Saunders Adult Health/Pharmacology Hematological and Muscoskeletal

The nurse has completed giving discharge instructions to a client with osteoarthritis who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement?

"All caregivers need to be told about the metal implant." A TJR is also known as a total joint arthroplasty (TJA). The client must inform other caregivers of the presence of the metal implant because certain tests and procedures will need to be avoided. After total knee replacement, the client needs to report signs and symptoms of infection and any changes in the shape of the knee. These could indicate developing complications. With a metal implant, the client may be on anticoagulant therapy and needs to report adverse effects of this therapy, including bleeding from a variety of sources, and the client will need antibiotic prophylaxis for invasive procedures.

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?

"Because I have no symptoms, my disease is not progressing." 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 planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information would the nurse include in the teaching?

"Bleeding and swelling caused increased pressure in an area that couldn't expand." Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The remaining options are inaccurate descriptions of compartment syndrome.

The nurse is caring for a client with a back injury sustained 1 year ago. To obtain the most complete assessment data about the client's chronic pain pattern, what would the nurse ask the client?

"Can you describe your daily activities in relation to your pain?" The client has chronic pain. This affects quality of life and is disruptive to even the simplest of tasks such as eating, bathing, or shopping. Therefore, the priority for the nurse is to ask the client about these issues. Option 1 addresses aggravating factors of the pain. Although options 2 and 4 are important, they are not specific to what the question is asking: assessment data about chronic pain pattern. These questions would be most helpful with planning of pain management.

The nurse reviews the medication history of a client and notes that the client is taking leflunomide. During assessment of the client, the nurse would ask which question to determine the effectiveness of this medication.

"Do you have any joint pain?" Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. The questions in the remaining options are unrelated to the action, use, or effectiveness of the medication.

The nurse is preparing instructions for a client who is diagnosed with osteomalacia who is at risk for skeletal injury. Which information would the nurse include in the teaching?

"Ensure adequate intake of foods fortified with vitamin D." A common cause of osteomalacia is vitamin D deficiency, so the client needs to include adequate dietary intake of vitamin D-fortified foods. Other causes include inadequate exposure to sunlight (to synthesize vitamin D) and disorders that interfere with the absorption and metabolism of vitamin D. Osteomalacia technically refers to bone softening, which results from demineralization of bone matrix and its failure to calcify. This is different from osteoporosis, which is a metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility and pathological fractures. Weight-bearing exercises are appropriate.

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse would make which response?

"Have the child perform simple isometric exercises during this time." Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement.

The nurse teaches a client who is going to have a plaster cast applied to treat a fracture about the procedure. Which statement by the client indicates a need for further teaching?

"I can bear weight on the cast in one-half hour." A plaster cast can tolerate weight bearing once it is dry, which takes from 24 to 72 hours, depending on the nature and thickness of the cast. A plaster cast gives off heat as it dries. The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed.

A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching?

"I can use a hair dryer on the low setting and allow the cool air to blow into the cast." Itching is a common complaint of clients with casts. Objects would not be put inside a cast because of the risk of scratching the skin, thereby providing a point of entry for bacteria. A plaster cast can break down when wet. Therefore, the best way to relieve itching is with a forceful injection of air inside the cast.

A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm, and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction?

"I can use lotion or powder around the cast edges to relieve itching." Teaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements and indicate that the parents understand cast care.

The home care nurse is making a monthly visit to a client with a diagnosis of pernicious anemia who has been receiving a monthly injection of cyanocobalamin. Before administering the injection, the nurse evaluates the effects of the medication and determines that a therapeutic effect is occurring if the client makes which statement?

"I feel stronger and have a much better appetite." Cyanocobalamin is essential for DNA synthesis. It can take up to 3 years for the vitamin B12 stores to be depleted and for symptoms of pernicious anemia to appear. Symptoms can include weakness, fatigue, anorexia, loss of taste, and diarrhea. To correct deficiencies, a crystalline form of vitamin B12, cyanocobalamin, can be given intramuscularly. The client statements in options 1, 2, and 3 do not identify a therapeutic effect of the medication.

