NUR 211 Exam 3 Practice Questions
(Simple Nursing) The nurse caring for a below the knee amputation (BKA) is preparing the client's stump for a prosthesis fitting. Which actions would be priority? Select all that apply. 1. assess for redness and swelling at the incision site 2. wrap the stump in a figure 8 pattern 3. elevate the stump on a pillow to dangle 4. instruct the client to hang the stump off the bed 5. instruct the client to lie prone 30 minutes three times/day 6. keep the stump in a dependent position
1, 2, 5, 6
(Saunders 743) A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? 1. "I need to avoid getting the cast wet." 2. "I need to cover the casted leg with warm blankets." 3. "I need to use my fingertips to lift and move my leg." 4. "I need to use something like a padded coat hanger end to scratch under the cast if it itches."
1
(Saunders 746) The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg
1
(Saunders 751) The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temperature of 101.6° F (38.7° C) orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep-breathing exercises
1
(Saunders 760) Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the primary health care provider about the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hypothyroidism 4. Diabetes mellitus
1
(Saunders 818) Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Provide a safe environment. 3. Address hallucinations therapeutically. 4. Provide stimulation in the environment. 5. Provide reality orientation as appropriate. 6. Maintain NPO (nothing by mouth) status.
1, 2, 3, 5
(Fundamentals 422) 45. A nurse is assessing a client experiencing chronic pain. Which characteristic is more common with chronic pain than with acute pain? Select all that apply. 1. _____ Gradual onset 2. _____ Long duration 3. _____ Anticipated end 4. _____ Psychologically depleting 5. _____ Responds to conventional interventions
1, 2, 4
(Saunders 745) The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply. 1. "I should not use someone else's crutches." 2. "I need to remove any scatter rugs at home." 3. "I can use crutch tips even when they are wet." 4. "I need to have spare crutches and tips available." 5. "When I'm using the crutches, my arms need to be completely straight."
1, 2, 4
(Simple Nursing) What is the first line of intervention for a client who has tested positive for cocaine and is becoming more agitated? 1. Move client to a room further down the hallway and provide a healthy snack. 2. Decrease environmental stimuli while monitoring the respiratory and cardiac status. 3. Immediately move the client closer to the nurse's desk for closer observation. 4. Medicate client with lorazepam 1mg PO and haloperidol 5 mg IM stat.
2
(Simple Nursing) Which of the following could be a sign of scoliosis in the young adolescent? 1. a noticeable limp in the morning 2. mild to severe back pain 3. mild swelling in both knees after activity 4. a "popping" sound when bending over
2
(Simple Nursing) Which of the following is considered to be one of the body's endogenous opioids? 1. bradykinin 2. endorphins 3. histamines 4. substance P
2
(Simple Nursing) Which of the following potent analgesics is recommended for chronic, persistent pain that takes up to 17 hours for full effect? 1. Naproxen 2. Fentanyl 3. Morphine 4. Oxycodone
2
(Simple Nursing) Which of the following nursing actions is a priority in clients experiencing respiratory depression as an adverse effect of opioid use? Select all that apply. 1. Withhold the drug 2. Hold the does for respiratory rates below 12 3. Teach deep breathing exercises 4. Prepare a rapid response 5. Notify the health care professional (HCP)
2, 3
(Simple Nursing) The nurse is creating a discharge teaching plan of care for a client with scoliosis. What should be included in the client's discharge plan of care? Select all that apply. 1. teach the client to participate in contact sports 2. teach the client to participate in physical exercise such as ROM 3. teach the client to visit friends often 4. teach the client to wear the Boston brace with a cotton shirt underneath 5. teach the client to lift heavy weights three times a week
2, 3, 4
(Simple Nursing) Which mechanism of injury can result in a spinal cord injury? Select all that apply. 1. hyperabduction 2. hyperflexion 3. hyperextension 4. vertical compression 5. excessive rotation
2, 3, 4, 5
(Simple Nursing) Realizing that liver toxicity is a severe side-effect of dantrolene, which clinical manifestation will the registered nurse (RN) educate the client to monitor for and report while taking this drug? Select all that apply. 1. the appearance of yellowish colored urine 2. the appearance of black, tarry stools 3. the appearance of right upper abdomen quadrant pain 4. the appearance of pale, dry skin 5. onset of nausea and vomiting
2, 3, 5
(Simple Nursing) Which of the following conditions can be associated with a finding of scoliosis in the client? Select all that apply 1. Down's syndrome 2. Cerebral palsy 3. Marfan's syndrome 4. Juvenile idiopathic arthritis 5. Muscular dystrophy
2, 3, 5
(Simple Nursing) Which of the following fractures puts the client at risk for a fat embolism? Select all that apply. 1. Radial compound fracture 2. Pelvic fracture 3. Ulnar spiral fracture 4. Compression fracture of the femur 5. Greenstick fracture of the fibula
2, 4
(Simple Nursing) A nurse applies a fentanyl patch to a client with chronic pain. Which of the following side effects must the nurse educate the client regarding the fentanyl patch? 1. Nausea 2. Vomiting 3. Constipation 4. Double vision
3
(Simple Nursing) The nurse is instructing the family regarding the Pavlik harness for treatment of their child's congenital hip dysplasia. Further education is needed when the family makes which statement? 1. "The Pavlik harness straps are only to be adjusted by the provider." 2. "A diaper is to be worn under the Pavlik harness straps." 3. "The Pavlik harness should stay on except during bathing and sleep." 4. "Clothes need to be placed under the Pavlik harness."
