NCLEX QUESTIONS answers Musculoskeletal Disorders 4/28/16

A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? 1. Feelings of isolation 2. Inability to tolerate activity 3. Concerns about appearance 4. Inability to physically move about

3. Concerns about appearance Rationale: The client is expressing concerns about appearance. The data in the question are unrelated to isolation and inability to tolerate activity. Although the client is unable to physically move about, this is not associated with what the client is upset about.

A client with osteoarthritis is receiving diclofenac sodium (Voltaren). The licensed practical nurse (LPN) reviewing the client's medication prescription sheet should verify the prescription with the registered nurse (RN) if which other medication is listed? 1. Primidone (Mysoline) 2. Warfarin (Coumadin) 3. Vitamin C supplement 4. Calcium carbonate (Tums)

2. Warfarin (Coumadin) Rationale: Diclofenac sodium is a nonsteroidal anti-inflammatory (NSAID) medication. Interactions may occur with anticoagulants such as warfarin, resulting in increased risk for bleeding. The LPN should consult with the RN regarding a potential medication interaction. The other medications do not interact with diclofenac sodium. Mysoline is an anticonvulsant, calcium carbonate is an antacid, and vitamin C is a nutritional supplement. These medications are not contraindicated when diclofenac sodium is administered.

The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones? 1. Shoulder and humerus 2. Bones of the hands and feet 3. Anterior rib cage and sternum 4. Axial skeleton including the vertebrae

4. Axial skeleton including the vertebrae Rationale: Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur.

The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by performing which action? 1. Monitoring for signs of dyspnea 2. Monitoring the client's temperature regularly 3. Maintaining external rotation of the right leg 4. Educating the client to report paresthesia of the right lower leg

1. Monitoring for signs of dyspnea Rationale: The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. The sign in option 3 is indicative of the hip fracture itself. Option 2 indicates signs of infection, and option 4 indicates signs of severe circulatory impairment.

The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement? 1."I will use a raised toilet seat." 2."I will bend carefully to put on socks and shoes." 3."I will sit in chairs without arms for better mobility." 4."I will exercise the leg past the point of 90-degree flexion.

1."I will use a raised toilet seat." Rationale: The client who has had an insertion of a femoral head prosthesis should use a raised toilet seat. The client should also maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees. The client should sit in chairs that have arms so there will be assistance when the client is ready to rise from the sitting position. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion.

The nurse has given medication instructions to a client beginning therapy with carisoprodol (Soma). The nurse determines that the client understands the effects of the medication if the client makes which statement? 1. "I can expect muscle spasticity as a side effect." 2. "I need to avoid alcohol while taking this medication." 3. "I can drive on city streets, but should avoid highway driving." 4. "I can take a missed dose when remembered, regardless of when the next dose is due."

2. "I need to avoid alcohol while taking this medication." Rationale: Carisoprodol, a centrally acting skeletal muscle relaxant, may cause central nervous system (CNS) side effects of drowsiness and dizziness. For this reason, the client avoids other CNS depressants, such as alcohol, while taking this medication. Driving or other activities requiring mental alertness are also avoided until the client's reaction to the medication is known. The medication is used to reduce muscle spasticity and pain. Missed doses should be taken if remembered within 1 hour.

The nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client's casted extremity for which reason? 1. The skin under the cast is at high risk for infection. 2. Compartment syndrome may lead to irreversible nerve and muscle tissue injury. 3. Alterations in the neurovascular status of the fingers may be early signs of fat embolism. 4. The client is at high risk of neurovascular compromise until the cast is completely dry.

2. Compartment syndrome may lead to irreversible nerve and muscle tissue injury. Rationale: The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. The skin under the cast is not necessarily at risk for infection. The signs of other complications, such as fat embolism and skin infection, are not monitored by assessment of the neurovascular status of the casted extremity, but by other observations. The risk of compartment syndrome is related to internal or external causes of increased pressure in muscle compartments, rather than to the cast being wet.

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted? 1. The client holds the walker using the handgrips. 2. The client advances the walker with reciprocal motion. 3. The client leans forward slightly when advancing the walker. 4. The client supports body weight on the hands while advancing the weaker leg.

2. The client advances the walker with reciprocal motion. Rationale: The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks, thus the client would not be supporting the weaker leg with the walker during ambulation.

The nurse is collecting data from a client who is being seen in the health care clinic. The client is complaining of unrelieved back pain that has persisted over the past 3 months. The nurse determines that which harmful effect can occur as a result of uncontrolled muscle pain? 1. Anorexia 2. Weakness 3. Weight loss 4. Hypertension

2. Weakness Rationale: Uncontrolled musculoskeletal pain can result in harmful effects, resulting in certain assessment findings, such as weakness, fatigue, and immobility. Anorexia is associated with the gastrointestinal system; weight loss is associated with the endocrine system; and hypertension is associated with the cardiovascular system in terms of uncontrolled pain.

A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client? 1. "There is no reason to be concerned. I have seen lots of these procedures." 2. "Skeletal traction is much more effective than skin traction in your situation." 3. "You have concerns about skeletal versus skin traction for your type of fracture?" 4. "Your fracture is very unstable. You will die if you don't have this surgery performed."

3. "You have concerns about skeletal versus skin traction for your type of fracture?" Rationale: Option 3 identifies the therapeutic communication technique of paraphrasing. Paraphrasing is restating the client's message in the nurse's own words. Option 4 identifies a communication block that reflects a lack of the client's right to an opinion. It also will cause fear in the client. In option 2, the nurse is offering a false reassurance, and this type of response will block communication. Option 1 is also a communication block and reflects a lack of the client's right to an opinion.

A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse will monitor the client closely for pain and provide the client with which instruction? 1. "I will be bringing your pain medication at 10:00 pm." 2. "You will not feel pain because of the spinal anesthesia." 3. "You will need to let me know when you start to get feeling back in your legs." 4. "You will not be able to take pain medication until you have been up to the bathroom."

3. "You will need to let me know when you start to get feeling back in your legs." Rationale: The nurse should encourage analgesics in the postoperative client as needed. The nurse explains that the client will start to feel sensation as the spinal anesthetic wears off. Along with the increased sensation, the client will also experience pain. Although option 2 may be correct information, it does not address the issue of pain assessment. Option 1 is not appropriate because the nurse does not schedule the pain medication administration. Option 4 is incorrect because the client should be medicated before any activity is attempted, especially in the postoperative period. Also, following this type of surgery, the client should be using a fracture bedpan and should not be up to the bathroom.

The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse should encourage the client to increase intake of which food? 1. Fish 2. Turkey 3. Cheese 4. Sweet potatoes

3. Cheese Rationale: The major dietary source of calcium is from dairy foods, including milk, yogurt, and a variety of cheeses. Calcium also may be added to certain products, such as orange juice, which are then advertised as being "fortified" with calcium. Calcium supplements are available and recommended for those with typically low calcium intake.

