Musculoskeletal Disorders - ML8 (1)

A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. How should the nurse respond to the client's concern? "Don't worry. Your new hip is very strong." "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation." "Use of a cushioned toilet seat helps to prevent dislocation."

"Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.

A client recovering from lumbar surgery is fitted for a contour splint. What should the nurse explain to the client about this device? "The splint immobilizes the body part in a functional position." "The splint permits free range of motion of the body area." "The splint supports the spine while you are in traction." "The splint will not be removed for several weeks."

"The splint immobilizes the body part in a functional position." Contoured splints are used for health issues to immobilize the area and support the body part in a functional position. Splints are easily removed and are not indicated for use in traction. The splint prevents, not permits, free range of motion of the body area.

A client being discharged after treatment for a compound fracture asks why antibiotics are needed for a broken bone. Which response by the nurse is most appropriate? "This prophylactic antibiotic therapy is required because your bone broke through your skin." "The antibiotics are prescribed to help the bone heal more quickly and more strongly." "If your temperature is normal for 48 hours, you may discontinue the medication." "You may discuss your prescriptions with your healthcare provider at your follow-up appointment."

"This prophylactic antibiotic therapy is required because your bone broke through your skin." The client should be instructed that antibiotics are prescribed as a preventive measure after a compound fracture because such fractures expose the bone to the environment and possible infection. Directing the client to discuss prescribed medications with the healthcare provider at a follow-up appointment does not address the client's questions or immediate needs. The client needs this medication regardless of body temperature. Antibiotics are not used to enhance the healing of a bone fracture.

The nurse is caring for a client admitted for pneumonia with a history of hypertension and heart failure. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. Using the Morse Fall Scale (see chart), what is this client's total score and risk level? 60, high risk 40, medium risk 30, medium risk 20, low risk

60, high risk Several factors designate this client as a high fall risk based on the Morse Fall Scale: history of falling (25), secondary diagnosis (15), plus IV access (20). The client's total score is 60. There is also concern that the client's gait is at least weak if not impaired due to hospitalization for pneumonia, which may add to the client's fall risk. After evaluating the client's risk, the nurse must develop a plan and take action to maximize the client's safety.

A client has a fiberglass cast on the right arm which was placed after internal fixation 1 week ago. The nurse notes a warm area on the cast. What priority action should the nurse take? Apply an ice pack to the warm area of the cast. Assess client's temperature and interview about pain at the site. Ask the client if the cast has gotten wet recently. Elevate the casted arm above the level of the heart.

Assess client's temperature and interview about pain at the site. The nurse noting a warm area on the cast should alert to the possibility of infection. Internal fixation involves surgical intervention, and once the cast is applied, the surgical site is not readily visible. The warm area may indicate inflammation at the site. Additional signs of infection include fever and increased pain. A fiberglass cast can get wet, and being wet does not increase warmth. If swelling and pain is present, ice and elevation is recommended but is not the priority over assessing for signs of infection.

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action? Assess range of motion. Administer I.V. morphine sulfate as needed. Elevate the ankle. Apply a warm compress.

Elevate the ankle. Soft tissue injuries should be treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase the risk of further injury. Morphine is not the drug of choice for pain due to inflammation.

A client was undergoing conservative treatment for a herniated nucleus pulposus, at L5 - S1, which was diagnosed by magnetic resonance imaging. Because of increasing neurological symptoms, the client undergoes lumbar laminectomy. The nurse should take which step during the immediate postoperative period? Logroll the client from side to side. Have the client sit up in a chair as much as possible. Elevate the head of the bed to 90 degrees. Discourage the client from doing any range-of-motion (ROM) exercises.

Logroll the client from side to side. Logrolling the client maintains alignment of the hips and shoulders and eliminates twisting in the operative area. The nurse should encourage ROM exercises to maintain muscle strength. Because of pressure on the operative area, having the client sit up in a chair or with the head of the bed elevated should be allowed only for short durations.

The nurse teaches the client to perform isometric exercises to strengthen the leg muscles after arthroplasty. Isometric exercises are particularly effective for clients with rheumatoid arthritis because they: strengthen the muscles while keeping the joints stationary. involve clients in their own care and thus improve morale. do not require specialized equipment. prevent joint stiffness.

strengthen the muscles while keeping the joints stationary. An exercise program is recommended to strengthen muscles after arthroplasty. Isometric (or muscle-setting) exercises strengthen muscles but keep the joint stationary during the healing process.Isometric exercise do not require specialized equipment, but this does not explain the benefits of the exercises.Isometric exercises may help improve a client's morale by promoting self-care, but this is not the reason for doing them.Because the joint is kept stationary, isometric exercise will not help prevent joint stiffness.

A nurse is teaching a client who was recently diagnosed with carpal tunnel syndrome. Which statement should the nurse include? "This condition is associated with various sports." "Using arm splints will prevent hyperflexion of the wrist." "Surgery is the only sure way to manage this condition." "Ergonomic changes can be incorporated into your workday to reduce stress on your wrist."

"Ergonomic changes can be incorporated into your workday to reduce stress on your wrist." Ergonomic changes, such as adjusting keyboard height, can help clients with carpal tunnel syndrome avoid hyperextension of the wrist. This condition is associated with repetitive tasks such as clerical work, not sports. The condition may be managed with medications, yoga, acupuncture, and wrist (not arm) splints.

A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge? "I will implement the exercise program as soon as I get home." "I will be careful not to cross my legs." "I can't wait to take a tub bath when I get home." "I will need an elevated toilet seat."

"I can't wait to take a tub bath when I get home." The client will need to avoid extremes of motion in the hip to avoid dislocation. The hip should not be flexed more than 90 degrees, internally rotated, or legs crossed. It is not possible to safely sit in the bathtub without flexing the hip beyond the recommended 90 degrees. The client can implement the prescribed exercise program at the time of discharge home. The client should take care not to stress the hip for 3 to 6 months after surgery. An elevated toilet seat will be necessary during the recovery from surgery.

A home care nurse visits a client with muscular dystrophy. Which comment by the client indicates that more information about an advance directive is needed? "I'm going to the doctor to get a new brace next week." "I've documented that my younger brother will make decisions about my care for me if I am not able to." "I've got a sore on my heel where my wheelchair rubs." "I don't ever want a feeding tube when the time comes that I can't eat."

"I don't ever want a feeding tube when the time comes that I can't eat." The client states a desire not to have a feeding tube but does not say that this wish is formally documented. There may be a need for teaching about advance directives. When the client says that a specific relative will make decisions and that this intent is documented, it is unlikely that further teaching is needed. Statements about a new brace or a sore relate to the client's condition and care plan and are not relevant to advance directives.

A client undergoes a total hip replacement. Which statement made by the client indicates to the nurse that the client requires further teaching? "The occupational therapist is showing me how to use a sock puller to help me get dressed." "I'll need to keep several pillows between my legs at night." "I need to remember not to cross my legs. It's such a habit." "I don't know if I'll be able to get off that low toilet seat at home by myself."

"I don't know if I'll be able to get off that low toilet seat at home by myself." The client requires additional teaching if they are concerned about using a low toilet seat. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. The nurse should instruct the client to use assistive devices, such as a raised toilet seat, 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. Teaching the client to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a client get dressed without flexing the hips beyond 90 degrees.

A client undergoes an arthroscopy at the outpatient clinic. After the procedure, the nurse provides discharge teaching. Which response by the client indicates the need for further teaching? "My physician may prescribe pain pills after the procedure." "Elevating my leg will reduce swelling after the procedure." "I may notice some bruising or swelling in my knee." "I should use my heating pad this evening to reduce some of the pain in my knee."

"I should use my heating pad this evening to reduce some of the pain in my knee." The client requires additional teaching if he states that he'll use a heating pad to reduce pain the evening of the procedure. The client shouldn't use heat at the procedure site during the first 24 hours because doing so may increase localized swelling. Ice is indicated during this time. Elevating the extremity helps reduce swelling. The client may experience some discomfort after the procedure for which the physician may order medication. Bruising and swelling are common after an arthroscopy.

A nurse is caring for a client who complains of lower back pain. Which instruction should the nurse give to the client to prevent back injury? "Stand close to the object you're lifting." "Narrow the stance when lifting." "Push or pull an object using your arms." "Bend over the object you're lifting."