3
(Simple Nursing) What statement made by a client prescribed carisoprodol for a muscle strain, indicates a need for further teaching by the registered nurse (RN)? 1. "This drug will help relax the muscle in the area of the sprain." 2. "This drug will help decrease muscle spasticity in the area of the injury." 3. "This drug can be taken for as long as I need it, even if it is 2 months." 4. "This drug can cause drowsiness, so I need to get up slowly."
3
(Simple Nursing) When is the most important time to teach a diabetic client who drinks excessively to monitor their blood glucose? 1. before meals and at bedtime 2. twice a day 3. at night 4. morning time
3
(Simple Nursing) Which drug is commonly used to manage opioid withdrawal symptoms such as diarrhea, profuse sweating, vomiting, abdominal cramps, and anxiety? 1. naloxone 2. vasopressin 3. clonidine 4. diazepam
3
(Simple Nursing) Which immediate complication should the nurse assess for in a client with a newly placed left leg cast? 1. Constipation 2. Sepsis 3. Compartment syndrome 4. Loss of appetite
3
(Simple Nursing) Which medication would be prescribed for a drowsy client who has taken ten hydrocode 10mg tablets and has respirations of 9 breaths per minute and O2 sat of 78% on 4L of BNC oxygen? 1. Flumazenil 2. Acetylcysteine 3. Naloxone 4. Oxycodone
3
(Simple Nursing) A client with alcohol abuse is admitted to the hospital. It has been 24 hours since her last drink. Which symptoms does the nurse expect the client to be exhibiting? Select all that apply. 1. hand tremors 2. seizures 3. anxiety 4. insomnia 5. palpitations
3, 4, 5
(Simple Nursing) Which clinical manifestation occurring within 24 hours of a spinal cord injury is an indicator of neurogenic shock? Select all that apply. 1. severe hypertension 2. severe tachycardia 3. severe hypotension 4. severe bradycardia 5. dysregulation of body temperature
3, 4, 5
(Simple Nursing) Which of the following clients should be screened for scoliosis? Select all that apply 1. males 10-12 years old 2. females 6-8 years old 3. males 13-14 years old 4. females 10-12 years old 5. clients with cerebral palsy
3, 4, 5
(Fundamentals 422) 42. Which statement by a client indicates a precipitating factor associated with pain? Select all that apply. 1. _____ "I usually feel a little dizzy and think I'm going to vomit when I have pain." 2. _____ "My pain usually comes and goes throughout the night." 3. _____ "I usually have pain after I get dressed in the morning." 4. _____ "My pain feels like a knife cutting right through me." 5. _____ "My abdominal incision hurts when I cough."
3, 5
(Fundamentals 335) A client has multiple fractures from a skiing accident. To best facilitate bone growth, the nurse should encourage the client to eat more foods high in calcium. Which food selected by the client indicates an understanding of those that are high in calcium? Select all that apply. 1. _____ Orange juice 2. _____ Peanut butter 3. _____ Cottage cheese 4. _____ Baked flounder 5. _____ Low-fat yogurt 6. _____ Cooked spinach
3, 5, 6
(Simple Nursing) The nurse witnesses a client who fell and sustained a compound fracture to the left arm. Which nursing intervention is the priority to take with this type of fracture? 1. Wrap the fractured arm with a compression bandage. 2. Attempt to manually reduce the fracture. 3. Keep the fractured arm below the heart. 4. Wrap the fracture with a sterile gauze and kerlix.
4
(Simple Nursing) The recovery nurse is assisting a client with a total knee arthroplasty 1 hour postoperatively. Which assessment warrants the health care provider (HCP) to be notified immediately? 1. the client has voided 45ml of straw urine. 2. The client's temperature is 98.9F or 37.1C. 3. The client's dressing has 0.5cm of bright red blood 4. The client's hemoglobin level is 7.0 gm/dl.
4
(Simple Nursing) What level of spinal cord injury has the greatest risk of resulting in respiratory impairment? 1. thoracic 2. lumbar 3. sacral 4. cervical
4
(Simple Nursing) What radiological diagnostic test is implemented initially to diagnose a spinal cord injury? 1. lumbar puncture 2. spinal x-ray series 3. magnetic resonance imaging (MRI) 4. computed tomography (CT)
4
(Simple Nursing) Which of the following is indicated for clients as pain management after surgery or long-term recovery? 1. Fentanyl 2. Oxycodone 3. Naproxen 4. Patient-controlled analgesia (PCA) pump
4
(Simple Nursing) Which of the following measurements is helpful in diagnosing scoliosis? 1. neck to waist ratio 2. body mass index (BMI) 3. bilateral leg inseams 4. cobb angle
4
(Simple Nursing) The nurse knows that scoliosis screening is primarily assessed in what age group? 1. Preschool age 2. Girls between the ages of 10-12 3. Boys ages 10-12 4. Postpubertal clients
2
(Fundamentals 416) 1. A nurse is caring for a client who is experiencing pain. For which common psychological response to pain should the nurse assess the client? 1. Concerned about loss of control and independence 2. Withdrawing from social interactions with others 3. Asking for medication to provide for relief 4. Experiencing nausea and vomiting
1
(Fundamentals 417) 11. Which concept should the nurse consider when assessing a client's pain? 1. The expression of pain is not always congruent with the pain experienced. 2. Pain medication can significantly increase a client's pain tolerance. 3. The majority of cultures value the concept of suffering in silence. 4. Most people experience approximately the same pain tolerance.