The nurse has provided instruction to a client with chronic kidney disease who has a prescription for epoetin alfa. Which statement by the client indicates that teaching was effective?

"I have to receive this medication subcutaneously." Epoetin alfa is administered parenterally by the intravenous or subcutaneous route. It cannot be given orally because it is a glycoprotein and would be degraded in the gastrointestinal tract.

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?

"I need to apply lotion under the brace to prevent skin breakdown." A brace may be prescribed to treat scoliosis. Braces are not curative but may slow the progression of the curvature to allow skeletal growth and maturity. The use of lotions or powders under a brace needs to be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace.

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?

"I need to avoid getting the cast wet." A plaster cast must remain dry to keep its strength. The cast needs to be handled with the palms of the hands, not the fingertips, until fully dry; using the fingertips results in indentations in the cast and skin pressure under the cast. Air needs to circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client would never scratch under the cast because of the risk of altered skin integrity; the client may use a hair dryer on the cool setting to relieve an itch.

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?

"I need to bring my infant back to the clinic in 1 month for a new cast." Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

A client has had a bone scan done. The nurse determines that the client demonstrates understanding of postprocedure care when the client makes which statement?

"I need to drink plenty of water for 1 to 2 days after the procedure." No special restrictions are necessary after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. The very small amount of radioactivity from the isotope presents no hazard to the client or staff. The remaining options are unrelated to postprocedure care.

A client arrives in the hospital emergency department and tells the nurse that they twisted the ankle while jogging. The client is seen by the primary health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours?

"I need to elevate my foot above the level of the heart." Soft tissue injuries such as sprains are treated with RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on health care provider prescription. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. The client would rest and not walk around, and the foot needs to be elevated and not placed in a dependent position.

The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication?

"I need to increase my fluid intake." Iron preparations can be very irritating to the stomach and are best taken between meals. Because iron supplements may be associated with constipation, the client would increase fluids and fiber in the diet to counteract this side effect of therapy. Iron preparations need to be taken with a substance that is high in vitamin C to increase its absorption. The tablet is swallowed whole and not chewed.

The nurse has given instructions to a client who sustained a ligament injury who is returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood?

"I need to report a fever, redness around my incisions, or persistent drainage to my health care provider." After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for the length of time prescribed by the surgeon. The client may resume the usual diet. Signs and symptoms of infection need to be reported to the primary health care provider.

The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction?

"I need to sit in my recliner when I get home." After total hip replacement, the client needs to be instructed to sit on a high, firm chair. The client would be instructed to keep the legs apart while sitting or lying to prevent disruption of the hip replacement; this may be accomplished by placing a blanket or a pillow between the legs. The use of an elevated toilet seat will prevent discomfort and pressure at the operative site. The surgeon needs to be notified if the client notes the development of any redness, irritation, or drainage at the incision site.

Probenecid has been prescribed for a client with a diagnosis of gout, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction?

"I need to take acetylsalicylic acid for relief of headache." The nurse needs to instruct the client taking probenecid to increase fluid intake to minimize calculous formation. Serum uric acid levels would also be monitored. The client needs to be instructed to take the medication with food to prevent gastrointestinal upset and to avoid the use of salicylates because they decrease the uricosuric effects of probenecid.

The nurse teaches the client with hypocalcemia how to take calcium carbonate. Which statement by the client indicates an understanding of the instructions?

"I need to take the tablet an hour after lunch." Calcium carbonate is best administered 1 to 1½ hours after meals. The tablets need to be given with a full glass of water. Therefore, options 2, 3, and 4 are incorrect times and methods for administration.

The nurse is providing instructions to the parent of a child with iron-deficiency anemia about the administration of a liquid oral iron supplement. Which statement, if made by the parent, indicates an understanding of the administration of this medication?

"I need to use a medicine dropper and place the iron near the back of the throat." An oral iron supplement needs to be administered through a straw or a medicine dropper placed at the back of the mouth because it will stain the teeth. The parents need to be instructed to brush or wipe the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acidic environment to facilitate its absorption in the duodenum.

A client has been experiencing muscle weakness over a period of several months. The primary health care provider suspects polymyositis. Which client statement correctly identifies a confirmation of test results and this diagnosis?

