Nurs 120 Week 1 Questions

A nurse is assessing the effectiveness of the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should alert the nurse to a possible complication? 1. Pitting edema around the stump dressing. 2. Looseness of the stump dressing. 3. The dressing forming a cone shape over the stump. 4. Figure-eight wrapping around the stump.

1. Pitting edema around the stump dressing.

A nurse is teaching a client who has left hemiparesis how to properly use a cane. Which of the following should the nurse include in the teaching? 1. Rubber tips should not be used on the end of a cane. 2. Hold the cane on the right side to provide support for the weaker extremity. 3. Place the cane approximately 61 cm (24in) in front of the feet before advancing. 4. Advance the right leg and the cane together to support the weaker leg.

2. Hold the cane on the right side to provide support for the weaker extremity.

A nurse is caring for a client who has a leg amputation. Which of the following client statements should indicate to the nurse that the client has a distorted body image? 1. "When I look in the mirror, all I see is a person without a leg." 2. "I have not always made good choices in life. I deserve to lose my leg." 3. "I don't think I will ever be able to play golf again with my friends." 4. "No matter how hard I work in physical therapy, I can't seem to make any progress."

1. "When I look in the mirror, all I see is a person without a leg."

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) in the proper use of assistive devices while ambulating residents. Which of the following statements should the nurse use when instructing the AP regarding the use of a cane? 1. "When the client moves, the cane is moved forward first." 2. "Canes are held on the weak side of the client's body." 3. "The grip should be level with the client's waist." 4. "The client should first move the strong leg, then the weak one."

1. "When the client moves, the cane is moved forward first."

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse recognizes that which of the following laboratory findings will impact wound healing? 1. Serum Albumin 3.2 g/dL 2. Hemoglobin 16 g/dL 3. WBC 8,000 µL 4. aPTT 1.8

1. Serum albumin 3.2 g/dL

A nurse is completing a treatment on a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse apply? 1. Transparent dressing 2. Wet-to-dry dressing 3. Dry sterile dressing 4. Antimicrobial dressing

1. Transparent dressing

A nurse is planning care for an older adult client who is at high risk for developing pressure ulcers. Which of the following is an appropriate measure for the nurse to include? 1. Use a draw sheet to move the client up in bed. 2. Apply cornstarch to keep sensitive skin areas dry. 3. Massage the skin over the client's bony prominences. 4. Elevate the head of the bed no more than 45 degrees.

1. Use a draw sheet to move the client up in bed.

A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. Which of the following findings indicates the client is experiencing a complication? 1. A palpable lump in the buttock. 2. A change in urinary output. 3. Client reports onset of thirst. 4. Client reports a change in taste.

2. A change in urinary output.

A nurse should reinforce teaching on how to use a three-point gait for which of the following clients requiring crutches? 1. A client who is able to bear full weight on both lower extremities. 2. A client who has bilateral leg braces due to paralysis of lower extremities. 3. A client who has a right femur fracture prescribed no weight bearing of affected leg. 4. A client who has bilateral knee replacements prescribed partial weight bearing of both legs.

3. A client who has a right femur fracture prescribed no weight bearing of affected leg.

A client who has a femur fracture states, "I can't stay in this bed any longer. I need to get home so I can take care of my family." The nurse responds by saying, "You have talked about your family. Can you tell me more about your specific concerns?" Which type of therapeutic communication response is the nurse using? 1. Summarizing 2. Empathizing 3. Focusing 4. Clarifying

3. Focusing

A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings requires immediate notification of the provider? 1. Moderate level of pain. 2. Dependent edema distal to the cast. 3. Inability to flex the toes of the casted foot. 4. Ecchymosis of the distal foot.

3. Inability to flex the toes of the casted foot.

A nurse is assessing a client who has a hip fracture. Which of the following findings should the nurse expect with a hip fracture? 1. Leg lengthening 2. Hip pallor 3. Muscle spasms 4. Leg abduction

3. Muscle spasms

A client has a fractured tibia as a result of a fall. The x-ray shows that the bone is splintered into several pieces around the shaft. The nurse knows that this client's fracture is 1. impacted. 2. transverse. 3. comminuted. 4. oblique.

3. comminuted.

A provider prescribes cyclobenzaprine (Flexeril) for a client who has a fractured ulna. When the client asks the nurse what this medication is supposed to do for him, the nurse should explain that cyclobenzaprine will: 1. kill microorganisms. 2. reduce itching. 3. relieve muscle spasms. 4. relieve pain.

3. relieve muscle spasms.

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following client statements indicates a need for further teaching? 1. "I will keep spare crutch tips handy." 2. I will bear the weight of my body on my hands." 3. "I will inspect my crutches every day for signs of wear." 4. "I have a set of spare crutches in my basement I can also use."

4. "I have a set of spare crutches in my basement I can also use."

Upon inspection of a client's skin, a nurse identifies a stage 3 pressure ulcer on the sacrum. Which of the following statements by the nurse describes a stage 3 pressure ulcer? 1. "There appears persistent reddening of the skin." 2. "There is slough on part of the wound area." 3. "There is a fluid-filled area under the skin." 4. "There is full thickness skin loss with a crater."

4. "There is full thickness skin loss with a crater."

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time? 1. Elevate the foot of the bed. 2. Encourage sitting up as much as possible. 3. Elevate the stump on a pillow. 4. Have the client lie prone several times a day.

4. Have the client lie prone several times a day.

A nurse caring for a client who has pelvic fractures suspects fat embolism syndrome. Which of the following findings is a late sign of this complication? 1. Tachypnea 2. Pyrexia 3. Tachycardia 4. Pulmonary edema

4. Pulmonary edema

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client will be in which of the following positions? 1. Supine and both legs extended. 2. With the right leg flat on the bed. 3. Semi-Fowler's with the legs elevated to 10°. 4. With the right leg at a 20° angle.

4. With the right leg at a 20° angle.

A nurse is caring for an older adult client who has left-sided weakness. Which of the following information regarding the use of a cane is appropriate? 1. Hold the cane with the left hand. 2. Place the cane on the right side, and advance the left foot forward. 3. Advance the cane forward 30-45 cm (12-18 in) with each step. 4. Move the right leg forward first when using the cane.

2. Place the cane on the right side, and advance the left foot forward.