1
(Fundamentals 418) 17. A nurse is obtaining a health history from a newly admitted client. Which client statement about alcohol intake is based on a common physiological response? 1. "After I go drinking, I have to urinate during the night." 2. "When I drink, I get hungry in the middle of the night." 3. "Falling asleep is hard, but once asleep I sleep great." 4. "If I drink too much, I oversleep in the morning."
1
(Fundamentals 418) 23. A nurse is helping a client who is experiencing mild pain to get ready for bed. Which nursing action is most effective to help limit pain? 1. Assisting with relaxing imagery 2. Obtaining a prescription for an opioid 3. Encouraging the client to take a warm shower 4. Recommending that the client be more active during the day
1
(Simple Nursing) A client with colorectal cancer undergoes bowel resection surgery. Which of the following medications is recommended to treat the client's postoperative pain? 1. Naproxen 2. Fentanyl 3. Morphine 4. Oxycodone
3
(Saunders 819) The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common among alcoholics."
1
(Saunders 820) A hospitalized client with a history of alcohol misuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be per formed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Restrain the client until the primary health care provider (PHCP) can be reached. 4. Tell the client that the client cannot return to this hospital again if the client leaves now.
1
(Simple Nursing) A client diagnosed with scoliosis asked the nurse why he cannot participate in contact sports. What is the nurse's best response? 1. "contact sports can cause more discomfort and lead to progression of the S spine." 2. "contact sports can cause injury and bleeding is a major problem with scoliosis." 3. "contact sports are very physical and you are too weak to participate." 4. "contact sports utilize force while playing and can cause damage to the bones."
1
(Simple Nursing) A client had placement of a cast to the right lower extremity 10 minutes ago and is complaining of severe pain and the inability to feel or move the right toes. What should the nurse do immediately? 1. notify the health care provider (HCP) 2. apply a cold compress to the client's toes 3. administer pain medication to the client 4. administer BNC oxygen at 2 L/M
1
(Simple Nursing) A client is prescribed a topical analgesic containing capsaicin. Which of the following must the nurse educate the client when applying the cream? 1. avoid the use of heating pads 2. washing the area of application after 30 minutes 3. discontinue the use of the medication if irritation occurs 4. the medication is safe to use on the face
1
(Simple Nursing) A client is receiving patient-controlled analgesia (PCA). What priority teaching is needed for who is allowed to administer the medication via PCA pump? 1. The client is the only one who can push the button to administer medication to himself/herself. 2. The nurse is the only one who can push the button to administer medication to the client. 3. The doctor is the only one who can push the button to administer medication to the client. 4. The client's family can push the button to administer medication to the client.
1
(Simple Nursing) A client is receiving patient-controlled analgesia (PCA). When is it appropriate to notify the healthcare provider (HCP) for an increase in dosage? 1. when the client attempts are two times the dose of the medication given 2. when the client attempts are three times the dose of the medication given 3. when the client attempts are five times the dose of the medication given 4. the client's doses are not to be increased after the initial set dosage.
1
(Simple Nursing) A client reports runny nose, diaphoresis, and the inability to sleep to the nurse. The nurse observes dilated pupils in the client. What medical concern does the nurse suspect? 1. Opioid withdrawal 2. Viral rhinitis 3. Influenza 4. Alcohol abuse
1
(Simple Nursing) A client was brought to the emergency department by EMS and the client had been submerged into a pond that was iced over for 1 hour. The client's pulses are weak and thready, has wheezing bilaterally, with crackles in the base of both lungs. Which intervention is priority for the nurse? 1. remove the client's wet clothes and cover with dry clothes & warm blankets 2. cover the client with warm blankets and a heating pad 3. remove the client's wet clothes and place the client in a hot bath 4. administer pain and nausea medications to the client
1
(Simple Nursing) A client with terminal cancer tells the hospice nurse that his son has asked him to have "a feeding tube put in soon". Which of the following is the nurse's best response? 1. "You son's wishes are considered but the final choice belongs to you." 2. "He loves you and wants you to live as long as possible." 3. "We can teach your family how to take care of the feeding tube." 4. "What do you think about your son's request?"
1
(Simple Nursing) An agitated client is in the emergency department producing various signs and symptoms such as severe coughing, anxiety, and aggression. When the client talks, the nurse notices the client has brown stained teeth and several spaces where the teeth are missing. Which substance should the nurse suspect? 1. Methamphetamines 2. Cocaine 3. Huffing paint 4. Cannabis
1
(Simple Nursing) An agitated, depressed client is in the emergency department asking for a prescription for hydrocodone because someone "stole their bottle of 10 mg of hydrocodone" that they take every 3-4 hours. Which term best describes what the client is experiencing? 1. Withdrawal 2. Tolerance 3. Enabling 4. Denial
1
(Simple Nursing) Before applying a new fentanyl patch, what is the first nursing action? 1. Remove the old patch. 2. Place the new patch next to the old patch. 3. Clean the area. 4. Dry the skin where the patch will be applied.
1
(Simple Nursing) Scoliosis is observed by which of the following changes in the musculoskeletal system? 1. A lateral curvature of the spine. 2. A rounded or hunch-backed appearance. 3. An outward curve at the bottom of the spine. 4. An abnormality of the hip joint.