The nurse is talking to a client who underwent a below-the-knee amputation 2 days earlier. The client says to the nurse, "I hate looking at this; I feel that I'm not even myself anymore." The nurse understands that the client is experiencing which problem? 1. Self-care deficit 2. Ineffective coping 3. Disturbed body image 4. Ineffective health maintenance

3. Disturbed body image Rationale: Disturbed body image is characterized by negative verbalizations or feelings about a body part. This is a common response after amputation. The nurse supports the client and assists the client to work through these feelings. The client may also have the other problems listed in options 1, 2, and 4, but disturbed body image is the problem that correlates best with the client statement

The nurse is reinforcing discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the need for further teaching? 1. "I need to report bleeding gums or tarry stools." 2. "I need to report fever, redness, or increased pain." 3. "I need to tell my other doctors about the metal implant." 4. "I don't need to be worried if the shape of my knee changes."

4. "I don't need to be worried if the shape of my knee changes." Rationale: After TKR, the client should report signs and symptoms of infection or any changes in the shape of the knee, which could indicate developing complications. With a metal implant, the client requires anticoagulant therapy and should know to report adverse effects of this therapy, such as bleeding. The client should tell all caregivers about the metal implant because certain diagnostic tests will need to be avoided, and antibiotic prophylaxis will be needed before invasive procedures.

The nurse is providing instructions to a client with a diagnosis of rheumatoid arthritis (RA) who is receiving aspirin (acetylsalicylic acid [ASA]) 5 g orally daily. Which statement by the client would indicate an understanding of the instructions? 1. "A slow pulse might indicate a reaction to the medication." 2. "If I have joint pain, I need to notify the health care provider." 3. "If I have discomfort with exercise, I need to stop the medication." 4. "I should notify the health care provider if I get any ringing in my ears."

4. "I should notify the health care provider if I get any ringing in my ears." Rationale: Aspirin is a nonsteroidal anti-inflammatory medication. Adverse reactions include gastrointestinal bleeding and/or gastric mucosal lesions, ringing in the ears (tinnitus), and generalized pruritus. Headache, dizziness, flushing, tachycardia, hyperventilation, sweating, and thirst also are adverse reactions. Options 1, 2, and 3 are incorrect client statements

Allopurinol (Zyloprim) has been prescribed for the client, and the client asks the nurse about the action of the medication. The nurse responds knowing that allopurinol has which action? 1. Allopurinol is used for the lysis of thrombi obstructing coronary arteries. 2. Allopurinol decreases sympathetic outflow from the central nervous system (CNS). 3. Allopurinol prevents calcium ion entry across cell membranes of the cardiac smooth muscle. 4. Allopurinol decreases uric acid production and reduces uric acid concentrations in both the serum and urine.

4. Allopurinol decreases uric acid production and reduces uric acid concentrations in both the serum and urine. Rationale: Allopurinol is an antigout medication. It decreases uric acid production by inhibiting the enzyme xanthine oxidase and reduces uric acid concentrations in serum and urine. Options 1, 2, and 3 are not actions of this medication.

The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which should be done? 1. Increase fiber and fluids in the diet. 2. Bend at the knees to pick up objects. 3. Strengthen the back muscles by swimming or walking. 4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

4. Get out of bed by sitting straight up and swinging the legs over the side of the bed. Rationale: Clients are taught to get out of bed by sliding near the edge of the mattress. The client then rolls onto one side and pushes up from the bed, using one or both arms. The back is kept straight, and the legs are swung over the side. Increasing fluids and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles. Proper body mechanics includes bending at the knees, not the waist, to lift objects.

The nurse is administering alendronate (Fosamax) to a client. Which nursing intervention is most important for the nurse to consider when giving this medication? 1. Make sure the medication is taken on a full stomach. 2. Make sure this medication is always taken at bedtime. 3. Make sure the medication is taken with just a sip of water. 4. Make sure the client remains upright for 30 minutes after taking the medication.

4. Make sure the client remains upright for 30 minutes after taking the medication. Rationale: Alendronate is a bone resorption inhibitor and calcium regulator used to treat osteoporosis. Clients must remain upright for at least 30 minutes after taking this medication to prevent esophageal irritation. The medication must be taken in the morning before consuming food and other medications and must be taken with 6 to 8 ounces of water.

The nurse is administering alendronate (Fosamax) to a client. Which nursing intervention is most important for the nurse to consider when giving this medication? 1. Make sure the medication is taken on a full stomach. 2. Make sure this medication is always taken at bedtime. 3. Make sure the medication is taken with just a sip of water. 4. Make sure the client remains upright for 30 minutes after taking the medication.

4. Make sure the client remains upright for 30 minutes after taking the medication. Rationale: Alendronate is used to prevent or treat osteoporosis. Clients must remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation and resultant ulceration. The medication must be taken in the morning before food and other medications and with 6 to 8 ounces of water.

A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care? 1. Assist the client in keeping her legs as close together as possible. 2. Ensure the client receives her daily tablet of enoxaparin (Lovenox). 3. Remind the client to use a handrail if she is lowering her hips into a 120-degree flexion. 4. Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively.

4. Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively. Rationale: Partial weight bearing usually is permitted 72 hours postoperatively. The client should keep her knees abducted with a wedge pillow. The client should not flex her hips any more than a 90-degree angle. Enoxaparin (Lovenox) is given by injection, not by a tablet.

The nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should reinforce which client instruction? 1. Resume regular full activity the following day. 2. Do not eat or drink anything until the following morning. 3. Keep the shoulder completely immobilized for the rest of the day. 4. Report to the health care provider the development of fever or redness and heat at the site.

4. Report to the health care provider the development of fever or redness and heat at the site. Rationale: Following arthroscopy, signs and symptoms of infection such as fever or inflammation (redness or heat) should be reported to the health care provider. The client may resume the usual diet immediately. The arm does not have to be immobilized completely once sensation has returned, but the client usually is encouraged to refrain from strenuous activity for at least a few days.

A health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which to enhance compliance with therapy? 1. Decrease fluid intake. 2. Decrease dietary fiber. 3. Chew the tablet thoroughly. 4. Take the medication following a meal.

4. Take the medication following a meal. Rationale: Iron preparations can be very irritating to the stomach and, to eliminate this problem from occurring, are best taken after a meal. They may also be taken 1 hour before a meal or between meals to enhance absorption. Health care provider preference will determine when the client should take the medication. The tablet is swallowed whole, not chewed. Because the client may experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy.