"I will know I have polymyositis if the muscle fibers are inflamed." In polymyositis, necrosis and inflammation are seen in muscle fibers and myocardial fibers. Option 1 refers to the decreased elastic tissue in the aorta seen in Marfan syndrome. Option 3 refers to increased fibrous tissue seen in ankylosis. Option 4 is the opposite of what is noted in this disorder.

The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures to minimize injury indicates that discharge teaching was effective? Select all that apply.

"I will not blow my nose if I get a cold." "I may continue to use an electric shaver." "I would use a soft-bristled toothbrush to avoid mouth trauma." Bleeding precautions are used to protect the client with thrombocytopenia from bleeding. The client with thrombocytopenia may experience internal and external bleeding. Bleeding is frequently provoked by trauma, but it also may be spontaneous. The client with thrombocytopenia needs to be educated about activities that increase the risk for bleeding, such as contact sports and trauma to oral, nasal, and rectal mucosa. This will help to eliminate options 3 and 4.

The client is given medication instructions for maintenance therapy for oral dantrolene sodium for the treatment of spasticity. Which client statement indicates understanding of the instructions?

"I will take 100 mg twice a day." For treatment of spasticity, dantrolene is administered orally. The initial dosage in adults is 25 mg once daily. The usual maintenance dosage is 100 mg two to four times daily. If beneficial effects do not develop within 45 days, dantrolene therapy would be discontinued.

The nurse is giving medication instructions to a client who is receiving baclofen as maintenance therapy. Which client statement about the maintenance dose of baclofen indicates that education was effective?

"I will take 15 mg 4 times daily." Baclofen is dispensed in tablets of 10 and 20 mg for oral use. Dosages are low initially and then are increased gradually. Maintenance doses range from 15 to 20 mg administered 3 to 4 times a day.

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply.

"I would not use someone else's crutches." "I need to remove any scatter rugs at home." "I need to have spare crutches and tips available." The client needs to use only crutches measured for the client. When assessing for home safety, the nurse ensures that the client knows to remove any scatter rugs and to avoid walking on highly waxed floors. The tips need to be inspected for wear, and spare crutches and tips should be available if needed. Crutch tips should remain dry. If crutch tips get wet, the client needs to dry them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not more than 30 degrees when the palms are on the handle.

A client is to receive a prescription for methocarbamol. The nurse provides instructions to the client about the medication. Which client statement would indicate a need for further education?

"If my vision becomes blurred, I don't need to be concerned about it." Methocarbamol is a muscle relaxant that works by blocking nerve impulses (or pain sensations) that are sent to the brain. The client needs to be told that the urine may turn brown, black, or green. Other adverse effects include blurred vision, nasal congestion, urticaria, and rash. The client needs to be instructed to notify the primary health care provider if these side/adverse effects occur.

Epoetin alfa is prescribed for a client diagnosed with chronic kidney disease. The client asks the nurse about the purpose of the medication. Which response by the nurse is most appropriate?

"It is used to treat anemia." Epoetin alfa is a medication that is used to treat anemia. It does not lower blood pressure or increase potassium. It is also not given after a dialysis treatment to prevent seizure activity. Hypertension is a side effect. Hyperkalemia and seizures are adverse effects of the medication.

A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse would consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement?

"My bedroom and bathroom are on the second floor of my home." Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. If stairs need to be climbed to reach a bathroom, hand rails would be installed and the area kept free of clutter. The nurse ensures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level. From the options provided, options 1, 2, and 3 do not indicate a need for modification of the environment.

The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction?

"Pain or fatigue is expected, and I would try to continue with the activity if this occurs." The client needs to be instructed to use pain or fatigue as an indicator and guide to increase, maintain, or decrease an activity level. If pain or fatigue is experienced, the client needs to rest. The client needs to learn to slide objects rather than lifting them and not remain in the same position for a long time. Whenever possible, the client would use large joints instead of small joints for activities and would use the joints in their most natural position.

A client with a fractured foot 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?

"The cane has a flared tip with concentric rings to give stability." A cane would 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 their concern.

