Saunder NcLEx questions
The nurse is talking to a client who had a below-the-knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? 1.Altered body image 2.Inability to care for self 3.Disruption in coping ability 4.Difficulty maintaining health
1 Altered 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 also may have the other problems as listed in the remaining options, but altered body image is the client problem that correlates best with the client's statement.
The home health nurse visits a client who is having an acute attack of gout. The nurse determines that the client needs further instruction regarding the treatment of gout if the client states to take which action? 1.Restricting fluids 2.Maintaining bed rest 3.Eating a low-purine diet 4.Taking nonsteroidal anti-inflammatory drugs
1 Ample fluid intake is encouraged to promote the excretion of uric acid. The client is placed on bed rest during an acute attack until the pain subsides. A diet low in purine normally is prescribed. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce pain and inflammation. Colchicine, which also may be prescribed, reduces the migration of leukocytes to the synovial fluid.
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 (10.3 kPa)
1 An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg (10.6 to 13.33 kPa). Oxygen saturation should be higher than 95%.
The nurse is receiving a client from the postanesthesia care unit following left above-knee amputation. Which is the priority nursing action at this time? 1.Elevate the foot of the bed. 2.Position the residual limb flat on the bed. 3.Put the bed in a reverse Trendelenburg's position. 4.Keep the residual limb flat, with the client lying on his or her operative side.
1 Edema of the residual limb is controlled by elevating the foot of the bed for the first 24 hours after surgery. After the first 24 hours, the residual limb is placed flat on the bed to reduce hip contracture. Edema is also controlled by residual limb wrapping techniques.
The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk? 1.Yogurt 2.Turkey 3.Shellfish 4.Spaghetti
1 The major dietary source of calcium is from dairy products including milk, yogurt, and a variety of cheeses. Calcium also can be added to certain products such as orange juice, which are then advertised as being fortified with calcium. Calcium supplements also are available and recommended for persons with typically low calcium intake. Turkey, shellfish, and spaghetti are not high-calcium products.
The nurse is teaching a client who had a lumbar laminectomy how to perform activities of daily living without causing strain on the back. Which action performed by the client indicates a need for further instruction? 1.Bends over to tie shoes 2.Sits in a recliner with feet elevated 3.Squats to pick up an item from the floor 4.Sleeps in a side-lying position with knees and hips bent
1 To prevent strain on the lower back, it is important to use proper body mechanics. This includes bending at the knees, and not at the waist, when picking up things or lifting. Options 2, 3, and 4 are all appropriate ways to avoid lower back strain.
The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. 1.Pyrexia 2.Elevated potassium level 3.Elevated white blood cell count 4.Elevated erythrocyte sedimentation rate 5.Bone scan impression indicative of infection
1,3,4,5 Osteomyelitis is an infection of the bone, bone marrow, and surrounding tissue. Clinical data indicative of osteomyelitis include pyrexia, elevated white blood cell count, elevated erythrocyte sedimentation rate, and a bone scan, computed tomography scan, or magnetic resonance imaging scan indicative of infection. Elevated potassium level is not specifically associated with osteomyelitis.
The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. 1.Twisting of the spine 2.Curvature of the spine 3.Hyperflexion of the spine 4.Sciatic nerve inflammation 5.Degeneration of the facet joints 6.Herniation of an intervertebral disk
1,3,6 Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Scoliosis (curvature), sciatica, and degenerative vertebral changes are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk.
he nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. 1.Fatigue 2.Weight gain 3.Restlessness 4.Morning stiffness 5.Pain with movement only
1,4 Early signs and symptoms of RA include fatigue, weight loss, fever, malaise, morning stiffness, pain at rest and with movement, and complaints of night pain. The involved joints appear edematous.
The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the plan of care needs to be revised if which outcome is noted? 1.Intact skin surfaces 2.Bowel movement every 4 days 3.Active range of motion of uninvolved joints 4.Absence of redness and swelling in the affected extremity
2 A bowel movement every 4 days is insufficient. The client should be having a bowel movement a minimum of every other day. Expected outcomes for impaired physical mobility for the client in traction include absence of thrombophlebitis (redness and swelling in the affected extremity), active range of motion to uninvolved joints, clear lung sounds, intact skin, and bowel movement every other day.
A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? 1.pH 2.Pao2 3.HCO3 4.Paco2
2 A significant feature of fat embolism is a significant degree of hypoxemia, with a Pao2 often less than 60 mm Hg (60 mm Hg). The data in the question indicate that the items in the remaining options are normal blood gas results.