The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the health care provider's (HCP) prescriptions and notes that the HCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure. copy and paste this website below https://coursewareobjects.elsevier.com/objects/elr/Silvestri/comprehensivePN6e/examreview/figures/1914.jpg 1. 1 2. 2 3. 3 4. 4

3. 3 https://coursewareobjects.elsevier.com/objects/elr/Silvestri/comprehensivePN6e/examreview/figures/1914.jpg Rationale: A pelvic sling is a traction device consisting of a hammock-like belt wherein the sling cradles the pelvis in its boundaries. It is used for the treatment of one or more pelvic fractures. Option 1 identifies a cervical halter skin traction. Option 2 identifies a pelvic belt traction. Option 4 identifies Russell's traction.

A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. How should the nurse answer this question for the client? 1. Every other hour for 60 minutes 2. For 30 minutes out of every hour 3. As much as tolerated while in bed 4. For 3 hours at a time, followed by 1 hour of rest

3. As much as tolerated while in bed Rationale: The client who has received a total knee replacement often has the leg put into a CPM machine while in the postanesthesia care unit. The device increases circulation and movement of the knee joint. It should be used as much as the client can tolerate.

Dantrolene (Dantrium) is prescribed for a client with a spinal cord injury for discomfort resulting from spasticity. The nurse tells the client about the importance of follow-up and the need for which blood study? 1. Creatinine level 2. Sedimentation rate 3. Liver function studies 4. White blood cell count

3. Liver function studies Rationale: Dantrolene can cause liver damage, and the nurse should monitor liver function studies. Baseline liver function studies are done before therapy starts, and regular liver function studies are performed throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks.

he nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints? 1. Footboards 2. Large pillows 3. Small pillows 4. Soft mattress

3. Small pillows Rationale: Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided.

A client is taking large doses of acetylsalicylic acid (aspirin) for rheumatoid arthritis. The nurse tells the client to report which signs and symptoms of ototoxicity? 1. Dizziness, tinnitus, purpura 2. GI bleeding, ecchymosis, tinnitus 3. Tinnitus, hearing loss, dizziness, ataxia 4. Gastrointestinal (GI) upset, hematuria, dizziness

3. Tinnitus, hearing loss, dizziness, ataxia Rationale: Ototoxicity is damage to the eighth cranial nerve, which is responsible for hearing and balance. Purpura and ecchymosis are caused by prolonged bleeding, but not ototoxicity. GI bleeding and upset may be caused by acetylsalicylic acid (aspirin) irritation but are not symptoms of ototoxicity.

A client has just had an application of a nonplaster (fiberglass) leg cast, and the nurse is reinforcing instructions for cast care at home. Which statement by the client indicates the need for further teaching? 1. "I need to avoid walking on wet or slippery floors." 2. "I should not use anything to scratch underneath the cast." 3. "I can use a damp cloth to wipe off surface dirt on the cast." 4. "I should use a hair dryer set to the hot setting to dry my cast if it gets wet."

4. "I should use a hair dryer set to the hot setting to dry my cast if it gets wet." Rationale: If a nonplaster cast gets wet, it should be dried with a hair dryer set only to a cool setting to prevent skin breakdown. The client should never scratch under a cast because of risk of skin breakdown and ulcer formation. The client also should avoid walking on wet or slippery floors to prevent falls. It is acceptable to remove surface soil on a cast with a damp cloth.

A client is experiencing an acute exacerbation of bursitis. The nurse encourages the client to avoid which least likely helpful measure until the current episode is resolved? 1. Resting the joint 2. Applying moist heat 3. Elevation of the joint 4. Active intermittent range of motion

4. Active intermittent range of motion Rationale: Local measures that help relieve bursitis (inflammation of a bursa) include joint rest, elevation, and the application of heat. Exercise is not helpful during the acute stage. In addition, nonsteroidal anti-inflammatory agents, analgesics, and short-term systemic corticosteroids may be prescribed.

The nurse is caring for a client diagnosed with Paget's disease. The nurse understands that this condition usually affects which bones? 1. Shoulder and humerus 2. Bones of hands and feet 3. Anterior rib cage and sternum 4. Axial skeleton including vertebrae

4. Axial skeleton including vertebrae Rationale: Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur. The anatomical areas noted in options 1, 2, and 3 usually are not affected.

A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes? 1. Pain 2. Hemorrhage 3. Edema of the stump 4. Separation of wound edges

4. Separation of wound edges Rationale: Clients with diabetes mellitus are at greater risk of wound infection and delayed wound healing because of this disorder. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative periods that apply to any client with an amputation. Pain is also considered normal, although the nurse carefully administers analgesia to minimize it.

A client with diabetes mellitus has had a right below-knee amputation. The nurse should be especially vigilant in monitoring for which complication related to the client's history? 1.Hemorrhage 2.Edema of residual limb 3.Slight redness of incision 4.Separation of wound edges

4.Separation of wound edges Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative residual limb edema and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact.

A health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication is going to be administered intrathecally. Which medication should the nurse expect to be prescribed and administered by this route? 1. Baclofen (Lioresal) 2. Chlorzoxazone (Paraflex) 3. Dantrolene sodium (Dantrium) 4. Cyclobenzaprine hydrochloride (Flexeril)

1. Baclofen (Lioresal) Rationale: Baclofen is a skeletal muscle relaxant that can be administered intrathecally. Therefore, options 2, 3, and 4 are incorrect.

A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse should monitor for which high-risk area for pressure and breakdown? 1. Right heel 2. Left heel 3. Scapulae 4. Back of the head

1. Right heel Rationale: There are specific areas that are under pressure and are at risk for breakdown in the client who has skeletal traction. These include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon.

An older client with rheumatoid arthritis has been instructed by the health care provider to take ibuprofen (Motrin IB) 300 mg orally 4 times daily. How would the nurse reading the medication prescription interpret the prescribed dosage? 1. The normal adult dosage 2. An unusual dosage for this diagnosis 3. Higher than the normal adult dosage 4. Lower than the normal adult dosage

1. The normal adult dosage Rationale: For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dosage for an older client is 300 to 800 mg 3 or 4 times daily. The other options are incorrect because they do not support the usual dosage regimen.

The nurse is reviewing the health care provider's prescriptions for an adult client who has been admitted to the hospital following a back injury. Carisoprodol (Soma) is prescribed for the client to relieve the muscle spasms; the health care provider has prescribed 350 mg to be administered 4 times a day. The nurse reviews the medication and determines what about the dosage? 1. This is the normal adult dosage. 2. This is a lower than normal dosage. 3. This is a higher than normal dosage. 4. This dosage requires further clarification.

1. This is the normal adult dosage. Rationale: The normal adult dosage for carisoprodol is 350 mg orally 3 or 4 times daily.