A client with a history of spinal cord injury is beginning medication therapy with baclofen. The nurse determines that the client understands the side/adverse effects of the medication if the client makes which statement?

"The medication may make me drowsy." Baclofen is a central-acting skeletal muscle relaxant useful in treating muscle spasticity, usually in upper motor neuron injury. Side/adverse effects include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. The other options are incorrect.

A client is receiving a new prescription for colchicine. Which information about this medication would the nurse include in an educational session?

"This is an anti-inflammatory agent specific for gout." Colchicine is an anti-inflammatory agent whose effects are specific for gout. Colchicine is not an analgesic and does not relieve pain. It is not a nonsteroidal anti-inflammatory drug, nor is it an osmotic diuretic.

The nurse is providing dietary instructions to the client with anemia. The client tells the nurse that the iron pills are very expensive and that it will be difficult to pay for the pills and buy the proper food. What is the most appropriate nursing response?

"Would you like for me to check into some other options for you?" Option 4 is correct because it validates the client's issue with cost. The nurse offers help in a nonthreatening manner that will allow the client to accept or decline. Option 2 is incorrect because the client needs to consume a proper diet. Options 1 and 3 block the communication process and are nontherapeutic and nonhelpful statements.

The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information would the nurse include?

"You will be able to bear some weight as tolerated with a walker or crutches by discharge." After total knee arthroplasty, there is an emphasis on physical therapy as part of the plan of care. By discharge, the client should have adequate flexion in the operative knee for ambulation and will be able to bear some weight as tolerated with a walker or crutches. However, the surgeon's prescriptions are always followed with regard to weight bearing. The other options are incorrect.

Calcium carbonate is prescribed for a client with hypocalcemia. How would the nurse instruct the client to take the medication?

1 hour after meals Calcium carbonate tablets would be taken with a full glass of water 30 to 60 minutes after meals; therefore, the remaining options are incorrect.

A fluorescent antinuclear antibody titer (FANA) is performed in a client suspected of having rheumatoid arthritis (RA). Which laboratory value is most consistent with RA?

1:20

The nurse is planning to teach a client with a muscle ligament injury how to stand on crutches. The nurse will incorporate into written instructions that the client would be told to place the crutches in what manner?

6 inches (15 cm) to the front and side of the toes The classic tripod position is taught to the client before instructions on gait are given. The crutches are placed 6 inches (15 cm) in front and to the side of the client. This placement provides an adequate base of support to the client and improves balance.

The nursing student is presenting a clinical conference and discusses the cause of β-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

A child of Mediterranean descent β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). This disorder is found primarily in individuals of Mediterranean descent. Options 1, 3, and 4 are incorrect.

The community health nurse is providing a teaching session on osteoporosis. The nurse informs these community residents that which is a risk factor for this disorder?

A diet low in vitamin D Some of the risk factors related to osteoporosis are a small skeletal frame and elevated thyroid hormone. Low dietary intake of calcium and vitamin D also constitutes a risk factor for osteoporosis.

A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How would the nurse interpret this client statement?

A normal response that indicates the presence of phantom limb sensation Phantom limb sensations are felt in the area of the amputated limb. These sensations can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area of the amputation. Whenever possible, the client needs to be prepared for these sensations. The client also may feel painful sensations in the amputated limb, called phantom limb pain. The origin of the pain is less well understood, but the client needs to be prepared for this, too, whenever possible.

The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse would plan to use which method to reposition the client?

A pillow to keep the right leg abducted during turning After femoral head replacement for a fractured hip with an intracapsular fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The nurse then repositions the client while maintaining proper alignment and abduction. A trochanter roll is useful in preventing external rotation, but it is used after the client has been repositioned. A trochanter roll is not used while the client is being turned.

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?

A sedentary 65-year-old woman who smokes cigarettes Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.

A client is being transferred to the nursing unit from the postanesthesia care unit after spinal fusion with rod insertion to treat spinal instability from severe arthritis. The nurse would prepare to transfer the client from the stretcher to the bed by using which best method?