"Stand close to the object you're lifting." Standing close to an object when lifting moves the body's center of gravity closer to the object, allowing the legs, rather than the back, to bear the weight. No one should bend over an object when lifting; instead, the back should be straight, and bending should be at the hips and knees. When lifting, spreading the legs apart widens the base of support and lowers the center of gravity, providing better balance. Pushing or pulling an object using the weight of the body, rather than the arms or back, prevents back strain. Using a larger number of muscle groups distributes the workload.

After the nurse teaches a client about wearing a back brace after a spinal fusion, which statement indicates effective teaching? "I should wear a thin cotton undershirt under the brace." "I will be sure to pad the area around my iliac crest." "I will apply lotion before putting on the brace." "I can use baby powder under the brace to absorb perspiration."

"I should wear a thin cotton undershirt under the brace." The client should wear a thin cotton undershirt under the brace to prevent the brace from abrading directly against the skin. The cotton material also aids in absorbing any moisture, such as perspiration, that could lead to skin irritation and breakdown. Applying lotion is not recommended before applying the brace because further skin breakdown can result (related to the collection of moisture where microorganisms can grow). Applying extra padding (e.g., to the iliac crests) is not recommended because the padding can become wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder and lotion is not recommended, because they can cause irritation and skin breakdown.

A client had a total hip replacement today. How should the nurse position the client when the client is transferred from the transport cart to the bed? Keep the lower extremities adducted by use of an immobilization device around both legs. Place weights alongside the affected extremity to keep the extremity from rotating. Maintain the affected extremity in slight abduction using an abduction splint or pillows placed between the thighs. Elevate both feet on two pillows.

"Pace yourself and rest frequently, especially after activities." A client with osteoarthritis must adapt to this chronic and disabling disease, which causes deterioration of the joint cartilage. The most common symptom of the disease is deep, aching joint pain, particularly in the morning and after exercise and weight-bearing activities. Because rest usually relieves the pain, the nurse should instruct the client to rest frequently, especially after activities, and to pace themself during daily activities. Telling the client to do the chores in the morning is incorrect because the pain and stiffness of osteoarthritis are most pronounced in the morning. Telling the client to do all chores after performing morning exercises or in the evening is incorrect because the client should pace themself and take frequent rests rather than doing all chores at once.

A client with osteoarthritis tells the nurse they are concerned that the disease will prevent them from doing their chores. Which suggestion should the nurse offer? "Pace yourself and rest frequently, especially after activities." "Do all your chores in the evening, when pain and stiffness are least pronounced." "Do all your chores in the morning, when pain and stiffness are least pronounced." "Do all your chores after performing morning exercises to loosen up."

"Pace yourself and rest frequently, especially after activities." The most likely indication of a dislocated hip is a shortening of the affected leg. Other indications of dislocation include increasing pain, loss of function to the extremity, and deformity. Abduction of the leg after total hip replacement is a desirable position to prevent dislocation. Loosening of the prosthesis does not necessarily indicate that the hip has dislocated. External rotation of the hip can occur without the hip's being dislocated. However, a neutral position of rotation is the desired position.

X-rays reveal a leg fracture in a client who was brought to the emergency department after falling on ice. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs? "Place both crutches on the first step and swing both legs upward to this step." "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." "Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side follow." "Place the crutches and injured leg on the first step, followed by the unaffected leg."

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg moving together. Any other method is incorrect and could increase the client's risk of falling.

On a visit to the family physician, a client is diagnosed with a bunion on the lateral side of the great toe, at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session? "Bunions may result from wearing shoes that are too big, causing friction when the shoes slip back and forth." "Bunions are congenital and can't be prevented." "Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." "Bunions are caused by a metabolic condition called gout."

"Some bunions are congenital; others are caused by wearing shoes that are too short or narrow." Bunions may be congenital or may be acquired by wearing shoes that are too short or narrow, which increases pressure on the bursa at the metatarsophalangeal joint. Acquired bunions can be prevented. Wearing shoes that are too big may cause other types of foot trauma but not bunions. Gout doesn't cause bunions. Although a client with gout may have pain in the big toe, such pain doesn't result from a bunion.

A nurse is performing an admission assessment on a client admitted with a pelvic fracture. Which statement by the client requires the nurse to seek more information from a legal standpoint? "I'm going to need help at home after I'm discharged." "Sometimes my spouse gets so angry with me." "I'm afraid I'll lose my job because I'm going to miss so much work." "I'm so clumsy."

"Sometimes my spouse gets so angry with me." Legally, the nurse must further investigate the client's statement concerning the spouse's anger. This statement suggests that the client's injury might be caused by domestic abuse. The other statements are common and don't require further investigation, from a legal standpoint, by the nurse.

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? "The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." "Bleeding is a complication associated with the continuous passive motion device." "The continuous passive motion device can decrease the development of adhesions." "Monitoring skin integrity is important while the continuous passive motion device is in place."

"The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." Further staff education is needed when the nurse states that the continuous passive motion device isn't needed because the client receives physical therapy twice per day. The continuous passive motion device should be used in conjunction with physical therapy because the device helps prevent adhesions. Bleeding is a complication associated with the continuous passive motion device; skin integrity should be monitored while the device is in use.

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine if the client is positive for the disorder. Which statement by the nurse is most accurate? "The diagnosis won't be based on the findings of a single test but by combining all data found." "You should discuss that matter with your physician." "SLE is a very serious systemic disorder." "Tell me more about your concerns about this potential diagnosis."

"The diagnosis won't be based on the findings of a single test but by combining all data found." There is no single test available to diagnose SLE. Therefore, the nurse should inform the client that diagnosis is based on combining the findings from the physical assessment and the laboratory tests results. Advising the client to speak with the physician, stating that SLE is a serious systemic disorder, and asking the client to express their feelings about the potential diagnosis don't answer the client's question.

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond? "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability." "This form of muscular dystrophy is a relatively benign disease that progresses slowly." "You should ask your physician about that." "You may experience progressive deterioration in all voluntary muscles."

"You may experience progressive deterioration in all voluntary muscles." The nurse should tell the client that muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician. Limb-girdle muscular dystrophy causes a gradual decrease in arm and pelvic muscle strength, resulting in slight disability. Facioscapulohumeral muscular dystrophy is a slowly progressive, relatively benign form of muscular dystrophy; it usually arises before age 10.

The day after a thoracotomy, a client experiencing intense incision pain has a temperature of 99° F (37.2° C); heart rate 96 beats/minute; blood pressure 136/86 mm Hg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases and an oxygen saturation of 98%. Which nursing action is the priority? Assist the client out of bed to sitting up in a chair. Turn and reposition the client every 2 hours when in bed. Administer analgesic medications as prescribed. Provide antipyretics as prescribed to reduce the fever.

Administer analgesic medications as prescribed. The priority is to relieve the pain and make the client comfortable. The vital signs are possible evidence of acute discomfort, although further assessment would be needed. Once the client is comfortable, assisting the client out of bed or turning and repositioning when in bed would be accomplished without adding to the discomfort. There is no evidence of acute respiratory complications; the oxygen saturation level is normal. Antipyretic medication would not be indicated for a client with this temperature.

After undergoing surgery the previous day for a total knee replacement, a client states not feeling ready to ambulate yet. What should the nurse do? Tell the client that they will contact the physician and report the client's noncompliance. Do nothing because the client has the ultimate right to determine the degree of participation. Document the client's refusal to ambulate. Discuss the complications that the client may experience if they don't cooperate with the care plan.

Discuss the complications that the client may experience if they don't cooperate with the care plan. The nurse should discuss the care plan and its rationale with the client. Calling the physician to report the client's noncompliance won't alter the client's degree of participation and shouldn't be used to force the client to comply. Doing nothing isn't acceptable. Although the client does have the right to make choices, it's the nurse's responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client's refusal, the nurse should first discuss the care plan with the client.

The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. What should the nurse advise the client to do? Ask the health care provider for a change of antibiotics. Eat a diet high in protein and vitamins C and D. Use herbal supplements. Encourage frequent passive range-of-motion to the affected extremity.

Eat a diet high in protein and vitamins C and D. The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, turmeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time.

Following a client's total hip replacement, what should the nurse do? Select all that apply. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours. For meals, elevate the head of the bed to 90 degrees. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises. Encourage the client to use the overhead trapeze to assist with position changes. Use a fracture bedpan when needed by the client.

