysema and Chronic bronchitis) management - Oxygen administration. A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response? A) The patients calcium will rise dramatically due to pituitary stimulation. B) Oxygen will increase the patients intracranial pressure and create confusion. C) Oxygen may cause the patient to hyperventilate and become acidotic. D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patients calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patients intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.
Parkland formula/Rule of nine/ Math calculation question (TWO QUESTIONS). A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? A. 18% B. 36% C. 9% D. 27%
D. 27% According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.
Know MI: Use of thrombolytics - assessment to determine usefulness of the therapy. A patient with ST-segment elevation in three contiguous electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?
c. "What time did your chest pain begin?" Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information will also be needed, but it will not be a factor in the decision about thrombolytic therapy.
Know Psoriasis: Nursing education for patients receiving UV therapy with methoxsalen. Methoxsalen (Oxsoralen) is a drug used for the treatment of psoriasis. Clients using this agent should not be in direct sunlight for which reason? a. Skin could become lightened or blanched. b. Psoriasis would spread. c. Exposed skin would burn or blister. d. Skin would become sensitive to light.
c. Exposed skin would burn or blister.
Know burns: Medications - Sulfamylon - Expected side effect. Mafenide Acetate (Sulfamylon) is prescribed for client with burn injury. When applying lotion client complains of local discomfort and burning. which of following is most appropriate action by RN? a. Notify physician b. Discontinue medication c. Inform client this is normal d. Apply thinner film than prescribed
c. Inform client this is normal Bacteriostatic for gram positive/ negative organisms used to treat burns to reduce bacteria present in avascular tissue. Will cause local burning/ discomfort and this is normal
Know tuberculosis: Transmission/precautions When caring for a patient who has been diagnosed with active tuberculosis, which of the following personal protection equipment will the healthcare provider wear? a.Sterile gloves b.Eye goggles c.Surgical mask d.Personal respirator (N-95)
d.Personal respirator (N-95)