A transfer (slider) board and the assistance of three people After spinal fusion, with or without instrumentation, the client is transferred from the stretcher to the bed using a transfer (slider) board and the assistance of three people, with one at the head to protect or support the client's head and neck. This strategy permits optimal stabilization and support of the spine while allowing the client to be moved smoothly and gently.

Dantrolene sodium has been administered to a client with a spinal cord injury. The nurse determines that the client is experiencing an adverse effect of the medication if which is noted?

Abdominal pain Dantrium is hepatotoxic. The nurse observes for indications of liver dysfunction, which include jaundice, abdominal pain, and malaise. The nurse notifies the primary health care provider if these occur. The signs and symptoms in the remaining options are expected side effects due to the central nervous system-depressant effects of the medication.

A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what would the nurse plan to use as the most important item for this maneuver?

Abductor splint 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.

Dantrolene sodium is prescribed for the client experiencing flexor spasms. The client asks the nurse how the medication is going to help. The nurse replies that this medication acts in which way?

Acts directly on the skeletal muscle to relieve the spasms Dantrolene sodium acts directly on skeletal muscle to relieve muscle spasticity. The primary action is the suppression of calcium release from the sarcoplasmic reticulum. This in turn decreases the ability of the skeletal muscle to contract. The other options are incorrect actions.

The client with a crush injury to the leg has a highly positive urine myoglobin level. The nurse would assess this client carefully for signs and symptoms of which problem?

Acute tubular necrosis The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream, where it is cleared from the body by the kidneys. When a large amount of myoglobin is being cleared from the body, there is a risk of the renal tubules being clogged with myoglobin, causing acute tubular necrosis. This is one form of acute kidney injury. The remaining options are unrelated to a positive myoglobin 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 would take which actions? Select all that apply.

Administer a prescribed analgesic. Explain the procedure to the client. Obtain informed consent for the procedure. 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 with rheumatoid arthritis who had a total knee arthroplasty tells the nurse that there is pain with extension of the knee. The nurse would perform which action?

Administer an analgesic. Pain with knee extension is a common complaint of clients after knee arthroplasty; therefore, administering an analgesic would be the appropriate action. Immobilizing the knee will not help. The pain may be the result of a flexion contracture that developed preoperatively as the client tried to reduce the pain by keeping the knee partially flexed much of the time. The nurse needs to encourage the client to keep the knee extended and administer analgesics as needed. Pain is expected postoperatively, so there is no need to notify the primary health care provider based on the symptom described. Full passive range of motion can be harmful to the knee replacement.

The nurse is instructing a client with iron-deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction would the nurse tell the client?

Administer the iron through a straw. In iron-deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement needs to be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. Clients need to be instructed to brush or wipe their teeth after administration. Iron is administered between meals, because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not mixed with liquids, cereal, or other food items.

The nurse is preparing to instruct the parents of a child with iron-deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction would the nurse give the parents?

Administer the iron through a straw. In iron-deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement needs to be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth. The parents would be instructed to brush or wipe the child's teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items.

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 would tell the client to perform which action?

Advance the crutches along with the left leg, and then advance the right leg. 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.

The nurse is evaluating the results of laboratory studies for a client receiving epoetin alfa. When would the nurse expect to note a therapeutic effect of this medication?

After 2 weeks of therapy Epoetin alfa stimulates erythropoiesis. It takes 2 to 6 weeks after initiation of therapy before a clinically significant increase in hematocrit is observed. Therefore, this medication is not intended for clients who require immediate correction of severe anemia, and it is not a substitute for emergency blood transfusions.

The nurse is reviewing laboratory results for a client taking dantrolene sodium. The nurse would notify the primary health care provider if which finding is noted on the laboratory report sheet?

Alanine aminotransferase (ALT) 96 U/L (96 U/L) Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests need to be performed prior to treatment and throughout the treatment interval. It is administered in the lowest effective dosage for the shortest time necessary. The normal alanine aminotransferase is 4 to 36 U/L (same as SI units). The other options indicate normal laboratory results.

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?

Alkaline phosphatase 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.

A client with a new medication prescription for allopurinol asks the nurse, "I know this is for gout, but how does it work?" The nurse's reply is based on which medication action?

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

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 would the nurse incorporate in the plan of care based on the statement by this client?