Encourage the client to use the overhead trapeze to assist with position changes. Use a fracture bedpan when needed by the client. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises. Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.

The nurse is counseling a client with osteoporosis about dietary choices to slow bone loss. What foods should the nurse teach the client to avoid? Canned fish such as salmon or tuna Foods and beverages high in caffeine Soy beans and soy products such as tofu Foods high in purines such as organ meats

Foods and beverages high in caffeine Caffeine may decrease calcium absorption and contribute to bone loss so should be avoided in high amounts. To help prevent osteoporosis, the nurse should encourage the client to consume at least the recommended daily allowance (RDA) of calcium. Before menopause, the RDA is 1,000 mg; after menopause, it is 1,500 mg. Foods high in calcium included canned fish (especially with bones) and dairy products. Uric acid levels are controlled with decreased purine intake, and this is related to risk for gout and does not relate to osteoporosis. Soy products have not been proven to reduce bone loss but may confer some benefits and do not need to be avoided.

A client complains that they experience pain and numbness in the fingers when typing on a computer keyboard. Which action will help the nurse assess for Phalen's sign? Having the client extend their wrists while the nurse provides resistance Having the client hold both hands above their head with their arms straight for 30 seconds Tapping gently over the median nerve in the wrist Having the client hold both wrists in acute flexion with the dorsal surfaces touching for 60 seconds

Having the client hold both wrists in acute flexion with the dorsal surfaces touching for 60 seconds Acute wrist flexion places pressure on the inflamed median nerve, causing the pain and numbness of carpal tunnel syndrome (Phalen's sign). Holding the hands above the head with arms straight for 30 seconds isn't an assessment technique. Tapping gently over the median nerve in the wrist tests for Tinel's sign, another sign of carpal tunnel syndrome. Placing the wrists in extension against resistance tests strength.

When developing a care plan for a client newly diagnosed with scleroderma, which nursing diagnosis has the highest priority? Impaired skin integrity Imbalanced nutrition: More than body requirements Risk for constipation Impaired gas exchange

Impaired skin integrity Impaired skin integrity is a concern for the client with scleroderma in its earlier stages. Meticulous skin care is required to prevent complications. Although Risk for constipation may also be appropriate, this nursing diagnosis isn't the priority. Clients with scleroderma are at risk for Imbalanced nutrition: Less than body requirements. The client with advanced scleroderma, not newly diagnosed scleroderma, is at increased risk for developing respiratory complications.

An older adult with a hip fracture is to use an alternating air pressure mattress at home to prevent pressure ulcers while recovering from surgery. The nurse is showing the client's family how to place the mattress (see below). What should the nurse instruct the family to do? Place the sheet on the bed, and then remove the pillow to allow full use of the mattress on the neck. Put a thick pad over the pressure mattress to prevent soiling, and place the bed sheet on top of the pad. Turn the mattress over so the air cells face the mattress of the bed, and cover the mattress with a bed sheet. Make the bed with the bedsheet on top of the pressure mattress.

Make the bed with the bedsheet on top of the pressure mattress. To obtain best results, one sheet should be used to cover the mattress. The air cells should be facing up as shown. Thick pads should not be used; if the client is incontinent, a "breathable" incontinent pad can be added. The client can use a pillow as needed.

The nurse is planning care with an older adult who is at risk for falling because of postural hypotension. Which intervention will be most effective in preventing falls in this client? Complete a fall diary. Attach a sensor to the client that will alarm when client attempts to get up. Encourage a family member to stay with the client. Instruct the client to sit, obtain balance, dangle legs, and rise slowly.

Instruct the client to sit, obtain balance, dangle legs, and rise slowly. There are many risk factors for falls in older adults. Postural hypotension is a common risk. The nurse should instruct the client about postural hypotension and provide practical information regarding how to sit on the bed or chair, dangle the legs first and then rise slowly, supported by a walker if necessary.A diary of instances of an individual's falls may predict future falls by tracking the events and behaviors at the time of the fall, but it is not the most effective in preventing the fall.Asking a family member to be present at all times is not necessary or realistic for this client whose fall risk is attributed to the potential for postural hypotension.Attaching a sensor to the client or bed is reserved for clients who are at a serious risk for injury.

A client has a C7 spinal cord injury. Which would be the most important nursing intervention during the acute stage of the injury? Maintain a patent airway. Turn and reposition every 2 hours. Monitor vital signs. Maintain proper alignment.

Maintain a patent airway. Initial care is focused on establishing and maintaining a patent airway and supporting ventilation. Innervation to the intercostal muscles is affected; if spinal edema extends to the C4 level, paralysis of the diaphragm usually occurs. The effects and extent of edema are unpredictable in the first hours, and respiratory status must be closely monitored. Suction equipment should be readily available.Monitoring vital signs, maintaining proper alignment, and turning and positioning are important, but the priority nursing intervention is maintaining a patent airway.

A client is being discharged following an open reduction and internal fixation of the left ankle, and is to wear a non-weight-bearing cast for 2 weeks. What should the nurse teach the client to do when using crutches? Maintain two to three finger widths between the axillary fold and underarm piece grip. Maintain balance by supporting body's weight on the axillae. Keep leg dependent when sitting. Use a four-point gait.

Maintain two to three finger widths between the axillary fold and underarm piece grip. The nurse instructs the client to maintain two finger widths between the axillary fold and the underarm piece grip of the crutches to prevent pressure on the brachial plexus. The client is advised to use the three-point gait; in the four-point and two point-gait there is partial weight bearing of both feet. The client is also advised to keep the affected leg elevated when sitting to prevent swelling, and to use the arms, not the axillae, to maintain balance and support.

The nurse is caring for a client who is 30 years of age with a fracture of the right femur and left tibia. Both legs have casts. The nurse assesses the following: respirations are 30 per minute and are rapid and shallow; there is presence of faint expiratory wheeze; and coughing produces thin pink sputum. The client is yelling at the nurse and wants to be released from the hospital; this is behavior unlike that previously reported. The last pain medication was administered 3 hours ago. What should the nurse do first? Administer pain medication. Cut slits in the top of the casts. Prescribe a chest X-ray. Notify the health care provider (HCP).

Notify the health care provider (HCP). The nurse's first action is to notify the HCP because the client is likely experiencing a fat embolus. Fat emboli are associated with embolization of marrow or tissue fat or platelets and free fatty acids to the pulmonary capillaries, producing rapid onset of symptoms. Multiple fractures and fractures of the long bones or pelvis increase a client's risk for developing a fat embolus; in addition, young adults between 20 and 30 years of age are at a higher risk for fat emboli with fractures. When fat emboli do occur, hypoxia results; therefore, it is most important the nurse assess changes in level of consciousness and observe changes in behavior such as restlessness and irritability. The nurse does not cut the cast; there is no indication that the casts are obstructing circulation. ABGs are used to confirm the diagnosis, not a chest X-ray. The client's behavior is a result of hypoxemia, not pain.

A client who has had a total hip replacement has a dislocated hip prosthesis. What should the nurse do first? Apply an ice pack to the affected hip. Notify the orthopedic surgeon. Stabilize the leg with Buck's traction. Position the client toward the opposite side of the hip.

Notify the orthopedic surgeon. If a prosthesis becomes dislocated, the nurse should immediately notify the surgeon. This is done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintain circulation. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. If prescribed by the surgeon, an ice pack may be applied post-reduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may prescribe the client be turned toward the side of the reduced hip, but that is not the nurse's first response.

A client arrives via ambulance with a suspected pelvic fracture from a motor vehicle collision. The client's vital signs are: blood pressure 85/50 mm Hg, heart rate 120 beats/min, respiratory rate 22 breaths/min, and an oxygen saturation of 98% on room air. The client is afebrile. The health care provider has written several prescriptions. What is the nurse's priority action? Obtain STAT hemoglobin and group and match. Draw blood cultures and white blood cell count. Send client to diagnostic imaging for pelvic x-ray. Administer 5 mg morphine intravenously.