The nurse is planning to teach proper use of a thoracolumbosacral orthosis to a client who has had spinal fusion with instrumentation. The nurse should include which teaching point in the 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 self-adhering 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 After spinal surgery, a brace or corset may be required temporarily to support the spine. Clients who have lumbar or thoracic spinal fusions wear a fiberglass brace, which resembles a shell. Initially, back braces or corsets may be worn constantly, whether the client is in or out of bed. If not required constantly, the brace is applied in the morning before getting out of bed. As the client's muscles strengthen, the use of braces or corsets is usually decreased. A back brace or thoracolumbosacral orthosis is individually fitted to the client. A layer of clothing is worn between the orthosis and the skin. The closures should be secure but not overly loose or tight. The brace should not irritate the skin with proper fitting. Always follow the primary health care provider's activity prescriptions.
A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? 1.Bed pillow 2.Abductor splint 3.Adductor splint 4.Overhead trapeze
2 After surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. A bed pillow and an overhead trapeze also are used, but neither is the priority item to be used in repositioning the client from side to side.
The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? 1.Calcium level of 9.0 mg/dL (2.25 mmol/L) 2.Uric acid level of 9.0 mg/dL (540 mcmol/L) 3.Potassium level of 4.1 mEq/L (4.1 mmol/L) 4.Phosphorus level of 3.1 mg/dL (1.0 mmol/L)
2 In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL (480 mcmol/L); a normal value for a male ranges from 4.0 to 8.5 mg/dL (240-501 mcmol/L) and for a female, from 2.7 to 7.3 mg/dL (160-430 mcmol/L). Options 1, 3, and 4 indicate normal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis.
Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the primary health care provider has prescribed which laboratory study? 1.Platelet count 2.Alkaline phosphatase 3.White blood cell count 4.Complete blood cell count
2 Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Diagnostic laboratory findings for Paget's disease include an elevated serum alkaline phosphatase level and elevated urinary hydroxyproline excretion. The remaining options are unrelated to diagnostic evaluation of this disease.
he nurse is creating a plan of care for a client in skin traction. Which frequent assessment should the nurse include in the plan as a priority intervention? 1.Urinary incontinence 2.Signs of skin breakdown 3.The presence of bowel sounds 4.Signs of infection around the pin sites
2 Skin traction is achieved by Ace wraps, boots, and slings that apply a direct force on the client's skin. Skin traction is usually removed and reapplied once a day. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can result from immobility, and although monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.
The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? 1.Urinary incontinence 2.Signs of skin breakdown 3.The presence of bowel sounds 4.Signs of infection around the pin sites
2 Skin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.
A client is treated in a primary health care provider's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which activity in the next 24 hours? 1.Resting the foot 2.Applying a heating pad 3.Applying an elastic compression bandage 4.Elevating the ankle on a pillow while sitting or lying down
2 Soft tissue injuries such as sprains are treated by RICE (rest, ice, compression, and 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.
An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? 1.Anemia 2.Fractures 3.Infection 4.Muscle sprains
2 The client is most at risk for fractures as a result of osteoporosis. Although other complications can occur, fracture is the greatest concern. Anemia and infection can occur with bone marrow disorders, and muscle sprains are unrelated to osteoporosis.
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 The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation.
The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take? 1.Massage the skin at the rim of the cast. 2.Petal the cast edges with adhesive tape. 3.Use a rough file to smooth the cast edges. 4.Apply lotion to the skin at the rim of the cast.
2 The nurse petals the edges of the cast with tape to minimize skin irritation. If a client has a cast applied and returns home, the client can be taught to do the same. Massaging the skin and applying lotion will not alleviate irritation. Using a rough file could cause increased irritation.
The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1.Hypotension 2.Weak pedal pulses 3.Redness at the pin sites 4.Drainage at the pin sites
2 Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage used to secure the traction system. This type of traction does not use pins; rather, elastic bandages or a prefabricated boot is worn by the client. Therefore, redness and/or drainage at the pin sites are incorrect. Hypotension is not directly associated with the use of this type of traction.
The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply. 1.Lying prone 2.Sitting using a lumbar roll or pillow 3.Standing with one foot on a step or stool 4.Lying on the side, with knees and hips straight 5.Lifting objects that need to be carried above elbow level 6.Leaning forward to reach objects, keeping the legs and knees straight
2,3 The client should avoid positions or activities that place strain on the lower back. The client should not sleep on the abdomen (prone) or on the side if the hips and knees are straight. It may be helpful for the client to stand with a foot elevated on a stool or to sit using a form of lumbar support. The client should not lean forward without bending the knees, stand in one position for long periods, or lift anything above elbow level
The nurse in the hospital emergency department is caring for a client with a fractured arm and is preparing the client for a reduction of the fracture that will be done in the casting room in the emergency department. The nurse should take which actions? Select all that apply. 1.Obtain an anesthesia consent. 2.Administer a prescribed analgesic. 3.Explain the procedure to the client. 4.Obtain informed consent for the procedure. 5.Inform the anesthesiologist of the time of the procedure.
