NUR 340 Exam 4 Prep U

Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first?

A 32-year old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter

A nurse is caring for a client with a cast on the left arm after sustaining a fracture. Which assessment finding is most significant for this client?

Fingers on the left hand are swollen and cool

A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate?

Gently washing the area surrounding the stoma using a facecloth and mild soap

After withdrawing the needle from blood donor's arm, the site begins to bleed excessively. What is the nurse's first action?

Hold firm pressure on the venipuncture site

A client who is post op bariatric surgery reports diarrhea. What is the most likely cause of the client's symptoms?

Poor dietary choices

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?

Provide a fan to blow cool air into the cast to relieve itching

A nurse is giving instructions to a client who's going home with a leg cast. Which teaching point is most critical?

Reporting signs of impaired circulation

A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session?

Reporting signs of impaired circulation

A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following?

Respiratory dysfunction

A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching?

"Don't take aspirin while you're taking warfarin"

A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response?

"Every unit of donated blood is typed and tested for antibodies to infections."

The nurse is caring for a client who had a surgical amputation of the left leg related to complication from diabetes. The client asks the nurse, "If my leg is really gone, then why am I having such bad pain?" What is the best response by the nurse?

"It is called phantom pain and may come and go"

A client has a plaster cast applied to the left leg. Which comment by the client following the procedure should the nurse address first?

"My toes are stiff."

The nurse is presenting health education to a 48-year-old man who was just diagnosed with type 2 diabetes. The client has a BMI of 35 and leads a sedentary lifestyle. The nurse gives the client information on the risk factors for his diagnosis and begins talking with him about changing behaviors around diet and exercise. The nurse knows that further client teaching is necessary when the client tells you what?

"There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented."

The nurse is teaching the client to instill eye drops. Which statement is correct?

"Wash your hands before and after instilling eye drops and do not touch the tip of the bottle"

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply.

- Encouraging a liberal fluid intake - Instructing the client to move the legs in a "pumping" exercise - Using elastic stockings, especially when decreased mobility would promote venous stasis - Applying a sequential compression device

A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed?

4:00 pm

A client has been involved in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. Other than the bone, what physical structures could be affected by this injury?

All options are correct: nerves, veins, etc.

The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery?

Anticoagulation therapy

The nurse is collecting the history of a client diagnosed with a cataract and is performing a focused assessment. Which finding should the nurse anticipate?

Blurred or cloudy vision

The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client's lungs and, when moving the gown, observes petechial hemorrhages on the skin of the chest. What is the first action by the nurse?

Call the physician to inform them of the findings

Which nursing assessment finding would be indicative of compartment syndrome in the client with a cast applied to the left forearm 3 hours earlier?

Capillary refill of left fingers greater than 3 seconds

A client who underwent an anterior colporrhaphy 6 hours ago has not voided. She reports some discomfort in her suprapubic area. Which of the following would the nurse expect to do?

Catheterize the client

A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client?

Changing the client's position within prescribed limits.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

Chest pain and dyspnea

The nurse is caring for a hospitalized client who has class II obesity and who has limited mobility. The nurse should address the client's risk for skin breakdown by:

Cleaning and drying regularly within the client's skin folds

A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. The nurse should identify the warning signs of what complication?

Compartment syndrome

In a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. Which complication does the assessments help the nurse to monitor in the client?

Compartment syndrome

Which condition is a downward displacement of the bladder toward the vaginal orifice?

Cystocele

After undergoing surgery the previous day for a total knee replacement, a client states, "I am not ready to ambulate yet." What should the nurse do?

Discuss the complications that the client may experience if there is lack of cooperation with the care plan

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?

Document that the stoma appears healthy and well perfused

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action?

Document these expected assessment findings

A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?

Elevate the affected extremity and use cold applications

An older female client who had a total hip replacement is to be discharged because her healing is almost complete. What would be most important for this client?

Exploring factors related to the client's home environment

Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure?

Fasciotomy

A client has been in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. What is the primary treatment for musculoskeletal trauma?

Immobilization

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client?

Ineffective breathing pattern

The client with a fractured femur is upset and agitated that skeletal traction will be necessary for 6 to 8 weeks. The client states, "How can I stay like this for weeks? I can't even move!" Based on these statements, the nurse would identify which of the following as the most appropriate nursing diagnosis?

Ineffective coping related to prolonged immobility

A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?

Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure

A nurse is caring for a client who recently underwent a total hip replacement. What is the best action by the nurse for client care?

Limit hip flexion of the client's hip when the client sits up

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?

Obtaining a culture

When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis?

Pain in the calf

A client undergoes an open reduction of a femur fracture, and returns to the orthopedic unit with a cast in place. What is the rationale for frequently assessing the client's pedal pulses?

Maintaining adequate circulation

A client has undergone an external fixation. Which actions would be the priority for this client?

Maintaining pin care

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN?

Measure blood glucose concentration every 4-6 hours

When caring for a client with a fracture, what assessment would take priority?

Neurovascular compromise

The nurse is caring for a client who has had a fracture reduction using a cast. What is most important for the nurse to assess?

Neurovascular status

The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery?

Never cross the affected leg when seated

To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treating inflammatory conditions of the eyes?

Nonsteroidal anti-inflammatory drugs (NSAIDs)

A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care?

Surgical intervention

A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications?

Teach the client to perform deep breathing and coughing exercises

A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario?

The client has a right to refuse the transfusion

The nurse is assessing a client who has a chronic pain disorder and who also has class II obesity. What principle should guide the care team's choice of pain treatments for this client?

The client may require higher doses of opioids than clients without obesity

A client has a newly created colostomy. After participating in counseling with the nurse and receiving support from the spouse, the client decides to change the colostomy pouch unaided. Which behavior suggests that the client is beginning to accept the change in body image?

The client touches the altered body part

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?

The client will be immobile during and shortly after surgery

A nurse is working on a surgical floor. The nurse must logroll a client following a:

laminectomy