Obtain STAT hemoglobin and group and match. The client is hypotensive, tachycardic, and tachypneic. These signs in a client with pelvic fracture could indicate internal blood loss and impending hypovolemic shock. The nurse's priority out of the options listed is to determine if acute blood loss is occurring by examining a hemoglobin level and having blood matching done in anticipation of the need for transfusion. The client should not get the intravenous morphine until the blood pressure is stabilized, and a bolus of normal saline should be started while awaiting other test results. While the risk of infection if this is an open pelvic fracture is high, blood culture and white blood cell count is not actually diagnostic of sepsis. The initial treatment for sepsis will focus on correcting hypovolemic shock as well. The difference will be the addition of antibiotics rather than blood products to treat the underlying cause. In either case, the nurse's priority is still administration of a bolus of IV fluids. The nurse must stabilize the client prior to sending for an x-ray.

A client has a plaster cast applied to the lower extremity that is still wet to touch. In which way should the nurse move the casted limb to elevate it on a pillow? Lift the limb from the knee. Lift the limb from the ankle. Place the fingers around the cast. Place the palms on both sides of the cast.

Place the palms on both sides of the cast. When moving a client with a wet plaster cast, only the palms of the hands should be used so that indentations in the cast from the fingers may be prevented. Indentations can result in areas of pressure on the skin. The limb should be supported at both the ankle and the knee because a plaster cast is heavy when wet.

Which goal is the priority for a client with a fractured femur who is in traction? Adapt to inactivity from the impaired mobility. Develop skills to cope with prolonged immobility. Choose appropriate diversional activities during the prolonged recover. Prevent effects of immobility while in traction.

Prevent effects of immobility while in traction. The priority for this client is to prevent the effects of prolonged immobility, such as preventing skin breakdown and encouraging the client to take deep breaths, and use active range-of-motion exercises for the joints that are not immobilized. Although not the priority, the nurse also should seek ways to help the client adjust to and cope with the present state of immobility. Emphasis should be placed on what the client can do, such as participating in daily care and exercises to maintain muscle strength. Finding diversional activities is not a priority at this moment. Although the client must adapt to the inactivity, helping the client develop coping skills is the priority at this time.

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis? Keep the hip flexed by placing pillows under the client's knee. Prevent internal rotation of the affected leg. Keep the affected leg in a position of adduction. Use measures other than turning to prevent pressure ulcers.

Prevent internal rotation of the affected leg. The nurse and other caregivers should prevent internal rotation of the affected leg. However, external rotation and abduction of the hip will help prevent dislocation of a new hip joint. Postoperative total hip replacement clients may be turned onto the unaffected side. The hip may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of flexion isn't necessary.

A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client? Rotate side to side. Flex and extend the ankle on affected side. Raise the hips using trapeze. Eat while lying flat.

Raise the hips using trapeze. The client in balanced suspension traction can raise the hips using a trapeze. The client can then use the bedpan. The client can be in a sitting position to eat. The client should not move side to side but can turn toward the affected side. The client should not flex or extend the ankle on the affected side.

The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. What is the intended outcome of the traction? Preserve normal length of the leg. Reduce and immobilize the fracture. Prevent movement in the bed. Prevent skin breakdown.

Reduce and immobilize the fracture. Skeletal traction is often used to regain normal length of the bone, but in this situation the main purpose of the traction is to reduce and immobilize the fracture. This type of traction allows the client to move in bed without dislocating the fracture. This client has an open fracture, but skeletal traction will not prevent further skin breakdown.

A client has been diagnosed with degenerative joint disease (osteoarthritis) of the left hip. Which factor in the client's history would most likely increase the joint symptoms of osteoarthritis? emotional stress obesity excessive alcohol use a long history of smoking

obesity The symptoms of osteoarthritis most commonly result from "wear and tear"—excessive and prolonged mechanical stress on the joints. Increased weight increases stress on weight-bearing joints. Therefore, an obese client with osteoarthritis should be encouraged to lose weight.Smoking, excessive alcohol use, and emotional stress do not increase the symptoms of osteoarthritis.

The nurse is providing discharge instructions to a client with a leg cast. Which teaching point is most critical? Report changes in sensation such as numbness or tingling. Exercise the joints above and below the cast, as prescribed. Avoid walking on the cast without the healthcare provider's permission. Do not put pressure on the axilla when using crutches.

Report changes in sensation such as numbness or tingling. Although all of these points are important, reporting signs of impaired circulation is the most critical. Signs of impaired circulation, such as numbness, tingling, increased pain, excessive swelling, or loss of motion, must be reported to the healthcare provider immediately to prevent permanent damage. The other options reflect more long-term concerns. The client should learn to use the crutches properly to avoid nerve damage. The client may exercise above and below the cast as prescribed. The client should be instructed to not walk on the cast without permission.

When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which information in the discharge plan? Select all that apply. Keep the affected leg and foot on the floor when sitting in a chair. The physical therapist will encourage progressive ambulation with use of assistive devices. Report signs of infection to health care provider (HCP). Change the dressing daily. Remove antiembolism stockings when sleeping.

Report signs of infection to health care provider (HCP). The physical therapist will encourage progressive ambulation with use of assistive devices. After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. The client will wear antiembolism stockings at all times, including when sleeping. After discharge, the client may undergo physical therapy on an outpatient basis per HCP prescription. The client should leave the dressing in place until the follow-up visit with the surgeon.

A client is to have a total hip replacement. What nursing actions should the preoperative plan include? Select all that apply. Administer antibiotics as prescribed to ensure therapeutic blood levels. Demonstrate crutch walking with a 3-point gait. Place Buck's traction on the bed. Request a trapeze be added to the bed. Apply a leg compression device. Teach isometric exercises of quadriceps and gluteal muscles.

Request a trapeze be added to the bed. Teach isometric exercises of quadriceps and gluteal muscles. Administer antibiotics as prescribed to ensure therapeutic blood levels. Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck's traction. The client will require antiembolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per prescription.

Which nursing diagnosis takes highest priority for a client with a compound fracture? Risk for infection related to effects of trauma Activity intolerance related to weight-bearing limitations Impaired physical mobility related to trauma Imbalanced nutrition: Less than body requirements related to immobility

Risk for infection related to effects of trauma A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

A client is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) to manage the pain of rheumatoid arthritis. What information should the nurse give to the client about taking these medications? Exercise the joints at least 1 hour after taking the medication. Take NSAIDs with food. Take antacids 1 hour after taking NSAIDs. Take NSAIDs at least three times per day.

Take NSAIDs with food. NSAIDs irritate the gastric mucosa and should be taken with food. NSAIDs are usually taken once or twice daily. Joint exercise is not related to the drug administration. Antacids may interfere with the absorption of NSAIDs.

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? Remove the traction at least every 8 hours. Teach the client how to prevent problems caused by immobility. Assess the client's level of consciousness. Apply the traction straps snugly.

Teach the client how to prevent problems caused by immobility. By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician's responsibility — not the nurse's.

A client with an extracapsular hip fracture is scheduled for surgical internal fixation with the insertion of a pin. What can the nurse tell the client about the reason for this type of treatment for the fracture? The risk of infection at the site is lessened. Neurovascular impairment risk is decreased. Hemorrhage at the fracture site is prevented. The client is able to be mobilized sooner.

The client is able to be mobilized sooner. Insertion of a pin for the internal fixation of an extracapsular fractured hip provides good fixation of the fracture. The fracture site is stabilized, and fractured bone ends are well approximated. As a result, the client is able to be mobilized sooner, thus reducing the risks of complications related to immobility. Internal fixation with a pin insertion does not prevent hemorrhage or decrease the risk of neurovascular impairment, which are potential complications associated with any joint or bone surgery. It does not lessen the client's risk of infection at the site.

A client has a leg immobilized in traction. Which observation by the nurse indicates that the client understands actions to take to prevent muscle atrophy? The client performs isometric exercises to the affected extremity three times per day. The client rolls the affected leg away from the body's midline twice per day. The client asks the nurse to add a 5-lb (2.3-kg) weight to the traction for 30 minutes per day. The client adducts the affected leg every 2 hours.

The client performs isometric exercises to the affected extremity three times per day. Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Adduction of the leg puts work onto the hip joint as well as altering the pull of traction. Rolling the leg, or external rotation, alters the pull of traction. Additional weight should not be added to traction unless prescribed by the health care provider (HCP); it will not prevent muscle atrophy.

A diet plan is developed for a client with gouty arthritis. The nurse should advise the client to limit his intake of fresh fish. green vegetables. citrus fruits. organ meats.

organ meats. Gouty arthritis is a disorder of purine metabolism. High-purine foods include organ meats, anchovies, sardines, shellfish, and meat extracts. Citrus fruits, green vegetables, and fresh fish are appropriate foods for a client with gouty arthritis.