1
(Simple Nursing) The nurse is assessing the preschool child and recognizes which finding is indicative of hip dysplasia? 1. Limp with a pelvic tilt 2. Failure to walk 3. Walking with the knees together 4. Walking on the inside of the feet
1
(Simple Nursing) The nurse is aware that a client with which disease process has a higher incidence of scoliosis? 1. Marfan syndrome 2. Hip dysplasia 3. Osgood-Schlatter disease 4. SCFE
1
(Simple Nursing) The nurse realizes that the pregnant mother needs further education about risk factors of hip dysplasia when she states which of the following? 1. Breech delivery 2. Prematurity 3. Family history of hip dysplasia 4. Multiple births
2
(Simple Nursing) The nurse is caring for a client who had a right above the knee amputation (AKA) two days prior and he is complaining of right foot pain rated #8 on a scale of 1 to 10. Which of these actions take priority? 1. administer the pain medication ordered for the client 2. explain to the client that this foot has been amputated and he cannot feel pain 3. call two unlicensed assistive personnel (UAP) to reposition the client for discomfort 4. call the health care provider (HCP) about the client's delusion of right foot pain
1
(Simple Nursing) What is the priority action of the nurse caring for a client receiving opioid analgesic medication via patient-controlled analgesic (PCA) pump? 1. pain assessment 2. intervention 3. administration of medication 4. reassessment
1
(Simple Nursing) Which client is at most risk for overdose while taking methadone for treatment during opioid withdrawal? 1. A 25 year old with a creatinine level of 3.0 mg/dL. 2. A 55 year old with stage 4 leukemia on chemotherapy. 3. A 36 year old taking birth control pills. 4. A 37 year old taking buspirone for anxiety.
1
(Simple Nursing) Which of the following clients have an increased risk of death, in relation to opioid use? 1. A 70-year-old male with recent total hip replacement surgery. 2. A 24-year-old female with a recent knee replacement surgery. 3. A 50-year-old female with a hysterectomy. 4. A 60-year-old male with prostate cancer.
1
(Simple Nursing) Which of the following defines the process of transduction in the pathophysiology of pain? 1. the tissue-damaging stimulus is converted into an electoral signal 2. pain signals are relayed from the injury site to the spinal cord and brain 3. the client responds to the painful stimulus he/she is experiencing 4. an alteration in the pain signal occurs as it travels on the pain pathway
1
(Simple Nursing) Which of the following is indicative of the use of a fentanyl patch? 1. chronic pain 2. acute pain 3. moderate pain 4. mild pain
1
(Simple Nursing) Which of the following is the most common long-term side effect of opioid use? 1. Constipation 2. Nausea 3. Vomiting 4. Pruritus
1
(Simple Nursing) Which of the following is the most common pharmacological agent given for mild to moderate pain? 1. Naproxen 2. Acetaminophen 3. Morphine 4. Fentanyl
1
(Simple Nursing) Which of the following topical agents is effective for relieving rheumatoid arthritis pain in adult clients? 1. Capsaicin 2. Menthol 3. Lidocaine 4. Salicylate
1
(Simple Nursing) Which signs and symptoms are most associated with opioid withdrawal? 1. Runny nose, diaphoresis, insomnia, and dilated pupils. 2. Coughing, fever, chills, and dilated pupils. 3. Itchy skin, nervous, and pinpoint pupils. 4. Coughing, sweating, fever, and constricted pupils.
1
(Simple Nursing) Which statement best describes the client being in denial and projection? 1. "I don't drink much. My wife now, she can put away the booze." 2. "I can't drink at all or I may relapse and start all over." 3. "I've been in AA meetings all week long." 4. "Yesterday was hard, but I called my sponsor and we talked."
1
(Simple Nursing) During an overdose of acetaminophen, which of the following labs must the nurse monitor? Select all that apply. 1. Alanine transaminase (ALT) 2. Aspartate transaminase (AST) 3. Creatinine 4. Glucose 5. Erythrocytes
1, 2
(Saunders 71) The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Atorvastatin
1, 2, 3
(Saunders 738) Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.
1, 2, 3
(Simple Nursing) Which of the following clients must avoid using non-steroidal anti-inflammatory drugs (NSAIDs)? Select all that apply. 1. a client with asthma 2. a client with peptic ulcer disease 3. a client with a recent nephrectomy 4. a client with rheumatoid arthritis 5. a client with gout
1, 2, 3
(Simple Nursing) Which statements show that the client's wife is enabling his substance abuse? Select all that apply. 1. "It's my fault that he drinks. If I stopped nagging him he wouldn't have to drink." 2. "I take care of the children because he is just so tired and upset. He has to sit in front of the tv trying to relax with a beer." 3. "I lied yesterday to his boss. He wanted to know why my husband wasn't at work." 4. "I told him no more drinking. If he does it again I'm out of here!" 5. "I take care of the children because when he comes home all he does is drink. I can't trust him with the children."