2,3,4 Before a fracture is reduced, the client is informed about the procedure, and an informed consent is obtained. An analgesic is given as prescribed because the procedure is painful. Closed reductions may be done in the emergency department without anesthesia. Therefore, an anesthesia consent and anesthesiologist are not needed. If anesthesia is used, the procedure is done in the operating room, not in the emergency department.
A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the most reassurance by making which statement? 1."Canes prevent falls; they do not cause them." 2."The cane would help to break a fall, even if you do slip." 3."The cane has a flared tip with concentric rings to give stability." 4."The physical therapist will determine if the cane is inadequate."
3 A cane should have a slightly flared tip with flexible concentric rings. This tip acts as a shock absorber and provides optimal stability. The remaining options are unrelated to the subject of providing reassurance regarding safety and do not provide the client with reassurance about his or her concern.
A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item? 1.A walker 2.A wooden crutch 3.A straight leg cane 4.A Lofstrand crutch
3 A straight leg cane is useful for the client with slight weakness in one leg. A walker is beneficial to the client with greater or bilateral weakness or one who is at risk for falls. Wooden crutches often are used by clients with a leg cast. Lofstrand crutches aid clients who need crutches but have limited arm strength.
The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome? 1.The client refuses care. 2.The client allows the family to assist in the care. 3.The client assists in self-care as much as possible. 4.The client allows the nurse to complete the care on a daily basis.
3 A successful outcome for the problem of self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal, considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refused care or allowed others to do the care.
The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? 1.Advance the crutches along with both legs simultaneously. 2.Advance the crutches along with the right leg, and then advance the left leg. 3.Advance the crutches along with the left leg, and then advance the right leg. 4.Advance the left leg along with right crutch, and then the right leg and left crutch.
3 A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Option 1 describes a swing-through gait. Option 2 describes a three-point gait used for a right leg problem. Option 4 describes a two-point gait.
A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? 1.Fever and bradycardia 2.Fever and hypertension 3.Tachycardia and hypotension 4.Bradycardia and hypertension
3 Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.
A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? 1.Fever, bradycardia 2.Fever, hypertension 3.Tachycardia, hypotension 4.Bradycardia, hypertension
3 Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and, in the case of a fractured femur, into the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension.
The nurse is caring for a client admitted for a herniated intervertebral lumbar disk who is complaining about stabbing pain radiating to the lower back and the right buttock. The nurse determines that the client's signs/symptoms are most likely due to which condition? 1.Pressure on the spinal cord 2.Pressure on the spinal nerve root 3.Muscle spasm in the area of the herniated disk 4.Excess cerebrospinal fluid production in the area
3 Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knife-like, and localized in the affected area. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. Pressure on a spinal nerve root causes the symptoms of sciatica.
The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? 1.Contact the primary health care provider. 2.Massage the skin at the edges of the cast. 3.Petal the cast edges with appropriate material. 4.Place a small facecloth in the cast around the edges of the cast.
3 If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. It is not necessary to contact the primary health care provider unless skin breakdown is noted. Massaging the skin will not eliminate the problem. Placing a small facecloth in the cast around the edges of the cast is not appropriate.
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 If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the PHCP so that a new one could be applied. Elevation on 1 pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the PHCP were called, the prescription likely would be to reapply the compression dressing anyway.
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 Low back pain that radiates down 1 leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test). Bed rest, heat (or sometimes ice), and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve back pain.
The client should avoid positions or activities that place strain on the lower back. The client should not sleep on the abdomen (prone) or on the side if the hips and knees are straight. It may be helpful for the client to stand with a foot elevated on a stool or to sit using a form of lumbar support. The client should not lean forward without bending the knees, stand in one position for long periods, or lift anything above elbow level
3 Osteomyelitis is a bone infection and may be caused by direct contamination of bone through an open wound. Bacteria invade the bone tissue and produce inflammation. Ischemia and necrosis of the bone tissue may follow if not treated. The remaining options are unrelated to the cause of osteomyelitis.
A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? 1."When I have pain, I will take ibuprofen." 2."I should perform low-impact exercises regularly." 3."Because I have no symptoms, my disease is not progressing." 4."I must notify my primary health care provider if I experience any hearing loss."