The nurse is assessing a client who had a left hip replacement 36 hours ago. Which findings indicate the prosthesis is dislocated? Select all that apply. The client reported a "popping" sensation in the hip. The client has sharp pain in the groin. The client cannot move his right leg. The left leg is shorter than the right leg. The client cannot wiggle the toes on the left leg.

The client reported a "popping" sensation in the hip. The left leg is shorter than the right leg. The client has sharp pain in the groin. Dislocation of a hip prosthesis may occur with positioning that exceeds the limits of the prosthesis. The nurse must recognize dislocation of the prosthesis. Signs of prosthesis dislocation include: acute groin pain in the affected hip, shortening of the affected leg, restricted ability or inability to move the affected leg, and reported "popping" sensation in the hip. Toe wiggling is not a test for potential hip dislocation.

A nurse is caring for a client who fell and fractured the neck of femur. When documenting the site for the family members, indicate on the image the area where the fracture occurred.

The neck of the femur is a flattened pyramidal process of bone connecting the femoral head with the femoral shaft just below the ball and socket. When a femoral neck fracture occurs, the ball is disconnected from the rest of the thigh bone.

Unlicensed assistive personnel (UAP) are helping a client who has had knee surgery 2 days ago get into bed. As the nurse makes rounds, which information requires the nurse to intervene? The side rails on the head and foot of the bed are in the up position. The night light is dimmed, giving low-level lighting to the room. The call light is pinned to the head of the bed in the client's reach. There is a clear path to the bathroom.

The side rails on the head and foot of the bed are in the up position. Side rails are considered restraints and are not used at both the head and foot of the bed. Using side rails at the head of the bed will aid the client in sitting up and are safe, but using side rails at both the head and the foot of the bed presents risks for a client who might become wedged between the rail and the bed or attempt to climb over them. The nurse discusses side rail use with the UAP and lowers the side rail at the foot of the bed. The nurse assures the bed is placed in low position. The accessible call light, dim lighting, and clear path to the bathroom are factors that contribute to fall prevention.

The nurse is caring for a client with a fractured fibula who has skeletal traction and skeletal pins. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? There is a small amount of clear fluid at the pin sites. The client wants to change position. The client is reporting pain and muscle spasm. The traction weights are resting on the floor.

The traction weights are resting on the floor. The weights should always hang freely. When the weights are on this floor, they are not exerting pulling force to provide reduction and alignment or to prevent muscle spasm. Attending to the weights may reduce the client's pain and spasm. Skeletal pins usually have a small amount of clear fluid. It is most important to check the traction system after a client changes position, because position changes may alter the traction.

A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action? Maintaining bed rest for 72 hours after the laminectomy Keeping a pillow under the client's knees at all times Turning the client from side to side, using the logroll technique Placing the client in semi-Fowler's position

Turning the client from side to side, using the logroll technique To avoid twisting the spine or hips when turning a client onto the side, the nurse should use the logroll technique. (Twisting after a laminectomy could injure the spine.) After surgery, the nurse shouldn't put anything under the client's knees or place the client in semi-Fowler's position because these actions increase the risk of deep vein thrombosis. Typically, the client is allowed out of bed by the first or second day after a laminectomy.

The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which chair would be the correct type to recommend? a padded upholstered chair a desk-type swivel chair a recliner with an attached footrest a high-backed chair with armrests

a high-backed chair with armrests A high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? crust around the pin insertion site pain at the insertion site a slight reddening of the skin surrounding the insertion site a small amount of yellow drainage at the left pin insertion site

a small amount of yellow drainage at the left pin insertion site The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.

The nurse is instructing an unlicensed assistive personnel (UAP) on how to correctly position a client who has had a recent total hip replacement. In which position should the nurse tell the UAP to place the affected leg when the client is lying on the nonoperative side? abduction and flexion adduction and flexion abduction and extension adduction and extension

abduction and extension After total hip replacement surgery, the leg should be maintained in a position of abduction and extension. A foam abduction pillow is usually placed between the legs to maintain this position.Placing the leg in an adducted and/or flexed position can lead to a dislocation of the prosthesis.

Which sign indicates that a client with a fracture of the right femur may be developing a fat embolus? numbness in the right leg acute respiratory distress syndrome migraine-like headaches muscle spasms in the right thigh

acute respiratory distress syndrome Fat emboli usually result in symptoms of acute respiratory distress syndrome, such as apprehension, chest pain, cyanosis, dyspnea, tachypnea, tachycardia, and decreased partial pressure of arterial oxygen resulting from poor oxygen exchange. Migraine-like headaches are not a symptom of a fat embolism, but mental confusion, memory loss, and a headache from poor oxygen exchange may be seen with central nervous system involvement. Numbness in the right leg is a peripheral neurovascular response that most likely is related to the femoral fracture. Muscle spasms in the right thigh are a symptom of a neuromuscular response affecting the local muscle around the femoral fracture site.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure? withholding all oral intake administering large doses of oral antibiotics as ordered administering large doses of I.V. antibiotics as ordered instructing the client to ambulate twice daily

administering large doses of I.V. antibiotics as ordered Treatment of acute osteomyelitis includes large doses of I.V. antibiotics (after blood cultures identify the infecting organism). Surgical drainage may be indicated, and the affected bone is immobilized. The client usually requires I.V. fluids to maintain hydration, but oral intake isn't necessarily prohibited.

A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include administration of opioids for pain control. vigorous physical therapy for the joints. administration of monthly intra-articular injections of corticosteroids. administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program.

administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program. NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

Which intervention would be least appropriate for a client who is in a double hip spica cast? encouraging the intake of cranberry juice having the client dangle at the bedside establishing regular times for elimination advising the client to eat large amounts of cheese

advising the client to eat large amounts of cheese The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged, and the client should be encouraged to drink at least 2,500 mL/day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises.

A client diagnosed with arthritis doesn't want to take medications. Physical therapy and occupational therapy have been consulted for nonpharmacologic measures to control pain. What might physical and occupational therapy include in the care plan to help control this client's pain? cold therapy an exercise routine that includes range-of-motion (ROM) exercises heat therapy and nonsteroidal anti-inflammatory medications (NSAIDs) acupuncture

an exercise routine that includes range-of-motion (ROM) exercises Physical and occupational therapy will most likely develop an exercise routine that includes ROM exercises to control the client's pain. Acupuncture may help relieve the client's pain; however, it isn't within the scope of practice for physical and occupational therapists. Heat therapy may help the client, but it's coupled with NSAIDs in this option, which goes against the client's wishes. Cold therapy aggravates joint stiffness and causes pain.

A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority? keeping the client from sliding to the foot of the bed ensuring that the weights hang free at all times assessing the extremity for neurovascular integrity keeping the ropes over the center of the pulley

assessing the extremity for neurovascular integrity Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation, which laboratory result is the priority for the nurse to report to the physician?

blood culture Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture would be reported immediately to the physician so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L (1.0 nkat/L) is within the normal range, and an ESR of 10 mm/hour is also within the normal range.

A client with acute osteomyelitis is to receive parenteral penicillin for 4 to 6 weeks. Before administering the first dose, the nurse asks the client about known drug allergies. An allergy to which antibiotic or antibiotic class necessitates cautious use of penicillin? erythromycin tetracyclines cephalosporins aminoglycosides

cephalosporins A client who is allergic to cephalosporins may also be allergic to penicillin. For the same reason, penicillin must be used cautiously in clients who are allergic to cephamycins, griseofulvin, or penicillamine. Cross-sensitivity between penicillin and tetracyclines, aminoglycosides, and erythromycins hasn't been observed.

Which nursing measure will likely decrease the risk of a surgical wound infection in a client with an internal fixation and hip pinning? inserting an indwelling urinary catheter to prevent possible soiling of the dressing changing the surgical dressings using sterile technique accurately measuring drainage from the surgical drainage tube monitoring the incision for signs of redness, swelling, and warmth

changing the surgical dressings using sterile technique Wound infection can best be prevented by using strict sterile technique during dressing changes.Inserting an indwelling urinary catheter is an unnecessary action in this case and would predispose the client to a urinary tract infection.Accurately measuring drainage is an important nursing action but will not prevent a wound infection.Monitoring the incision for signs of infection is an important nursing action but will not prevent a wound infection.