Altered body image 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.

A client with chronic kidney disease has been receiving epoetin alfa for the past 2 months. What would the nurse determine is an indicator that this therapy has been effective?

An increase in serum hematocrit Epoetin alfa stimulates red blood cell production. Initial effects would be seen within 1 to 2 weeks, and the hematocrit reaches normal levels in 2 to 3 months.

The nurse is reviewing the medical record of a newly assigned client and notes that the client is receiving cyclobenzaprine hydrochloride for the treatment of muscle spasms. The nurse questions the prescription if which disorder is noted in the admission history?

Angle-closure glaucoma Because cyclobenzaprine has anticholinergic effects, it would be used cautiously in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. It is intended for short-term (2- to 3-week) therapy. The conditions of hypothyroidism, chronic bronchitis, and recurrent pneumonia are not a concern with this medication.

The nurse is reviewing the health care record of a client with a new diagnosis of rheumatoid arthritis (RA). The nurse understands that which is an early clinical manifestation of RA?

Anorexia Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. Early clinical manifestations of RA include complaints of fatigue, generalized weakness, anorexia, and weight loss. Anemia, amenorrhea, and night sweats are not early manifestations of RA.

The nurse is providing instructions regarding skin care to a client after removal of a leg cast. The nurse would instruct the client to take which measure?

Apply an emollient lotion to the skin to enhance softening. The skin under a casted area may be discolored and crusted with dead skin layers. The client needs to gently soak and wash the skin for the first few days; however, soaking for 1 hour 6 times daily is excessive and could lead to skin breakdown. The skin would not be scrubbed vigorously because this action also could lead to skin breakdown. The skin needs to be patted dry, and a lubricating lotion would be applied. The client would avoid overexposing the skin to the sunlight.

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?

Applying a heating pad 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.

A client has been administered cyclobenzaprine for the management of muscle spasms in the cervical spine. The client is experiencing drowsiness, dizziness, and dry mouth. How would the nurse interpret these findings?

Are the most common side effects of this medication Drowsiness, dizziness, and dry mouth are the most common side effects of cyclobenzaprine, and these side effects usually diminish with continued therapy. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasm that accompanies a variety of conditions. The remaining options are incorrect.

The nurse is performing an assessment on a client after a closed reduction of a fractured right humerus and application of a plaster cast. To assess for signs of compartment syndrome, the nurse would perform which action?

Assess capillary refill, temperature, color, and amount of pain in the right hand. The major signs and symptoms of compartment syndrome include pallor or cyanosis; pain, even following the administration of opioid analgesics; vascular compromise demonstrated by weakened or absent pulses and poor capillary refill; and edema of the extremity distal to the area of the fracture. Cognitive level, temperature of the cast, and the presence of drainage or odors on or beneath the cast are not assessments related to compartment syndrome.

A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?

Assist the client to a sitting position with the head tilted forward. The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client would be assisted to a sitting position with the head tilted slightly forward, and pressure needs to be applied to the nares by pinching the nose toward the septum for 10 minutes. Ice packs can be applied to the nose and forehead. If these actions are unsuccessful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication. The primary health care provider also may prescribe packing of the nostrils. The client would be provided with an emesis basin and needs to be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.

The nurse overhears the primary health care provider (PHCP) tell a client with rheumatoid arthritis that the condition needs to be treated with gold therapy. The nurse interprets that the PHCP is referring to which medication?

Auranofin Auranofin is a gold preparation used to manage rheumatoid arthritis in clients with insufficient therapeutic response to nonsteroidal anti-inflammatory drugs. Prednisone is a corticosteroid. Pentostatin and fludarabine phosphate are antineoplastic agents.

The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse would inform the client that the changes are most likely due to what type of response?

Autoimmune The most likely cause for rheumatoid arthritis is activation of an autoimmune response. This is thought to trigger antigen-antibody responses and release of lysosomes from phagocytic cells, which ultimately attack the cartilage and synovia, with resultant synovitis. Other theories related to the cause of rheumatoid arthritis have been proposed, but the most likely cause is an autoimmune reaction.

The nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen. Which instruction would be included in the teaching plan?