1, 2, 3
(Simple Nursing) A client is admitted to the orthopedic unit with an external fixator due to a fractured humerus. Which of these findings should alert the nurse to call the health care provider (HCP) immediately? Select all that apply. 1. the client has a temperature of 101.8F 2. the skin around the insertion site of the fixator is draining green exudate. 3. the client's hemoglobin is 7.1 gm/dL 4. the client becomes confused, restless with dyspnea 5. the client's white blood count is 9.0
1, 2, 3, 4
(Simple Nursing) A client is admitted with alcoholic cirrhosis. The client had his last drink 48 hours ago. Which medications may be ordered to help prevent delirium tremens? Select all that apply. 1. diazepam 2. lorazepam 3. atenolol 4. clonidine 5. morphine
1, 2, 3, 4
(Simple Nursing) The nurse is caring for a client who was admitted to the ICU with hypothermia. The client's core body temperature is 93F. Which interventions does the nurse anticipate to implement? Select all that apply. 1. Mechanical ventilation 2. Cardiac monitoring with defibrillation 3. Rewarming processes starting with trunk and then extremities 4. Warmed IV fluids with 2 large bore IVs 5. Placing client in a whirlpool 6. Massage the client's trunk and extremities
1, 2, 3, 4
(Simple Nursing) The nurse is preparing a teaching plan for a client who had a total left hip replacement. Which interventions should be included in the client's teaching plan? Select all that apply. 1. Abduct the legs. 2. Do not cross the legs. 3. Do not lean forward. 4. No sitting in a chair at 90 degrees. 5. Lie on the affected hip when in bed. 6. Pivot on the affected leg/hip when transferring.
1, 2, 3, 4
(Simple Nursing) When creating a plan of care for a 2-day post-operative amputee, which of these should the nurse include? Select all that apply. 1. Provide instructions on lifestyle changes with the amputee. 2. Offer emotional support to the amputee for the loss of a limb or body part. 3. Risk for alteration in body image due to the loss of a limb or body part. 4. Instruct and encourage active rang of motion exercises for strengthening. 5. Instruct the amputee to get up in a chair for 6-8 hours a day. 6. Encourage the amputee to dangle the stump off the bed 3 times a day.
1, 2, 3, 4
(Simple Nursing) Which of the following are taught as recovery coping skills for a recovering alcoholic? Select all that apply. 1. expressing accountability 2. joining Alcoholics Anonymous meetings 3. seeking out a sponsor 4. setting realistic goals 5. stopping after the first drink
1, 2, 3, 4
(Simple Nursing) Which of these disease processes place the client at a higher risk of having a total knee replacement? Select all that apply. 1. Osteoarthritis 2. Rheumatoid arthritis 3. Gouty arthritis 4. Knee injuries 5. Parkinson's disease
1, 2, 3, 4
(Simple Nursing) A client suffering with alcohol abuse had a motor vehicle accident that nearly killed an entire family. The client has been sober for two weeks. He arrives at the outpatient clinic seeking help to remain sober. Which of the following interventions may be implemented? Select all that apply. 1. Finding him a sponsor to help him. 2. Allow the client to vent his feelings. 3. Promoting abstinence from alcohol. 4. Obtaining a prescription for disulfiram. 5. Setting the client up with support groups for recovering alcoholics.
1, 2, 3, 4, 5
(Simple Nursing) A client was brought to the emergency department after having a motor vehicle accident and was found in a ditch. The police suspect the client was laying int the ditch for two days. The client has a history of alcohol abuse. Which of the following symptoms does the nurse expect the client may be experiencing from the lack of alcohol? Select all that apply. 1. Seizures 2. Unstable vital signs 3. Hyperreflexia 4. Hallucinations 5. Mental confusion
1, 2, 3, 4, 5
(Simple Nursing) Which of the following are risk factors for developing a bone fracture? Select all that apply. 1. Prolonged bed rest 2. Chronic steroid use 3. Trauma 4. Osteoporosis 5. Child abuse
1, 2, 3, 4, 5
(Simple Nursing) A client with a known history of alcohol abuse is at risk for what issues? Select all that apply. 1. balance problems 2. poor nutrition 3. severe hypoglycemia 4. central nervous system depression 5. death
1, 2, 3, 4, 5, 6
(Simple Nursing) While providing a nursing inservice about muscle relaxers, which common facture for all muscle relaxers will the registered nurse (RN) discuss? Select all that apply. 1. "when taking any muscle relaxer, sedation and drowsiness occur" 2. "when taking any muscle relaxer wine, can be drunk, but not beer" 3. "when stopping any muscle relaxer, the drug must be tapered off" 4. "when taking any muscle relaxer, minimal side-effects are expected" 5. "when taking any muscle relaxer, the primary goal of the therapy is pain relief"
1, 3
(Simple Nursing) A client with rheumatoid arthritis is educated to take ibuprofen to relieve the symptoms. Which of the following must the nurse educate the client on the safety of the analgesic drug? Select all that apply. 1. do not take on an empty stomach 2. may be taken with asthma drugs 3. do not take vitamin E supplements 4. do not take ginkgo supplements 5. may be taken with omega-3 supplements
1, 3, 4
(Simple Nursing) Which of the following are signs of impending death? Select all that apply. 1. Mottling and cyanosis of extremities 2. Increase in blood pressure 3. Increase in heart rate 4. Loss of muscle tone 5. Changes in respirations.
1, 4, 5
(Simple Nursing) What is the best explanation of the "alarm" stage of stress? 1. "The body is placed under psychological stress and responds by releasing antidiuretic hormone." 2. "The body enters 'fight or flight' mode and releases epinephrine and norepinephrine in response" 3. "The body experiences pain and releases anti-inflammatory mediators to reduce pain sensations" 4. "A person is placed under physical stress and responds by releasing aldosterone to reduce blood pressure."