A nurse is working in a rehabilitation program with clients using various assistive equipment. The nurse should evaluate which clients using assistive equipment for skin breakdown? Select all that apply. client using a walker client using crutches client that uses a prosthetic client that uses a wrist splint client that uses a transfer bench

client that uses a transfer bench client that uses a wrist splint client that uses a prosthetic The clients in rehabilitation that are learning to apply prosthetic devices or wrist splints must be taught how to apply the device correctly to avoid skin pressure that can lead to skin breakdown. The client who is using a transfer bench must be able to use this correctly to minimize friction and shear which can lead to skin breakdown. Use of walkers and crutches do not involve specific risks for skin breakdown as other assistive devices do.

A client is taking methotrexate for severe rheumatoid arthritis. The nurse instructs the client that it will be necessary to monitor: serum glucose. serum electrolytes. sedimentation rate. complete blood count (CBC) with differential and platelet count.

complete blood count (CBC) with differential and platelet count. This client should be monitored for blood dyscrasias, evidenced by decreased platelet count and white blood cell count with changes in the CBC differential.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital? conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. while walking, do weight bearing on the cast to increase balance. keep the affected limb in extension and abduction at all times. sit up straight in a chair to develop the back muscles, as this will help the client walk with crutches.

conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking. The other choices are incorrect based on functionality and muscle use.

A client has a left tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the fracture despite the morphine injection administered 30 minutes ago. Which area should be the nurse's next assessment? pain with a pain rating scale distal pulse potential for drug tolerance vital sign changes

distal pulse The nurse should assess the client's ability to move the toes and for the presence of distal pulses, including a neurovascular assessment of the area below the cast. Increasing pain unrelieved by usual analgesics and occurring 4 to 12 hours after the onset of casting or trauma may be the first sign of compartment syndrome, which can lead to permanent damage to nerves and muscles. Although the nurse can use a pain rating scale or assess for changes in vital signs to objectively assess the client's pain, the client's comments suggest early and important signs of compartment syndrome requiring immediate intervention. The nurse should not confuse these signs with the potential for drug tolerance. This assessment might be appropriate once the suspicion of compartment syndrome has been ruled out.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan? elevating the stump for the first 24 hours maintaining the client on complete bed rest applying heat to the stump as the client desires removing the pressure dressing after the first 8 hours

elevating the stump for the first 24 hours Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

The nurse is planning an educational program about the prevention of osteoporosis for a group of women. Which preventive measures would be appropriate for the nurse to include in the teaching plan? encouraging weight-bearing exercise on a regular basis ingesting 2,000 mg of calcium supplements daily sunbathing for 1 hour a day during the summer months increasing daily intake of protein

encouraging weight-bearing exercise on a regular basis Exercise, especially weight-bearing exercise such as walking or jogging, is recommended on a regular basis to maintain high-density bone mass. The diet should be high in calcium and vitamin D; increasing the daily intake of protein is not appropriate. It is recommended that premenopausal women consume about 1,000 to 1,200 mg of calcium daily. Sunbathing is not recommended.

When a client is placed in balanced skeletal traction, the nurse should: apply and remove the traction weights at regular intervals throughout the day. ensure that the traction weights hang freely from the bed at all times. increase the traction weight gradually as the client's tolerance increases. remove the weights briefly as necessary to reposition the client in bed.

ensure that the traction weights hang freely from the bed at all times. In balanced skeletal traction, the appropriate pressures and counter pressures are applied to the fracture site, with the traction weights hanging freely at all times.The amount of traction weight used is determined by radiography and the alignment of the fracture.These weights are in place continuously and should never be lifted, reduced, or eliminated.

Passive range-of-motion (ROM) exercises for the legs and assisted ROM exercises for the arms are part of the care regimen for a client with a spinal cord injury. Which observation by the nurse would indicate a successful outcome of this treatment? external rotation of the hips at rest absence of tissue ischemia over bony prominences free, easy movement of the joints absence of paralytic foot drop

free, easy movement of the joints ROM exercises help preserve joint motion and stimulate circulation. Contractures develop rapidly in clients with spinal cord injuries, and the absence of this complication indicates treatment success. Range of motion will keep the ankle joints freely mobile. Foot drop, however, is prevented by proper positioning of the ankle and foot, which is usually accomplished with high-top sneakers or splints. External rotation of the hips is prevented by using trochanter rolls. Local ischemia over bony prominences is prevented by following a regular turning schedule.

A male client comes to the clinic with complaints of pain in his great toe. The client reports that the pain is worse at night. Assessment reveals tophi. The nurse suspects the client has gouty arthritis. osteoarthritis. reactive arthritis. rheumatoid arthritis.

gouty arthritis. Gout results from the inability to metabolize purines. This condition is most commonly seen in men and usually affects the legs, feet, and knees. Osteoarthritis is caused by degeneration of the joints. Rheumatoid arthritis is a systemic disorder more common in women of childbearing age. Reactive arthritis is seen with infections and is most common in young adult males.

After a total hip replacement, the client tells the nurse that the pain in the operative hip has increased. Assessing the hip and leg, the nurse notes that the leg is internally rotated and shorter than the other leg and that the client has difficulty moving the leg. Based on this information, the nurse determines that the client: requires repositioning to achieve better alignment of the leg. would benefit from additional muscle-strengthening exercises. has experienced a dislocation of the hip prosthesis. has experienced increased pain due to a muscle spasm.

has experienced a dislocation of the hip prosthesis. Classic signs of dislocation of the hip prosthesis include increasing pain, abnormal rotation, shortened leg, difficulty or inability moving the leg, and misalignment of the leg. The nurse should notify the surgeon so that the prosthesis can be repositioned.Muscle spasm will cause pain but would not be responsible for the internal rotation and shortening of the extremity.Repositioning the client will not help this situation. The surgeon will have to relocate the hip joint.Muscle-strengthening exercises may help prevent subsequent dislocations; however, hip precautions must be maintained until complete healing has occurred.

To protect a client's skin under a back brace, the nurse should: place padding as necessary for a snug fit. have the client wear a close-fitting thin cotton shirt under the back brace. lubricate the areas where the client's back brace will contact skin surfaces. apply powder to the areas where the client's back brace will contact skin surfaces.

have the client wear a close-fitting thin cotton shirt under the back brace. Having the client wear a thin cotton shirt that is close fitting to avoid having extra folds that could cause pressure under a back brace helps to protect the skin and to keep the brace free of skin oils and perspiration.Using padding may increase pressure points.Lubricating or powdering the skin under the back brace will not provide protection from irritation by the brace.

A client has been diagnosed with osteoporosis after a bone density test and is asking what has caused it. Discussion of risk factors would include: diet deficient in vegetables and fruits, high intake of red meats, and increased alcohol intake excessive sunlight exposure, adequate calcium intake, and lactose intolerance regular exercise, low fat intake, and recurrent trauma to the bones through increased weight-bearing activities heavy smoking, sedentary lifestyle, and high intake of carbonated drinks

heavy smoking, sedentary lifestyle, and high intake of carbonated drinks Osteoporosis has been linked to heavy smoking. A sedentary lifestyle results in more osteoclastic or breakdown activity rather than bone building or osteoblastic activity. Because carbonated drinks tend to have high phosphate levels, the inverse relationship of phosphorus to calcium results in a depletion of calcium. Sunlight exposure for vitamin D and calcium intake all promote bone density. Regular exercise and weight-bearing activities also preserve bone mass. A deficient diet has not been proven to contribute to osteoporosis.

A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should: administer an oil retention enema. place the client on the bedpan every 3 to 4 hours. perform passive range of motion to extremities. increase the client's fluid intake to 3,000 mL/day.

increase the client's fluid intake to 3,000 mL/day. The most appropriate nursing action is to first increase the client's fluid intake to 3,000 mL/day to soften stool.A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool.Placing the client on the bedpan every 3 to 4 hours is not enough to stimulate a bowel movement.While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement.

A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care? infection difficulty chewing solid foods ineffective coughing and deep breathing confusion

ineffective coughing and deep breathing In kyphosis, the thoracic spine bends forward with convexity of the curve in a posterior direction, making effective coughing and deep breathing difficult. Although the client may develop other problems because respiratory status deteriorates when pulmonary secretions are not adequately cleared from airways, ineffective coughing and deep breathing should receive priority attention.