Avoid the use of alcohol. Baclofen is a skeletal muscle relaxant. The client needs to be cautioned against the use of alcohol and other central nervous system depressants, because baclofen potentiates the depressant activity of these agents. Constipation, rather than diarrhea, is a side effect. Restriction of fluids is not necessary, but the client needs to be warned that urinary retention can occur. Fatigue is related to a central nervous system effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the PHCP about fatigue.

The primary health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication will be administered intrathecally. Which medication would the nurse expect to be prescribed and administered by this route?

Baclofen Baclofen is the skeletal muscle relaxant that can be administered intrathecally, which means within the spinal column. Therefore, the remaining options are incorrect.

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse would ask the client if the pain is worsened or aggravated by which factor?

Bending or lifting Low back pain that radiates down one leg (sciatica) is consistent with herniated lumbar disc. 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 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?

Bends over to tie shoes 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 things up or lifting. Options 2, 3, and 4 are all appropriate ways to avoid lower back strain.

The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease?

Bone pain 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. Bone pain is the most common symptom of Paget's disease and may manifest in areas close to a joint. The pain is related to progressive enlargement and deformity of the bone. Hearing loss, numbness of the face, or (more rarely) blindness can occur when the thickened bone of Paget's disease compresses vital nerves in the skull. Fatigue or difficulty with ambulation may occur but would not be the most common symptom.

The nurse is caring for a client diagnosed with osteitis deformans (Paget's disease). Which does the nurse identify as the cause of the client's stooped posture and bowing of lower extremities?

Bone resorption and regeneration Paget's disease is characterized by skeletal deformities resulting from abnormal bone resorption followed by abnormal regeneration. It is not caused by problems with muscle, nervous system, or joint functioning.

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?

Bowel movement every 4 days A bowel movement every 4 days is insufficient. The client would 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.

The nurse is administering an intravenous dose of methocarbamol to a client with a musculoskeletal injury. For which adverse effect would the nurse monitor?

Bradycardia Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these adverse effects. Options 1, 2, and 4 are not effects with administration of this medication.

The nurse is performing a musculoskeletal assessment of an immobile client for disuse osteoporosis. Which would the nurse assess to obtain the best information about the bone remodeling process?

Calcitonin Bone remodeling is the result of osteoblastic and osteoclastic activities, which are influenced by the degree of stress that is placed on the bone. The three substances that play an important role in this process are parathyroid hormone (which regulates calcium levels and bone resorption), vitamin D (which is active in bone formation and calcium resorption from bone), and calcitonin (which antagonizes parathyroid hormone and inhibits bone resorption). The other substances listed do not play a role in this process.

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?

Call the primary health care provider. Severe 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 would be done after trying to determine and treat the cause. The nurse would never remove the weights from the traction system without a specific prescription to do so.

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 an assessment of the client's neurovascular status through the monitoring of which parameter?

Capillary refill, sensation, color, and pulse of the left foot 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 it 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 is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client?

Check the neurovascular status of the area distal to the extremity. To prevent further damage, the neurovascular status must be assessed for temperature, color, sensation, movement, and capillary refill. Tourniquets are not used to control hemorrhage in extremities because of the risk of tissue ischemia. Direct pressure is applied at the site and over the proximal artery nearest the fracture if bleeding occurs. Clients need to be kept in a supine position to help prevent hypotension and shock. Shoes are not removed because this action may cause increased trauma.

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?

Check the neurovascular status of the toes on the casted leg. 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 whether 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.

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and would include which intervention?

Check the primary health care provider's (PHCP's) prescriptions for the amount of weight to be applied. When a child is in traction, the nurse would check the PHCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of complications of immobilization. The nurse would provide therapeutic and diversional play activities for the child.

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and would include which action in the plan?

Check the weights to ensure that they are off the floor. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights would not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food?

Chicken liver Liver and other organ meats would be omitted from the diet of a client who has gout because of their high purine content. Purines are a form of protein. The food items identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout.

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?

Clear mentation 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 would be 80 to 100 mm Hg (10.6 to 13.33 kPa). Oxygen saturation needs to be higher than 95%.

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse would suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply.