The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority assessment? 1. Calf pain 2. Heel breakdown 3. Bladder distention 4. Extremity shortening

1.Calf pain Rationale: Deep vein thrombosis is a potentially serious complication of lower extremity surgery. Calf pain is a sign of this complication. Although bladder distention may occur postoperatively, option 3 is incorrect because it is not specific to the information in the question. Extremity lengthening or shortening may occur as a result of knee replacement but is not the highest priority. Additionally, heel breakdown is not the highest priority.

A client has a new medication prescription for allopurinol (Zyloprim). A practical nursing student co-assigned with the licensed practical nurse (LPN) states, "I know this is for gout, but how does it work?" In formulating a response, the LPN includes that allopurinol works in which manner? 1. Decreases uric acid production 2. Reduces the production of fibrinogen 3. Lowers the risk of sulfa crystal formation in the urine 4. Prevents influx of calcium ions during cell depolarization

1.Decreases uric acid production Rationale: Allopurinol is classified as an antigout medication. It decreases uric acid production by inhibiting the xanthine oxidase enzyme, and it reduces uric acid concentrations in both serum and urine. The other options are incorrect.

A client with a history of spinal cord injury is beginning medication therapy with baclofen (Lioresal). The nurse who is providing medication information should caution the client about which side effect of this medication? 1. Drowsiness 2. Muscle pain 3. High blood pressure 4. Sensitivity to bright light

1.Drowsiness Rationale: Baclofen is a centrally acting skeletal muscle relaxant. Side effects include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. The other options are incorrect because they are not side effects.

A client is being given a transcutaneous electrical nerve stimulation (TENS) unit to use for relief of chronic pain. Which instructions should the nurse reinforce to the client about the TENS unit? Select all that apply. 1. Using this unit will help relieve the pain. 2. Hospitalization is required for this treatment. 3. The unit works after attaching electrodes to the skin. 4. The unit needs to be prescribed by the health care provider. 5. The unit will decrease the amount of pain medication needed. 6. The electrodes attached to the unit are placed on the skin around the area of pain.

1.Using this unit will help relieve the pain. 3.The unit works after attaching electrodes to the skin. 4.The unit needs to be prescribed by the health care provider. 5.The unit will decrease the amount of pain medication needed. 6.The electrodes attached to the unit are placed on the skin around the area of pain. Rationale: The TENS unit is a portable system that relieves pain and reduces the need for analgesics. It is attached to the skin of the body around the area of pain by electrodes. It is not necessary that the client remain in the hospital for this treatment. However, this pain relief method needs to be prescribed by a health care provider.

A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? 1. The cast will be bivalved. 2. A window will be cut in the cast. 3. The cast will be replaced with an air splint. 4. Extra padding will be put over this area of the cast.

2. A window will be cut in the cast. Rationale: A window may be cut in a dried cast to relieve pressure, monitor pulses, relieve discomfort, or remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling, to facilitate taking x-rays, or to make a half-cast for use as an intermittent splint. Padding is not placed on top of a cast. The use of an air splint is not indicated.

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? 1. A bone fragment has injured the nerve supply in the area. 2. Bleeding and swelling cause increased pressure in an area that cannot expand. 3. An injured artery causes impaired arterial perfusion through the compartment. 4. The fascia expands with injury, causing pressure on underlying nerves and muscles.

2. Bleeding and swelling cause increased pressure in an area that cannot expand. Rationale: Compartment syndrome is caused by bleeding and swelling within a compartment lined by fascia, which does not expand. The bleeding and swelling place pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.

The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted? 1. Intact skin surfaces 2. Bowel movement every 5 days 3. Equal calf measurements bilaterally 4. Active range of motion (ROM) of uninvolved joints

2. Bowel movement every 5 days Rationale: Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (measurable by equal calf measurements and absence of pain or redness in the calf area), active baseline ROM to uninvolved joints, intact skin, and a bowel movement every other day

A client has been taking indomethacin (Indocin) for gout and experiencing side/adverse effects. Which assessment should the nurse expect the health care provider to prescribe? 1. Monitoring for steatorrhea 2. Checking for occult blood 3. Checking the color of stool 4. Monitoring the pH of stool

2. Checking for occult blood Rationale: One adverse effect of indomethacin (Indocin) is gastrointestinal bleeding. The stool guaiac test is noninvasive and is widely used as a gross screening for blood in the gastrointestinal tract. It is not used for any of the other reasons listed in options 1, 3, or 4.

A client with a history of spinal cord injury is receiving baclofen (Lioresal) for muscle spasms. The nurse determines that the client is experiencing a side effect of this medication if the client experiences which sign/symptom? 1. Muscle pain 2. Drowsiness 3. Hypertension 4. Photosensitivity

2. Drowsiness Rationale: Baclofen is a centrally acting skeletal muscle relaxant. Side effects of baclofen include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Options 1, 3, and 4 are incorrect.

A client with a spinal cord injury has been experiencing discomfort because of spasticity, and dantrolene (Dantrium) is prescribed for the client. Before initiating therapy, the nurse anticipates that which testing will be prescribed? 1. Renal function studies 2. Liver function studies 3. Otoscopic examination 4. Blood pressure measurements

2. Liver function studies Rationale: Dantrolene can cause liver damage, and the nurse should monitor the liver function studies. Baseline liver function studies are done before therapy starts, and regular liver function studies are performed throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. Options 1, 3, and 4 are not specifically related to the administration of this medication.

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which to maintain client safety after this procedure? 1. Head of bed flat 2. Overhead trapeze 3. Pillows under the length of the legs 4. Logrolling technique for repositioning

2. Overhead trapeze Rationale: Following spinal fusion, the head of the bed is generally kept in a flat position. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs by surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote twisting of the spine after surgery.

The nurse notes that meloxicam (Mobic) is prescribed for a client. The nurse anticipates the client to have which diagnosis? 1.Pneumonia 2.Osteoarthritis 3.Heart failure 4.Chronic kidney disease

2.Osteoarthritis Rationale: Meloxicam is used for the treatment of osteoarthritis. It is a medication with some cyclooxygenase (COX-2) selectivity and has analgesic, anti-inflammatory, and antipyretic actions. This medication is not used for the conditions noted in options 1, 3, and 4.

The nurse has reinforced the client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching? 1. "Crutch tips will not slip, even when wet." 2. "Use of someone else's crutches is a bad idea." 3. "Crutch tips should be inspected periodically for wear." 4. "He or she needs to have spare crutches and tips available."

1. "Crutch tips will not slip, even when wet." Rationale: Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage

2.Serous drainage Rationale: A small amount of serous drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported

The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking which criteria? Select all that apply. 1.The client's renal system 2.The client's mental status 3.The client's mobility status 4.The client's respiratory function 5.The client's cardiovascular system

2.The client's mental status 4.The client's respiratory function Rationale: The early signs of fat embolism include changes in the client's mental status or signs of impaired respiratory function caused by impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairment are likely to occur secondary to impaired respiratory function. The client's mobility status is unrelated to the signs of fat embolism.