2
(Simple Nursing) A client experiences nausea and vomiting after applying a fentanyl patch for chronic pain. Which of the following nursing priorities should the nurse teach the client about long-term use of a fentanyl patch? 1. inform the client that there are no long-term side effects of the fentanyl patch 2. inform the client that tolerance may develop 3. inform the client that the relief of the fentanyl patch is only temporary 4. inform the client that multiple patches may be applied for severe pain.
2
(Simple Nursing) A client is receiving patient-controlled analgesia (PCA) postoperatively. After three hours the nurse finds the client is having trouble breathing and is feeling dizzy and lightheaded. Which of the following is the nurse's priority action? 1. Report findings to the healthcare provider (HCP). 2. Wake the client and assess vital signs. 3. Document the findings. 4. Discontinue the medication.
2
(Simple Nursing) A client suspected of opioid overdose experiences respiratory depression and hypotension. Which of the following antidotes must be given to the client to counteract the toxicity of the analgesic drug? 1. Atropine 2. Naloxone 3. Flumazenil 4. Acetylcysteine
2
(Simple Nursing) A client with osteoarthritis presents with joint pain. Along with ibuprofen to relieve inflammation, which of the following is recommended? 1. Warm the affected area. 2. Use topical analgesics on the affected area. 3. Glucocorticoids. 4. Hydroxychloroquine.
2
(Simple Nursing) A client with superficial frostbite was admitted to the floor. The client's hands were blue mottled and had a waxy yellow appearance. Which intervention would the nurse implement as priority? 1. Cover the client's hands with wool gloves and a warm blanket. 2. Warm water soaks in the whirlpool for 30 minutes. 3. Apply pressure dressings to the client's hands. 4. Massage and rub cream on the client's hands.
2
(Simple Nursing) The new nurse needs further education in regards to traction when she makes which statement? 1. it is imperative to maintain proper alignment of the affected limb 2. weights should hang freely unless the patient is being transported 3. frequent position changes will be needed even during traction 4. skin integrity is monitored frequently and documented
2
(Fundamentals 353) An obese client has limited mobility after an open reduction and internal fixation of a fractured hip. For which human response related to increased blood coagulability should the nurse monitor this client? 1. Muscle deterioration 2. Pain in the calf 3. Hypotension 4. Bradypnea
2
(Fundamentals 6 Pg. 314) A client has a cast from the hand to above the elbow because of a fractured ulna and radius. After the cast is removed, the nurse teaches the client active range-of-motion exercises. Which client action indicates that further teaching is necessary? 1. Moves the elbow to the point of resistance 2. Keeps 90° elbow flexion after the procedure 3. Assesses the elbow's response after this procedure 4. Puts the elbow through its full range at least 3 times
2
(Saunders 744) A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates
2
(Saunders 747) The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture
2
(Saunders 75) The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the primary health care provider (PHCP) immediately. 4. Check the medication administration history on the PCA pump.
2
(Saunders 758) The nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen. Which instruction should be included in the teaching plan? 1. Restrict fluid intake. 2. Avoid the use of alcohol. 3. Stop the medication if diarrhea occurs. 4. Notify the primary health care provider (PHCP) if fatigue occurs.
2
(Saunders 825) The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I should get out of this bad situation." Which is the most helpful response by the nurse? 1. "Why don't you tell your spouse about this?" 2. "What do you find difficult about this situation?" 3. "This is not the best time to make that decision." 4. "I agree with you. You should get out of this situation."
2
(Simple Nursing) The nurse is creating a plan of care for a client who has had a below-the-knee amputation of the right leg. When should the plan of care include exercising the residual limb? 1. immediate post-operatively 2. 1 to 2 days post-operatively 3. when the client begins rehab 4. 1 week after surgery
2
(Saunders 759) The nurse is analyzing the laboratory studies on a client receiving dantrolene to treat muscle spasms from an injury. Which laboratory test would identify an adverse effect associated with the administration of this medication? 1. Platelet count 2. Creatinine level 3. Liver function tests 4. Blood urea nitrogen level
3
(Saunders 762) The nurse is administering an intravenous dose of methocarbamol to a client with a muscle skeletal injury. For which adverse effect should the nurse monitor? 1. Tachycardia 2. Rapid pulse 3. Bradycardia 4. Hypertension
3
(Saunders 894) A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? 1. "The decision is made by the medical examiner." 2. "An autopsy is mandatory for any client who is DOA." 3. "I will contact the medical examiner regarding your request." 4. "It is required by federal law. Tell me why you don't want the autopsy done."
3
(Fundamentals 417) 10. A client has a history of severe chronic pain. Which is the most important intervention associated with providing nursing care to this client? 1. Asking what is an acceptable level of pain 2. Providing interventions that do not precipitate pain 3. Focusing on pain management intervention before pain is excessive 4. Determining the level of function that can be performed without pain
3
(Fundamentals 418) 16. A nurse is assessing a client in pain. Which word might the nurse use when documenting the pattern of a client's pain? 1. Tenderness 2. Moderate 3. Episodic 4. Phantom
3
(Fundamentals 418) 21. Which is most important for nurses to understand when caring for clients in pain? 1. Clients who are in pain will request pain medication. 2. Clients usually are able to describe the characteristics of their pain. 3. Clients need to know that the nurse believes what they say about their pain. 4. Clients will demonstrate vital signs that are congruent with the intensity of their pain.