A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to get help when lifting objects. install safety devices in the home. wear worn, comfortable shoes. wear protective devices when exercising.

install safety devices in the home. Most accidents occur in the home, and safety devices such as hand rails are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or lifting objects. Protective devices aren't usually necessary when the client exercises.

A nurse is caring for a client who recently underwent a total hip replacement. The nurse should: allow the client's legs to be crossed at the knees when out of bed. use soft chairs when the client is sitting out of bed. limit hip flexion of the client's hip when he sits. ease the client onto a low toilet seat.

limit hip flexion of the client's hip when he sits. The nurse should instruct the client to limit hip flexion to 90 degrees when he sits. The nurse should supply an elevated toilet seat so that the client can sit without having to flex his hip more than 90 degrees. The nurse should instruct the client not to cross his legs to avoid dislodging or dislocating the prosthesis. The nurse should caution the client against sitting in chairs that are too low or too soft; these chairs increase flexion, which is undesirable.

Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? osteoporosis anemia weight loss local joint pain

local joint pain Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain. Rheumatoid arthritis has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight.

The client returns from surgery for a below-the-knee amputation with the residual limb covered with dressings and a woven elastic bandage. At first, the bandage was dry. Now, 30 minutes later, the nurse notices a small amount of bloody drainage. The nurse should first: change the dressing. notify the health care provider. reinforce the dressing. mark the area of drainage.

mark the area of drainage. The nurse should mark the bloody drainage and observe it again in 10 minutes to assess if the bleeding is continuing.There is no need to notify the health care provider immediately because some oozing and bloody drainage are expected.A fresh postoperative dressing should not be changed unless the health care provider prescribes it. Although the wound edges will be closed, no epithelialization has occurred yet to protect the deep tissues. Undressing the wound at this point increases the risk of a wound infection.Given the slight amount of drainage, there is no need to reinforce the dressing.

A client seeks care for lower back pain of 2 weeks duration. Which assessment finding suggests a herniated intervertebral disk? pain radiating down the posterior thigh back pain when the knees are flexed atrophy of the lower leg muscles Homans' sign

pain radiating down the posterior thigh A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

The client comes to the clinic reporting activity restriction and sexual dysfunction. Tests are completed and a diagnosis of L5-S1 herniated disk impinging on the right nerve root is made by the healthcare provider. What assessment findings should the nurse expect to note? pain radiating across the left pelvis pain radiating down the left leg pain radiating up the spinal column pain radiating down the right leg

pain radiating down the right leg The nurse would expect pain to radiate across the lower back and down the right leg with the right nerve root. In addition to sciatica pain, this type of herniated disc can lead to weakness when raising the big toe and possibly in the ankle, also known as foot drop. Numbness and pain can also be felt on top of the foot. The right nerve root does not govern sensations felt in the left leg or pelvis or radiating up the right leg.

The emergency room nurse is caring for a client who fell, breaking the tibia. The nurse determines that the client understands the risk of compartment syndrome when knowing to report which early symptom following treatment? skin flushing swelling paresthesia heat

paresthesia Compartment syndrome is the compression of the nerves, blood vessels, and muscle inside a closed space. It may occur after trauma to an extremity. The earliest sign of compartment syndrome is paresthesia. This is one of the "5 Ps" of compartment syndrome. The others are pain out of proportion to the injury, pallor and delayed capillary refill, normal-to-absent pulses in distal extremity, and paralysis in the limb (a late sign). Flushing, swelling, and heat are not associated with compartment syndrome.

The client sustained a tibia fracture and a cast was applied. The client is reporting increasing pain when flexing toes. Which symptoms does the nurse assess as associated with compartment syndrome? Select all that apply. pulselessness pain palpitations paresthesia petechiae

paresthesia pain pulselessness The symptoms associated with compartment syndrome include pain, pallor, paresthesia, pulselessness, and paralysis. Palpitations and petechiae are not included in these symptoms.

Elderly clients who fall are most at risk for which injuries? wrist fractures pelvic fractures humerus fractures cervical spine fractures

pelvic fractures Elderly clients who fall are most at risk for pelvic and lower extremity fractures. These injuries are devastating because they can seriously alter an elderly client's lifestyle and reduce functional independence. Wrist fractures usually occur with falls on an outstretched hand or from a direct blow. Such fractures are commonly found in young men. Humerus fractures and cervical spine fractures aren't age-specific.

The nurse is preparing a primary prevention program to reduce the incidence of osteoporosis in a population. For which risk factors will the nurse screen to identify the subgroup of the population who is at greatest risk for developing osteoporosis? postmenopausal women who are overweight postmenopausal women who are inactive older men and women who are active smokers women who are diagnosed as hypothyroid

postmenopausal women who are inactive In primary osteoporosis, the rate of bone resorption accelerates while bone formation slows. Although the cause of primary osteoporosis is unknown, an important contributing factor may be faulty protein metabolism resulting from estrogen deficiency and a sedentary lifestyle and is more common in underweight, rather than overweight women. Typically, primary osteoporosis would occur in females who are postmenopausal. Although smoking does increase the risk for primary osteoporosis, this is not as significant as being postmenopausal and decreased activity level. Hyperthyroidism increases the risk for secondary osteoporosis but hypothyroidism is not a significant risk factor unless it is overtreated.

A client in a double hip spica cast is constipated. The surgeon cuts a window into the front of the cast. Which outcome is intended? The window in the cast will allow: the surgeon to manipulate the fracture site. the nurses to reposition the client. The window will allow the nurse to palpate the superior mesenteric artery. relief from pressure due to abdominal distention.

relief from pressure due to abdominal distention. The hip spica cast is used for treatment of femoral fractures; it immobilizes the affected extremity and the trunk securely. It extends from above the nipple line to the base of the foot of both extremities in a double hip spica. Constipation, possible due to lack of mobility, can cause abdominal distention or bloating. When the spica cast becomes too tight due to distention, the cast will compress the superior mesenteric artery against the duodenum. The compression produces abdominal pain, abdominal pressure, nausea, and vomiting. To relieve the compression, the surgeon can cut a "window" in the cast. The nurse should assess the abdomen for decreased bowel sounds, not the superior mesenteric artery. The surgeon cannot manipulate a fracture through a small window in a double hip spica cast. The nurse cannot use the window to aid in repositioning because the window opening can break and negate the effect of the cast.

A client is recovering from an attack of gout. Client teaching should include the need to lose weight because weight loss will increase uric acid levels and reduce stress on joints. weight loss will reduce purine levels. weight loss will reduce uric acid levels and reduce stress on joints. weight loss will reduce inflammation.

weight loss will reduce uric acid levels and reduce stress on joints. Weight loss will reduce uric acid levels and reduce stress on joints. Weight loss won't reduce purine levels, reduce inflammation or increase uric acid levels.

Which nursing intervention is essential in caring for a client with compartment syndrome? removing all external sources of pressure, such as clothing and jewelry starting an I.V. line in the affected extremity in anticipation of venogram studies wrapping the affected extremity with a compression dressing to help decrease the swelling keeping the affected extremity below the level of the heart

removing all external sources of pressure, such as clothing and jewelry Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

The nurse is creating a plan of care for an older adult client with osteoarthritis. Which nursing diagnosis is most appropriate? imbalanced nutrition: Less than body requirements related to effects of aging activity intolerance related to sedentary lifestyle risk for injury related to altered mobility self-care deficit related to immobility

risk for injury related to altered mobility Typically, a client with osteoarthritis has stiffness in large, weight-bearing joints, such as the hips. This joint stiffness alters functional ability and range of movement, placing the client at risk for falling and injury. Therefore, risk for injury is the most appropriate nursing diagnosis. Activity intolerance related to sedentary lifestyle assumes that the client with osteoarthritis is limited in physical activity. Self-care deficit related to immobility assumes that the client with osteoarthritis is unable to complete self-care activities. Imbalanced nutrition: Less than body requirements is incorrect because osteoarthritis does not affect nutrition.

Which equipment should the nurse plan to use to help prevent external rotation of the client's right leg postoperatively? a high footboard sandbags a metal bed cradle a rubber air ring

sandbags It is best to support the client's leg in its proper anatomic position and to prevent external rotation by supporting the leg with sandbags. A trochanter roll can also be used. Sandbags should be placed along the length of the thigh and lower leg.A footboard, rubber air ring, or metal frame will not help prevent external rotation of the leg.