A client diagnosed with gout has been started on medication therapy with allopurinol (Zyloprim). The nurse reinforces teaching with this client regarding which point about this medication? 1. "The medication takes effect immediately." 2. "Take the medication on an empty stomach." 3. "It is important to drink 3 L of fluid per day." 4. "Development of a rash frequently occurs with this medication."

3. "It is important to drink 3 L of fluid per day." Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day. This helps prevent formation of kidney stones because uric acid is being flushed from the body. Allopurinol should be given with or immediately following meals or milk. Development of a rash, irritation of the eyes, or swelling of the lips or mouth could indicate hypersensitivity, and the health care provider should be notified. A full therapeutic effect may not occur for a week or longer.

A client has just been given a prescription for methocarbamol (Robaxin), and the nurse reinforces instructions to the client. Which statement by the client indicates the need for further teaching? 1."This medication can cause nasal congestion." 2."The medication may turn the urine brown or green." 3."Blurred vision is a common but unimportant effect." 4."This medication is intended to relieve muscle spasms."

3."Blurred vision is a common but unimportant effect." Rationale: Methocarbamol is a skeletal muscle relaxant. The client should be told that the urine may turn brown, black, or green. Adverse effects include blurred vision, nasal congestion, urticaria, and rash. The client must be instructed that if these adverse effects occur, the health care provider needs to be notified

A client is treated in the health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours? 1.Resting the foot 2.Application of an Ace wrap 3.Application of a heating pad 4.Elevating the ankle on a pillow while sitting or lying down

3.Application of a heating pad Rationale: Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, elevation) for the first 24 hours after the injury. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used in the first 24 hours because it could increase venous congestion, which would increase edema and pain.

Baclofen (Lioresal) is prescribed for the client with multiple sclerosis. The nurse evaluates that the medication is having the intended effect if which finding is noted in the client? 1. Increased muscle tone 2. Increased range of motion 3. Decreased muscle spasms 4. Decreased local pain and tenderness

3.Decreased muscle spasms Rationale: Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and degree of muscle spasms in clients with multiple sclerosis, spinal cord injury, or other diseases. The other options are incorrect.

An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the priority relates to addressing which client problem? 1. Risk for constipation 2. Impaired tissue integrity 3. Risk for activity intolerance 4. Disturbed thought processes

1. Risk for constipation Rationale: Although all of these problems may apply to this client, lying supine, being older, and having cognitive impairment places the client at extreme risk for constipation and possibly impaction. The client likely does have disturbed thought processes because of the Alzheimer's disease and impaired tissue integrity because of the fracture. Because activity is restricted, activity tolerance is unknown.

The nurse has reinforced discharge instructions to a client with multiple sclerosis who is receiving baclofen (Lioresal). Which statement by the client indicates an understanding of the medication? 1. "I need to watch for urinary retention." 2. "I need to stop the medication if diarrhea occurs." 3. "If I develop fatigue, I need to notify the health care provider." 4. "I need to restrict my fluid intake while I take this medication."

1. "I need to watch for urinary retention." Rationale: Baclofen is a central nervous (CNS) depressant. It is not necessary to restrict fluids, but the client should be warned that urinary retention can occur. Fatigue is related to a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary for the client to notify the health care provider. Constipation rather than diarrhea is an adverse effect of baclofen. Additionally, the client should be cautioned against the use of alcohol and other CNS depressants because baclofen potentiates the depressant activity of these agents.

An adult client with muscle spasms is taking an oral maintenance dose of baclofen (Lioresal). The nurse reviews the medication record, expecting that which dose would be prescribed? 1. 15 mg 4 times a day 2. 25 mg 4 times a day 3. 30 mg 4 times a day 4. 40 mg 4times a day

1. 15 mg 4 times a day Rationale: Baclofen is dispensed in 10- and 20-mg tablets for oral use. Dosages are low initially and then gradually increased. Maintenance doses range from 15 to 20 mg administered 3 or 4 times a day.

A client experiencing spasticity because of a spinal cord injury has been prescribed dantrolene (Dantrium). Before administering the first dose, the nurse checks to see whether which baseline study has been done? 1. Liver function 2. Renal function 3. Otoscopic examination 4. Blood glucose measurements

1.Liver function Rationale: Dantrolene can cause liver damage; therefore, the nurse should monitor the results of liver function studies. They should be done before therapy starts and periodically throughout therapy. The incorrect options are not specifically related to the administration of this medication.

A licensed practical nurse (LPN) is told that baclofen (Lioresal) is prescribed for an assigned client. The LPN questions the registered nurse about the health care provider's prescription if which condition is noted on the client problem list? 1. Seizure disorder 2. Hyperthyroidism 3. Diabetes mellitus 4. Coronary artery disease

1.Seizure disorder Rationale: Baclofen is a skeletal muscle relaxant. Clients with seizure disorders may have a lowered seizure threshold when baclofen is administered. Concurrent therapy may require an increase in the anticonvulsant medication. The conditions noted in options 2, 3, or 4 are not contraindications or concerns for the client receiving baclofen.

The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan? 1. "Use a sling on the left arm." 2. "Lift the left arm up over the head." 3. "Lift the right arm up over the head." 4. "Make a fist with the hand of the casted arm."

2. "Lift the left arm up over the head." Rationale: Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides isometric exercise to maintain muscle strength. Range of motion of the affected fingers is also a useful general measure. Lifting the right arm is of no particular value.

A client with rheumatoid arthritis is taking acetylsalicylic acid (aspirin) on a daily basis. Which medication dose should the nurse expect the client to be taking? 1. 1 g daily 2. 4 g daily 3. 325 mg daily 4. 1000 mg dail

2. 4 g daily Rationale: Aspirin may be used to treat the client with rheumatoid arthritis. It may also be used to reduce the risk of recurrent transient ischemic attack (TIA) or stroke ( brain attack) or reduce the risk of myocardial infarction (MI) in clients with unstable angina or a history of a previous MI. The normal dose for clients being treated with aspirin to decrease thrombosis and MI is 300 to 325 mg/day. Clients being treated to prevent TIAs are usually prescribed 1.3 g/day in 2 to 4 divided doses. Clients with rheumatoid arthritis are treated with 3.6 to 5.4 g/day in divided doses.

A client has had surgery to repair a fractured left hip. The nurse plans to use which important item when repositioning the client from side to side in the bed? 1. Bed pillow 2. Abductor splint 3. Adductor splint 4. Overhead trapeze

2.Abductor splint Rationale: Following surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. An overhead trapeze and bed pillow are also used, but they are not the priority item to be used in repositioning.