3
(Fundamentals 419) 26. A nurse is caring for clients receiving a variety of interventions for pain management. Which pain relief method has the shortest duration of action? 1. Client-controlled analgesia 2. Intramuscular sedatives 3. Intravenous narcotics 4. Regional anesthesia
3
(Fundamentals 419) 30. When the nurse is assessing a client, the client states, "The pain moves from my chest down my left arm." Which characteristic of pain is associated with this statement? 1. Pattern 2. Duration 3. Location 4. Constancy
3
(Fundamentals 420) 33. A nurse strains a back muscle when moving a client up in bed. Which can the nurse do at home that utilizes the gate-control theory of pain relief to minimize the discomfort? 1. Use guided imagery. 2. Perform progressive muscle relaxation. 3. Apply a cold compress to the site for 20 minutes. 4. Take a nonsteroidal anti-inflammatory medication every 6 hours.
3
(Fundamentals 9) Which condition identified by the nurse places a client at the highest risk for impaired self-care when toileting? 1. Amputation of a foot 2. Early dementia 3. Fractured hip 4. Pregnancy
3
(Saunders 65) A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what his pain level is on a scale of 0 to 10." 2. "I know that I should follow up after giving medication to make sure it is effective." 3. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." 4. "I know that pain in the older client might manifest as sleep disturbances or depression."
3
(Saunders 739) The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites
3
(Saunders 740) The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity
3
(Saunders 741) A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture
3
(Saunders 749) The nurse is caring for a client who had an above knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1. Apply ice to the site. 2. Call the primary health care provider (PHCP). 3. Rewrap the residual limb with an elastic compression bandage. 4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.
3
(Saunders 750) A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1. Bed rest 2. Ibuprofen 3. Bending or lifting 4. Application of heat
3
(Saunders 169) The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know they will not be abandoned by the nurse.
3, 5, 6
(Saunders 748) A client with diabetes mellitus has had a right below knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges
4
(Saunders 21) A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "Whoever is available at the time will sign as a witness for you." 4. "I will call the nursing supervisor to seek assistance regarding your request.
4
(Saunders 329) The nurse has just administered ibuprofen to a child with a temperature of 102° F (38.8° C). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate in 4 hours. 4. Remove excess clothing and blankets from the child.
4
(Saunders 736) The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? 1. "I can resume regular exercise tomorrow." 2. "I can't eat food for the remainder of the day." 3. "I need to stay off the leg entirely for the rest of the day." 4. "I need to report a fever or swelling to my healthcare provider."
4
(Saunders 737) The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1. Try to reduce the fracture manually. 2. Assist the victim to get up and walk to the sidewalk. 3. Leave the victim for a few moments to call an ambulance. 4. Stay with the victim and encourage him or her to remain still.
4
(Fundamentals 416) 3. A client with a diagnosis of cancer of the ovary had her uterus and both ovaries and fallopian tubes removed (hysterectomy with bilateral salpingo-oophorectomy) and a surgical debulking via an abdominal incision 2 days ago. The client reports abdominal pain at level 5 on a 0-to-10 pain scale. After assessing the pain further, which should the nurse do first? 1. Reposition the client. 2. Offer a relaxing back rub. 3. Use distraction techniques. 4. Administer the prescribed analgesic.
4
(Fundamentals 416) 7. A client requests pain medication for severe pain. Which should the nurse do first when responding to this client's request? 1. Use distraction to minimize the client's perception of pain. 2. Place the client in the most comfortable position possible. 3. Administer pain medication to the client quickly. 4. Assess the various aspects of the client's pain.
4
(Fundamentals 417) 13. A nurse is performing an admitting interview. Which client statement about pain should cause the most concern for the nurse? 1. "I try to pretend that it is not part of me, but it takes a lot of effort." 2. "My pain medication works, but I'm afraid of becoming addicted." 3. "At home, I take something for the pain before it gets too bad." 4. "They say my pain may get worse, and I can't stand it now."
4
(Fundamentals 418) 18. A nurse is assessing a client experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain? 1. Self-focusing 2. Sleep disturbances 3. Guarding behaviors 4. Variations in vital signs
4
(Fundamentals 418) 19. At which time does a nurse medicate a client for pain for it to be considered preemptive analgesia? 1. Before a client goes to sleep 2. At equally distant times around the clock 3. As soon as a client reports the occurrence of pain 4. Before doing a dressing change that has been painful in the past
4
(Fundamentals 436) One hour after the reduction of a compound fracture of the ulna and radius and application of a cast, the nurse observes a centimeter circle of drainage on the client's cast. Which should the nurse do first? 1. Inform the surgeon immediately. 2. Reinforce the cast with a gauze dressing. 3. Monitor the area frequently for expansion. 4. Circle the spot with a pen and date, time, and initial the area.
4
(Saunders 742) The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? 1. Elevated for 3 hours, then flat for 1 hour 2. Flat for 3 hours, then elevated for 1 hour 3. Flat for 12 hours, then elevated for 12 hours 4. Elevated on pillows continuously for 24 to 48 hours
4
(Saunders 753) A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1. Allows bony healing to begin before surgery and involves pins and screws 2. Provides rigid immobilization of the fracture site and involves pulleys and wheels 3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels
4
(Saunders 824) The nurse is assessing a client who was admitted 24 hours ago for a fractured humerus. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. Hypotension, ataxia, hunger 2. Stupor, lethargy, muscular rigidity 3. Hypotension, coarse hand tremors, lethargy 4. Hypertension, changes in level of consciousness, hallucinations
4
(Simple Nursing) A client arrives at the clinic for her pre-op visit before undergoing a BKA on the left leg next week. The client asks the nurse if diabetes and her lower ankle wound that has been open for 7 months were the causes of her upcoming amputation. What is the nurse's best response? 1. "Are you keeping your blood glucose levels below 200 mg/dl?" 2. "How often do you check the bottoms of your feet?" 3. "You will need to talk with your health care provider (HCP) about why you are having an amputation." 4. "Diabetes, peripheral artery disease, and osteomyelitis can be contributing factors for amputations."