A client is ordered diazepam to treat severe skeletal muscle spasms. During this therapy, the nurse monitors the client closely for adverse reactions. Which adverse reaction is most likely to occur? skin rash bradycardia hypotension sedation

sedation Most adverse reactions to diazepam and other benzodiazepines involve the central nervous system; less than 1% involve other body systems. Therefore, the client is more likely to experience sedation than bradycardia, skin rash, or hypotension.

A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis? hypoactive bowel sounds weakness and atrophy of the arm muscles sensory deficits in one arm severe lower back pain

severe lower back pain The most common finding in a client with a herniated lumbar disk is severe lower back pain, which radiates to the buttocks, legs, and feet - usually unilaterally. A herniated disk also may cause sensory and motor loss (such as foot drop) in the area innervated by the compressed spinal nerve root. During later stages, it may cause weakness and atrophy of leg muscles. The condition doesn't affect bowel sounds or the arms.

A client has had a total hip replacement. When assessing the client, which sign most likely indicates that the hip has dislocated? external rotation of the affected leg loosening of the prosthesis abduction of the affected leg shortening of the affected leg

shortening of the affected leg The most likely indication of a dislocated hip is a shortening of the affected leg. Other indications of dislocation include increasing pain, loss of function to the extremity, and deformity. Abduction of the leg after total hip replacement is a desirable position to prevent dislocation. Loosening of the prosthesis does not necessarily indicate that the hip has dislocated. External rotation of the hip can occur without the hip's being dislocated. However, a neutral position of rotation is the desired position.

Which exercise should the nurse advise the client to avoid after a lumbar laminectomy? pelvic tilts knee-to-chest lifts hip tilts sit-ups

sit-ups Sit-ups are not recommended for the client who has had a lumbar laminectomy because these exercises place too great a stress on the back. Knee-to-chest lifts, hip tilts, and pelvic tilt exercises are recommended to strengthen back and abdominal muscles.

Which activities should the nurse teach the client to do to strengthen the hand muscles in preparation for using crutches? squeezing a rubber ball flexing and extending the wrists pushing the hands into the mattress while raising the body in bed combing the hair

squeezing a rubber ball A client being prepared for crutch walking should be taught to support weight with the hands when crutch walking. Supporting weight in the axillae is contraindicated owing to the risk of possible nerve damage and circulatory obstruction. The client should be taught to squeeze a ball vigorously to help strengthen the hands in preparation for weight bearing with the hands.Hair combing is not likely to strengthen the hands.Wrist flexion and extension may help with wrist joint mobility but will not strengthen the hands.Using the hands to push into the mattress will not be helpful because the mattress will not provide sufficient resistance to strengthen the hands.

After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching? sweeping the front porch sitting outside on firm cushions making the bed walking from side to side drying the dishes

sweeping the front porch Sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client should not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there.

When admitting a client with a fractured extremity, what area should the nurse assess first? the actual fracture site the area proximal to the fracture the area distal to the fracture the opposite extremity for baseline comparison

the area distal to the fracture The nursing assessment is first focused on the region distal to the fracture for neurovascular injury or compromise. When a nerve or blood vessel is severed or obstructed at the actual fracture site, innervation to the nerve or blood flow to the vessel is disrupted below the site; therefore, the area distal to the fracture site is the area of compromised neurologic input or vascular flow and return, not the area above the fracture site or the fracture site itself. The nurse may assess the opposite extremity at the area proximal to the fracture site for a baseline comparison of pulse quality, color, temperature, size, and so on, but the comparison would be made after the initial neurovascular assessment.

The nurse assigns an unlicensed assistive personnel (UAP) to the care of a client who has just returned from surgery for repair of a fractured right wrist and application of an arm cast. The nurse should stress to the UAP the importance of reporting: the client cannot move the fingers on the right hand. results of hourly neurovascular assessments. intake and output record for the shift. the client is feeling heat from the plaster cast.

the client cannot move the fingers on the right hand. The UAP should report immediately to the nurse any sign that the client cannot move the fingers on the casted arm, numbness or tingling, or feelings of tightness because these may indicate impaired neurovascular status.The nurse, not the UAP, is responsible for neurovascular assessments.Intake and output would usually not be particularly significant in a client with a fractured arm.It is normal for the client to feel heat immediately after application of a plaster cast.

The client with rheumatoid arthritis has been taking large doses of aspirin to relieve joint pain. The nurse should assess the client for: dysuria. drowsiness. chest pain. tinnitus.

tinnitus. Tinnitus (ringing in the ears) is a common symptom of aspirin toxicity.Dysuria, chest pain, and drowsiness are not associated with aspirin toxicity.

The nurse is caring for an older adult male who had open reduction internal fixation of the right hip 24 hours ago. The client is now experiencing shortness of breath and reports having "tightness in my chest." The nurse reviews the recent lab results. The nurse should report which lab results to the health care provider? erythrocyte sedimentation rate (ESR): 22 mm/h troponin: 1.4 mcg/L (1.4 µg/L) serum glucose: 120 mg/dL (6.7 mmol/L) hematocrit (Hit): 40% (0.40)

troponin: 1.4 mcg/L (1.4 µg/L) Troponin is a cardiac biomarker and is normally almost undetectable in the blood. A level of 1.4 means there has likely been some damage to the heart muscle. Though serum glucose (normal 60 to 100 mg/dL [3.3 to 5.5 mmol/L]) and ESR (normal is less than 20 for males greater than 50 years old) are slightly elevated, this could be explained by normal stress and inflammatory response to surgery. The hematocrit is low (normal 40% to 45% [0.4 to 0.5] for men) but also not unexpected for a client following surgery.

The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which nursing care can be included in the plan of care? giving the client a complete bed bath raising the head of bed to 90 degrees to sit the client up turning the client side to side to give back care using a fracture bedpan when the client uses the trapeze to raise the hips

using a fracture bedpan when the client uses the trapeze to raise the hips The client with a femoral fracture in balanced suspension traction can raise the hips using a trapeze in order to use the fracture bedpan while maintaining the line of the traction. The client should not turn side to side as it will disrupt the line of traction. The nurse can give back care when the client raises the body using the trapeze. The client should not be given a complete bed bath. Rather, the client is encouraged to participate in self-care and movement in bed, such as with a trapeze. The client should be positioned so that the feet do not press against the footboard. Therefore, elevating the head of the bed no more than 25 degrees is recommended to keep the client from moving down in the bed.

The client with an above-the-knee amputation is to be fitted with a functioning prosthesis. The nurse has been teaching the client how to care for the residual limb. Which behavior would demonstrate that the client has an understanding of proper residual limb care? The client: applies powder to the residual limb. removes the prosthesis whenever he sits down. inspects the residual limb weekly with a mirror. washes and dries the residual limb daily.

washes and dries the residual limb daily. Washing and thoroughly drying the residual limb daily are important hygiene measures to prevent infection.Nothing should be applied to the residual limb after it is cleansed. Powder may cause excessive drying and cracking of the skin, and cream may soften the skin excessively.The residual limb should be inspected daily with a mirror for early signs of skin breakdown.To reduce residual limb swelling, the prosthesis should be removed only at night.

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client? whether the client parks the car on the street whether the client drives a car with a stick shift whether the client needs to navigate stairs routinely at home whether pets are present in the home

whether the client needs to navigate stairs routinely at home Knowing whether the client must routinely navigate steps at home is most important. If the client must navigate steps, special crutch-walking techniques must be taught to safely navigate the stairs. Although pets, parking on the street, and driving a car with a stick shift can pose problems for the client, these factors aren't important to know before discharging the client with crutches.

The nurse is teaching a client with osteoporosis about taking alendronate sodium. The nurse emphasizes that the client is to take the medication: with a full glass of water and remain upright for 30 minutes. with a full glass of juice and then rest for 30 minutes. with food. at bedtime.

with a full glass of water and remain upright for 30 minutes. Clients are instructed to take alendronate on arising, 30 minutes before eating, with a full glass of water. Because it can cause severe esophageal irritation, the client must remain upright for 30 minutes after administration.Taking alendronate with food or juice significantly reduces absorption.