The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? 1. The brace should be applied directly next to the skin. 2. The device is applied before getting out of bed in the morning. 3. The Velcro closures should be fairly loose to avoid constriction. 4. Areas of skin redness at the edges of the brace indicate a good, snug fit.

2. The device is applied before getting out of bed in the morning. Rationale: A back brace or TLSO is individually fitted to the client. The brace should not irritate the skin with proper fitting. The brace is applied in the morning before getting out of bed. The closures should be secure but not overly loose or tight. A layer of clothing is worn between the orthosis and the skin.

Which statement by the client who has received home care instruction following an arthroscopy of the knee indicates a need for further teaching? 1. "I should elevate my knee while sitting." 2. "I should avoid excessive use of the joint for several days." 3. "I can apply heat to my knee if it becomes uncomfortable." 4. "I should return to the health care provider in about 7 days for follow-up."

3. "I can apply heat to my knee if it becomes uncomfortable." Rationale: Following arthroscopy, the client is instructed to avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return to the health care provider for follow-up in about 7 days. Ice is applied to the affected joint for pain and swelling, and analgesics are administered as prescribed.

A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on performing which action? 1. Performing pin site care 2. Explaining to the client the upcoming pin care procedure 3. Ensuring that the weights on the traction setup are hanging free 4. Providing for diversion such as watching television or reading a newspaper

3. Ensuring that the weights on the traction setup are hanging free Rationale: When a client has skeletal traction, the priority is to assess the traction setup. The nurse must ensure that the weights on the traction setup are hanging free. If the weights are resting on or against any support, the purpose of the traction is defeated. Options 1, 2, and 4 are components of care; however, option 3 is the priority.

A client with rheumatoid arthritis has been taking aspirin (acetylsalicylic acid [ASA]) more frequently than prescribed because the arthritis has been causing more discomfort than usual. The client complains of joint pain and has an elevated temperature. The nurse is concerned about the possibility of aspirin toxicity and asks the client which question that may confirm this suspicion? 1. "Are you constipated?" 2. "Are you having any diarrhea?" 3. "Do you have any double vision?" 4. "Do you have any ringing in your ears?"

4. "Do you have any ringing in your ears?" Rationale: Mild intoxication with aspirin is called salicylism and is commonly experienced when the daily dosage is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication with this medication. Options 1, 2, and 3 are unrelated to aspirin toxicity.

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? 1. Try to manually reduce the fracture. 2. Assist the person to get up and walk to the sidewalk. 3. Leave the person for a few moments to call an ambulance. 4.Stay with the person and encourage the person to remain still.

4.Stay with the person and encourage the person to remain still. Rationale: With a suspected fracture, the client is not moved unless it is dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the client, the site of the fracture is immobilized to prevent further injury.

The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room? 1. Anesthesia consent 2. Consent for the procedure 3. Administration of an analgesic 4. Explanation of the procedure to the client

1. Anesthesia consent Rationale: Before a fracture is reduced, the client is informed about the procedure and consent is obtained. An analgesic is given as prescribed because the procedure is painful. Anesthesia may or may not be administered, depending on severity. Closed reductions may be done in the emergency department without anesthesia. If anesthesia is used, the procedure is done in the operating room

The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? 1. Elevating the limb and applying ice to the affected leg 2. Elevating the limb and covering the limb with bath blankets 3. Keeping the leg horizontal and applying ice to the affected leg 4. Placing the leg in a slightly dependent position and applying ice

1.Elevating the limb and applying ice to the affected leg Rationale: Compartment syndrome is prevented by controlling edema. This is achieved most optimally with elevation and application of ice. Therefore, the other options are incorrect.

The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? 1.Pork 2.Seafood 3.Sardines 4.Plain yogurt

1.Pork Rationale: Foods high in calcium include plain yogurt, dairy products, seafood, sardines, green vegetables, calcium-fortified orange juice, and cereal. Of the items listed in the options, pork would contain the least amount of calcium

Dantrolene sodium (Dantrium) is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds knowing that which is the therapeutic action of this medication? 1. Depresses spinal reflexes 2. Acts directly on the skeletal muscle to relieve spasticity 3. Acts within the spinal cord to suppress hyperactive reflexes 4. Acts on the central nervous system (CNS) to suppress spasms

2. Acts directly on the skeletal muscle to relieve spasticity Rationale: Dantrolene acts directly on skeletal muscle to relieve muscle spasticity. The primary action is the suppression of calcium release from the sarcoplasmic reticulum. This in turn decreases the ability of the skeletal muscle to contract. Options 1, 3, and 4 are not actions of the medication.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicates to the nurse favorable resolution of the fat embolus? 1. Minimal dyspnea 2. Clear chest x-ray 3. Oxygen saturation 85% 4. Arterial oxygen level of 78 mm Hg

2. Clear chest x-ray Rationale: A clear chest x-ray is a favorable indicator that fat embolus is resolving. When fat embolism occurs, the chest x-ray has a "snowstorm" appearance. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%.

A client with multiple sclerosis is receiving diazepam (Valium), and the home care nurse reinforces instructions to the client regarding the side effects of the medication. The nurse tells the client that which is a side effect of this medication? 1. Insomnia 2. Incoordination 3. Inability to urinate 4. Increased salivation

2. Incoordination Rationale: Incoordination and drowsiness are common side effects resulting from this medication. Options 1, 3, and 4 are unrelated to the use of this medication.

The nurse is caring for a client with gout who is taking colchicine (Colcrys). The client has been instructed to restrict the diet to low-purine foods. Which food should the nurse instruct the client to avoid while taking this medication? 1. Spinach 2. Scallops 3. Potatoes 4. Ice cream

2. Scallops Rationale: Colchicine is a medication used for clients with gout to inhibit the reabsorption of uric acid by the kidney and promote excretion of uric acid in the urine. Uric acid is produced when purine is catabolized. Clients are instructed to modify their diet and limit excessive purine intake. High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast.

The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium (Dantrium). Which laboratory test(s) would identify an adverse effect associated with the administration of this medication? 1.Creatinine 2.Liver function tests 3.Blood urea nitrogen 4.Hematological function tests

2.Liver function tests Rationale: Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and periodically throughout the treatment course. It is administered in the lowest effective dosage for the shortest time necessary. Options 1 and 3 are tests that assess kidney function.

Auranofin (Ridaura) has been prescribed for a client with rheumatoid arthritis. The nurse who is collecting data 2 weeks later interprets that the client may be experiencing the signs of medication toxicity based on what data collection findings? Select all that apply. 1. Reports loss of appetite 2. Observes several mouth lesions 3. Notes a rash noted on trunk and neck 4. Reports a metallic taste in the mouth 5. Notes purplish blotches on the skin

2.Observes several mouth lesions 3.Notes a rash noted on trunk and neck 4.Reports a metallic taste in the mouth 5.Notes purplish blotches on the skin Rationale: Auranofin (Ridaura) is the one gold preparation that is given orally rather than by injection. Gastrointestinal side effects, including diarrhea, abdominal pain, nausea, and loss of appetite, are common early in therapy but usually subside in the first 3 months. Early symptoms of toxic effects include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth.