4
(Simple Nursing) A client is experiencing toxicity to acetaminophen. Which of the following antidotes must be given to the client to counteract the toxicity of the analgesic drug? 1. Atropine 2. Naloxone 3. Flumazenil 4. Acetylcysteine
4
(Simple Nursing) A client presents with severe frostbite. The nurse begins rewarming the affected area. Which of the following may be necessary for the treatment of pain caused by the rewarming process? 1. Fentanyl 2. Ibuprofen 3. Morphine 4. Topical analgesic
4
(Simple Nursing) A client reports that he continues to have pain in his left foot, although it was amputated three weeks earlier. Which of the following identifies the source of his ongoing discomfort? 1. ischemic pain 2. neuropathic pain 3. referred pain 4. phantom pain
4
(Simple Nursing) A client was admitted with frostbite to the hands and large blisters have formed on each finger. The client asked if he can pop the blisters for faster healing. What is the best response by the nurse? 1. "Yes, I will pop all the blisters for you so quicker healing may occur." 2. "No, the health care provider will pop all the blisters for quicker healing." 3. "Yes, you may pop all the blisters if you would like to." 4. "No, you should never pop the blisters due to the severity of the frostbite."
4
(Simple Nursing) A client with chronic back pain tells the nurse they need more pain medicine because what they are taking now is not working anymore. Which term best identifies the problem? 1. withdrawal 2. dependence 3. relapse 4. tolerance
4
(Simple Nursing) A family in the Emergency Department has received news that their 10-month old baby died. Which is the nurse's first action? 1. Inquire if the family would consider organ donation 2. Encourage the family to return home to be with other loved ones 3. Ask the family which funeral home should be notified 4. Provide a quiet place for the family to grieve
4
(Simple Nursing) A nurse is caring for a 5-year-old client with influenza. The client has symptoms of a fever and muscle aches. Which of the following pharmacological agents is recommend for the client? 1. Ibuprofen 2. Morphine 3. Codeine 4. Acetaminophen
4
(Simple Nursing) An elderly client presents to the emergency department with a runny nose, diaphoresis, insomnia, and dilated pupils. The client has reported methadone use for opioid abuse. Which signs and symptoms are early warning signs of oxycodone toxicity? 1. Oxygen level of 98% and mild nausea 2. Nauseated without vomiting 3. Oxygen saturation level of 92% and vomiting x1 4. Nausea with frequent vomiting
4
(Simple Nursing) Realizing that rhabdomyolysis is a severe side-effect of baclofen, what primary clinical manifestation will the registered nurse (RN) instruct the client to monitor for and report to the healthcare provider if it is observed? 1. increased agitation 2. sudden mood change 3. muscle weakness 4. muscle pain
4
(Simple Nursing) The adolescent patient has been hospitalized for scoliosis surgery. Which one is the highest priority in regards to pre-surgical teaching? 1. Log roll the patient so they can stay in one plane. 2. Instructions on how to use the Milwaukee brace. 3. Follow up appointment dates and instructions. 4. Instructions on how to use the PCA pump.
4
(Simple Nursing) The client with a fracture has had their pain well controlled and required minimal prn pain medication is informing the nurse that his arm fracture hurt worse now than it did when it happened. The client's vitals and lab work have been normal. The nurse anticipates what diagnosis? 1. Osteomyelitis 2. Sepsis 3. Normal part of healing 4. Compartment syndrome
4
(Simple Nursing) The client with a traumatic compound fracture of the humerus should be assessed for which of the following? 1. Neurogenic shock 2. Cerebrospinal fluid (CSF) leak 3. Crutch training 4. Signs of infection
4
(Simple Nursing) The new nurse needs further education when he/she makes what statement to the seasoned nurse regarding a client with hip dysplasia? 1. "The unaffected leg is expected to be longer than the other." 2. "Extra gluteal fold can be found on the affected side." 3. "A click may be heard when abducting the legs." 4. "The client will have abnormal curvature of the spine."
4
(Simple Nursing) The nurse anticipates which orthopedic device will be utilized after surgical correction of hip dysplasia? 1. TLSO brace (thoracic lumbar sacral orthosis brace) 2. Pavlik harness 3. Serial casting 4. Spica cast
4
(Simple Nursing) The nurse is discussing common fractures with the new nurse. The nurse correctly identifies what type of fracture as being concerning for abuse? 1. Greenstick 2. Buckle 3. Oblique 4. Spiral
4
(Fundamentals 421) 41. Which is important for a nurse to consider when a client reports the presence of pain? Select all that apply. 1. _____ The extent of pain is directly related to the amount of tissue damage. 2. _____ Fatigue decreases the intensity of pain experienced by the client. 3. _____ Behavioral adaptations are congruent with statements about pain. 4. _____ Giving opioids to a client in pain will lead to an addiction. 5. _____ The person feeling the pain is the authority on the pain.
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