3 Paget's disease is characterized by skeletal deformities caused by abnormal bone resorption followed by abnormal regeneration. It is a chronic disease, and most persons who are affected by it are asymptomatic. Even though there may be no symptoms, excessive bone loss may have occurred. Over-the-counter nonsteroidal anti-inflammatory drugs may be used for pain, and low-impact exercises may reduce pain and increase mobility. Bones in the ear may be affected, and pressure from an enlarged temporal bone may cause hearing loss. If hearing loss occurs, the primary health care provider is notified.
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 Signs of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema.
A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? 1.Dry sterile dressings 2.Hydrocolloid dressings 3.Moist sterile saline dressings 4.One-half strength povidone-iodine dressings
3 The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. Because this is an open wound, dry dressings should not be used. A hydrocolloid dressing is not indicated for use with clean, open incisions. The incision is clean, not dirty, so povidone-iodine should not be required. Also, this agent is irritating to tissues.
The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? 1.The pain level of the client 2.Blood pressure and respiratory rate 3.Capillary refill, sensation, color, and pulse of the left foot 4.The range of motion of the left knee when a continuous passive motion machine is used
3 The nurse would check capillary refill, sensation, color, and pulse of the affected extremity in a neurovascular assessment. Monitoring the pain level may be a component of the assessment but is not specifically related to neurovascular status. Blood pressure and respiratory rate may also be components of the nursing assessment but are not specific to neurovascular status. Range of motion is related to musculoskeletal status, not neurovascular status.
A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? 1.Using a footboard 2.Providing an overhead trapeze 3.Slightly elevating the foot of the bed 4.Slightly elevating the head of the bed
3 The part of the bed under an area in traction usually is elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. The remaining options are incorrect.
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 is the priority nursing action? 1.Provide pin care. 2.Medicate the client. 3.Call the primary health care provider. 4.Remove 2 lb (0.9 kg) of weight from the traction system
3Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the primary health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so.
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 A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.
The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. What should the nurse instruct the client to do? 1.Wear the sling at nighttime. 2.Keep a sling on the arm at all times. 3.Avoid range-of-motion exercises to the affected arm. 4.Lift the shoulder of the casted arm over the head periodically throughout the day.
4 A stiff or frozen shoulder can develop as a complication of a cast on an upper extremity. The client should be instructed to lift the shoulder of the casted arm over the head periodically throughout the day to prevent this complication. The client should not keep a sling on the arm at all times or wear the sling at nighttime. Range-of-motion exercises to the casted extremity would assist in preventing this complication.
The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? 1.Elevate the casted leg. 2.Contact the primary health care provider. 3.Administer another dose of pain medication. 4.Check the neurovascular status of the toes on the casted leg.
4 An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) often is the first sign of increasing pressure within a tissue compartment. The nurse needs to obtain additional assessment data to determine if the primary health care provider needs to be notified immediately or whether other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay necessary treatment.
The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include? 1.It will drain fluid that has accumulated below the knee. 2.It is used to obtain a muscle biopsy for pathology studies. 3.It will determine the degree of range of motion of the joint. 4.It will identify if there is joint injury and provide a route for surgical repair if indicated.
4 Arthroscopy is used to diagnose acute and chronic conditions of the joint. In addition, surgical repairs can be done during this procedure. This procedure does not quantitate the degree of range of motion of the joint. Obtaining a muscle biopsy is not performed through an arthroscope, nor is this invasive procedure necessary to remove fluid from below the knee.
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 Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative hemorrhage and edema of the residual limb 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 the incision is dry and intact.
A client who suffered a contusion after being hit on the thigh with a racquetball has been told that it is acceptable to apply heat to the area 72 hours after the injury. The nurse explains the rationale for this treatment to the client, stating that which is the physiological benefit of heat in this case? 1.It induces muscle relaxation. 2.It prevents abscess formation. 3.It reduces the likelihood of strain as a complication. 4.It promotes reabsorption of blood from the injured tissue.
4 The primary benefit from applying heat to a contusion is to speed up the rate of absorption of blood that has hemorrhaged into the affected soft tissue. Although heat also promotes muscle relaxation, this is not the intended benefit of this therapy in treating a contusion. Heat is not applied to reduce abscess formation or prevent muscle strain.
The nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse should take which priority action? 1.Take a set of vital signs. 2.Call the radiology department. 3.Reassure the client that everything will be fine. 4.Immobilize the right leg before moving the client.
4 When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is not hospitalized, and a primary health care provider is called for the hospitalized client. The nurse should remain with the client and provide realistic reassurance. The nurse does not prescribe radiographs. Telling the client that everything will be fine is nontherapeutic. Although vital signs will be taken, the priority is to immobilize the leg.
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 With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.