A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury? 1. Check the blood pressure. 2. Check the pin sites for drainage. 3. Check the neurovascular status of the affected extremity. 4. Monitor the client's ability to perform active range of motion to the affected extremity.

3. Check the neurovascular status of the affected extremity. Rationale: Bone fragments and tissue edema associated with a fracture can cause nerve damage. The nurse should assess for pallor and coolness of the affected extremity, paresthesias, or complaints of increasing pain. Although the blood pressure measurement provides an overall indication of circulatory status, it is not directly related to the neurovascular status of the extremity and would not provide information about the presence of nerve injury. Checking pin sites for drainage provides information about infection. The client should not be encouraged to perform active range of motion to an extremity that is fractured and in traction

A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. How should the nurse interpret this injury? 1. Strain 2. Sprain 3. Fracture 4. Contusion

3. Fracture Rationale: Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis. A sprain is an injury to a ligament caused by a wrenching or twisting motion. Symptoms include pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on the muscle. Symptoms include soreness and pain with muscle use.

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next? 1. Provide pin care. 2. Medicate the client. 3. Notify the registered nurse. 4. Remove 2 pounds of weight from the traction.

3. Notify the registered nurse. Rationale: A client who complains of severe pain may need realignment or may have traction weights prescribed that are too heavy. The nurse realigns the client and if ineffective, notifies the registered nurse, who will then contact the health care provider. Severe leg pain, once traction has been established, indicates a problem. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction without a specific prescription to do so. Providing pin care is unrelated to the problem as described.

The nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the nurse's initial action? 1. Reassess the vital signs. 2. Perform a neurological assessment. 3. Place the client in a supine position. 4. Place the client in a Fowler's position.

4. Place the client in a Fowler's position. Rationale: Clients with fractures are at risk for fat embolism. If the nurse suspects fat embolism, the nurse should place the client in a sitting (Fowler's) position to relieve dyspnea. Supplemental oxygen is indicated to reduce the signs of hypoxia. The health care provider needs to be notified. A neurological assessment needs to be performed, but this would not be the initial nursing action. Vital signs will need to be taken, but this action may delay initial and required interventions.

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action? 1. Elevate the casted leg. 2. Contact the health care provider. 3. Administer another dose of pain medication. 4. Check the neurovascular status of the toes on the casted leg.

4.Check the neurovascular status of the toes on the casted leg. Rationale: An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) is often the first sign of increasing pressure in a compartment, in this case, the casted extremity. The nurse needs to obtain additional data in order to determine whether the health care provider needs to be notified immediately or whether other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay treatment if needed.

A client has been started on cyclobenzaprine (Flexeril) for the management of muscle spasms in the cervical spine. The client is experiencing drowsiness, dizziness, and dry mouth. The nurse interprets these signs/symptoms as which response? 1. These are the common side effects of this medication. 2. These effects represent an allergic reaction to the medication. 3. These effects are related to the problem with the cervical spine. 4. These effects are dose-related; the client should cut the medication dose in half.

1. These are the common side effects of this medication. Rationale: Drowsiness, dizziness, and dry mouth are the most common side effects of cyclobenzaprine. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasm that accompanies a variety of conditions. Options 2, 3, and 4 are incorrect.

The nurse is providing care to a client diagnosed with multiple sclerosis and prescribed baclofen (Lioresal). Which information should the nurse plan to reinforce in the client instructions? 1. Watch for urinary retention as a side effect. 2. Stop taking the medication if diarrhea occurs. 3. Notify the health care provider if fatigue occurs. 4. Restrict fluid intake while taking this medication.

1. Watch for urinary retention as a side effect. Rationale: Baclofen is a central nervous system (CNS) depressant that can cause urinary retention. The client should not restrict fluid intake. Constipation rather than diarrhea is an adverse effect of baclofen. Fatigue is a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary to notify the health care provider if fatigue occurs.

A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown? 1. Scapulae 2. Left heel 3. Right heel 4. Back of the head

2. Left heel Rationale: Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon.

A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs should best be addressed by referral to which service? 1. Surgeon 2. Social worker 3. Physical therapist 4. Clinical nurse specialist

2. Social worker Rationale: Following spinal surgery, concerns about finances and employment are best handled by referral to a social worker. This individual will provide information about resources available to the client. The physical therapist has the best knowledge of techniques for increasing mobility and endurance. The clinical nurse specialist and surgeon do not have information related to financial resources.

The nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which findings does the nurse identify as early signs of possible fat embolism? 1. Decreased heart rate and increased restlessness 2. Decreased heart rate and decreased respiratory rate 3. Increased heart rate and adventitious breath sounds 4. Increased heart rate and increased oxygen saturation

3. Increased heart rate and adventitious breath sounds Rationale: Fat embolism commonly causes signs and symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. Options 1, 2, and 4 are incorrect.

Which intervention would be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm? 1. Monitor vital signs every 4 hours. 2. Administer oral analgesics as needed. 3. Place the left arm in a dependent position for 24 hours. 4. Monitor the site for swelling, bleeding, and hematoma formation.

3. Place the left arm in a dependent position for 24 hours. Rationale: The biopsy site would be elevated for 24 hours to reduce edema, not placed in a dependent position. Other aspects of care include monitoring the site for swelling, bleeding, and hematoma formation; monitoring vital signs; and administering analgesics for site discomfort.

The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching? 1. "I should elevate my arm to reduce the swelling." 2. "I should use a sling to limit movement and keep my arm elevated." 3. "I should return to the health care provider in about 10 days to have the sutures removed." 4. "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."

4. "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery." Rationale: Postoperatively, depending on the type of surgical procedure, the client will have a bulky dressing in place for 4 to 7 days. The affected arm is elevated to reduce swelling. A sling is useful to limit movements and to keep the arm elevated. The sutures are removed in about 10 days after surgery. Within 2 to 3 weeks postoperatively, the client will begin physical therapy, with exercises to promote full range of motion of the wrist and prevent adhesion formation in the carpal tunnel.

A licensed practical nurse (LPN) is reviewing laboratory results for a client taking dantrolene sodium (Dantrium). The LPN should suggest that the registered nurse notify the health care provider if which finding is noted on the laboratory report sheet? 1. Creatinine 0.6 mg/dL 2. Blood urea nitrogen 9 mg/dL 3. Platelet count 290,000 cells/mm3 4. Lactate dehydrogenase (LDH) 600 units/L

4. Lactate dehydrogenase (LDH) 600 units/L Rationale: Dantrolene sodium is a skeletal muscle relaxant. Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, tests of liver function should be performed before treatment and throughout the treatment interval. It is administered in the lowest effective dosage for the shortest time necessary. The LDH level reported in option 4 is high; the other options indicate normal laboratory results.

The nurse is caring for a client who has just had rotator cuff repair. The client asks the nurse how soon he can resume his tai chi classes. The nurse should make which statement to the client? 1."You will never be able to do tai chi again!" 2."Tai chi is good for you, so you can start any time." 3."Tai chi uses only your leg muscles, so it would be all right." 4."You shouldn't be doing any exercises that require the use of your upper arms until you have been cleared to do so by the health care provider."

4."You shouldn't be doing any exercises that require the use of your upper arms until you have been cleared to do so by the health care provider." Rationale: Tai chi is a slow, relaxed, and graceful series of movements. In tai chi, each movement flows into the next one and the entire body is always in motion, with the movements performed gently and at uniform speed. The upper arms often are held in a horizontal fashion. Clients who have had shoulder repair (rotator cuff repair) will not be able to lift the affected arm to perform the movements. Doing so can undo the surgical repair and cause the client severe pain. The client may be able to resume tai chi at some point in the future when permitted by the health care provider.

A licensed practical nurse (LPN) is reviewing the medical record of a newly assigned client and notes that the client is receiving cyclobenzaprine hydrochloride (Flexeril) for the treatment of muscle spasms. The LPN questions the prescription if which disorder is noted in the admission history? 1.Hypothyroidism 2.Chronic bronchitis 3.Recurrent pneumonia 4.Angle-closure glaucoma

4.Angle-closure glaucoma Rationale: Cyclobenzaprine hydrochloride is a skeletal muscle relaxant. Because cyclobenzaprine hydrochloride has anticholinergic effects, it should be used cautiously in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. It is intended for short-term (2- to 3-week) therapy. The conditions noted in options 1, 2, and 3 are not contraindications or concerns for the client receiving cyclobenzaprine hydrochloride.

The nurse is caring for a client who had a below-the-knee amputation of the right leg. A cast that was placed on the residual limb has fallen off. Which action should the nurse take immediately? 1.Contact the surgeon. 2.Document the findings. 3.Replace the cast with a new one. 4.Wrap the residual limb with an elastic compression bandage.

4.Wrap the residual limb with an elastic compression bandage. Rationale: If a cast or elastic dressing inadvertently comes off of the residual limb of a client with an amputation, the nurse immediately wraps the residual limb with an elastic compression bandage. If this is not done immediately, excessive edema will develop in a short time. The nurse does not replace a cast. The nurse should notify the surgeon if a cast comes off so that another cast can be applied. The nurse should document the occurrence and the actions taken.

The nurse is caring for a client with Paget's disease of the bone. The nurse understands that the client is receiving calcitonin (Cibacalcin) to produce which effect? 1. Decrease bone reabsorption. 2. Increase bone metabolism. 3. Promote the urine excretion of calcium. 4. Decrease gastrointestinal absorption of calcium.

1. Decrease bone reabsorption. Rationale: Paget's disease is a disorder of the bone that involves bone destruction and regrowth. This results in bone deformities. Calcitonin works in conjunction with parathyroid hormone (PTH) to regulate calcium by decreasing the rate of bone reabsorption and regulating bone metabolism. Options 2, 3, and 4 are not the purposes for administering this medication to this client.

The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate? 1. Document the findings. 2. Place the leg in a flat position. 3. Check the client's blood pressure. 4. Immediately notify the health care provider

1. Document the findings. Rationale: Following total hip replacement, the hip incision may have a wound-suction drain in place, which is expected to drain usually less than 50 mL every 8 hours. The nurse should document the findings. The nurse may check the client's blood pressure, but this action is not directly related to the amount of drainage from the device. There is no need to call the health care provider immediately. Placing the leg flat in bed should be done only if prescribed by the health care provider. Additionally, this action is unrelated to the subject of the question.

Cyclobenzaprine (Flexeril) is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which disorder would indicate a need to contact the health care provider regarding the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hyperthyroidism 4. Diabetes mellitus

1. Glaucoma Rationale: Because this medication has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. Cyclobenzaprine hydrochloride should be used only for short-term 2- to 3-week therapy. The disorders in options 2, 3, and 4 are not a concern when the client is taking cyclobenzaprine.

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm? 1. Heat 2. Cold 3. Analgesics 4. Prescribed intermittent traction

2. Cold Rationale: Traction, analgesics, and heat may all be used to relieve the pain of muscle spasm in the client with a vertebral fracture. The use of ice is incorrect because ice is applied to a site for only the first 24 hours after an injury. Application of ice to the spine of a client could be uncomfortable, increase spasms, and result in feeling chilled.

A client has a newly fractured fibula that is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch-walking gait before discharge? 1. Two-point gait 2. Three-point gait 3. Swing-through gait 4. Four-point alternate gait

2. Three-point gait Rationale: The client with a new fracture that is casted with a plaster cast needs to avoid weight bearing. Option 2 is the only option that identifies a gait that allows non-weight bearing on the affected extremity. The client should not bear weight on the affected extremity until the health care provider evaluates the client on the follow-up examination.

The nurse is reinforcing instructions to the client with a below-the-knee amputation (BKA) with regard to measures to protect the residual limb. The nurse should be sure to include which point in discussions with the client? 1. Put a clean nylon sock on the residual limb daily. 2. Use a mirror to inspect all areas of the residual limb. 3. Toughen the skin of the residual limb by rubbing it with alcohol. 4. Apply lotion daily to prevent cracking of the skin of the residual limb.

2. Use a mirror to inspect all areas of the residual limb. Rationale: The client should use a mirror to visualize all areas of the residual limb after BKA. This will be most effective in helping the client detect any areas of redness or breakdown early. The client should not apply oils, creams, or lotions because they soften the skin too much for safe prosthesis use. The client should wear a clean woolen (not nylon) sock on the residual limb each day. The client should avoid using alcohol because it could cause drying or cracking of the skin.

This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's symptoms are indicative of which complication? 1.Fat embolism 2.Venous thrombosis 3.Volkmann's thrombosis 4.Compartment syndrome

4.Compartment syndrome Rationale: In this situation, the edema and the cast are compressing the structures within the leg. As pressure within the fascia compartment increases, nerves and blood vessels are occluded, resulting in ischemia and unrelieved pain, known as compartment syndrome. The health care provider needs to be notified as soon as possible. Fat embolism may result from a fracture, but the client is not experiencing any signs or symptoms of this complication. Venous thrombosis may occur after fractures but would not affect sensation. Volkmann's contracture is a result of compartment syndrome in an upper extremity following a fractured humerus.