Client report of severe, deep, unrelenting pain Client report of pain as nurse assesses finger movement Client report of numbness and tingling sensation in the fingers The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome.

The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture would be included by the nurse in the client's education?

Comminuted fracture A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone: one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone.

A client with chronic kidney disease is receiving ferrous sulfate. The nurse instructs the client that which finding is a common side/adverse effect associated with this medication?

Constipation Ferrous sulfate is an iron supplement used to treat anemia. Constipation is a frequent and uncomfortable side effect associated with the administration of oral iron supplements. Stool softeners often are prescribed to prevent constipation. Options 1, 2, and 3 are not side or adverse effects associated with this medication.

n monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply.

Control of symptoms during periods of emotional stress. Normal white blood cell, platelet, and neutrophil counts Radiological findings that show no progression of joint degeneration An increased range of motion in the affected joints 3 months into therapy Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow the progression of joint degeneration. In addition, an improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflammation and irritation at the medication injection site could indicate signs of infection.

The nurse is caring for a client who had surgery to repair a fractured left-sided hip using a posterior approach. In implementing hip precautions, which action would the nurse teach the client to avoid?

Crossing legs at the ankle Following surgery to repair a fractured hip using a posterior approach, client education should include the following: avoiding crossing the legs at the ankle or the knee, using an elevated toilet seat, placing a pillow between the legs while lying down for the first 6 weeks, keeping the legs abducted from the midline, and keeping the hip in a neutral position at all times.

The home care nurse is providing instructions to a client with a musculoskeletal injury regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How would the nurse accurately demonstrate this technique?

Crutches and the affected leg down, followed by the unaffected leg When going down the stairs with crutches, the client would be instructed to move the crutches and the affected leg down and then to move the unaffected leg down. To go up the stairs, the client needs to first move up the unaffected leg and then move up the affected leg and crutches.

A client has been diagnosed with osteomalacia, or adult rickets. The nurse would anticipate that the primary health care provider will include a new prescription for which vitamin supplement?

D Osteomalacia technically refers to bone softening that results from demineralization of bone matrix and failure to calcify. A common cause is vitamin D deficiency in the diet. Other causes are inadequate exposure to sunlight (to synthesize vitamin D) and disorders that interfere with absorption and metabolism of vitamin D. Deficiencies of the vitamins noted in the remaining options are not associated with osteomalacia.

The nurse is assigned to care for a client with multiple sclerosis who is receiving an intravenous dose of methocarbamol. The nurse monitors the client, knowing that which is an expected side effect?

Dark green-colored urine Methocarbamol is a skeletal muscle relaxant. It may cause the urine to turn a brown, black, or dark green color, and the client needs to be told that this is a harmless effect. This medication can cause hypotension. Drowsiness and dizziness can also occur. Therefore, the remaining options are incorrect.

A client with multiple sclerosis is receiving baclofen. The nurse assessing the client monitors for which finding as an indication of a primary therapeutic response to the medication?

Decreased muscle spasms Baclofen is a skeletal muscle relaxant and acts at the spinal cord level to decrease the frequency and amplitude of muscle spasms in clients with spinal cord injuries or diseases or with multiple sclerosis. Increased muscle tone and strength and increased range of motion of all extremities are not directly related to the effects of this medication. Decreased nausea is an incorrect option.

Baclofen is prescribed for the client with multiple sclerosis. The nurse determines that the medication is having the intended effect if which finding is noted in the client?

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

The nurse is preparing to care for a client with chronic kidney disease and anemia. When planning care, which describes the relationship between chronic kidney disease and anemia?

Decreased production of erythropoietin is causing anemia. Clients with chronic kidney disease do not manufacture adequate amounts of erythropoietin, which is a glycoprotein needed to synthesize red blood cells. Renin, aldosterone, and angiotensin are substances that assist in maintaining blood pressure.

The nurse is caring for a client who was just admitted to the hospital for the treatment of iron overload. The nurse anticipates that the primary health care provider will prescribe which medication to treat the iron overload?

Deferoxamine Deferoxamine is a medication used to treat iron overload. Granisetron is an antiemetic. Ketoconazole and terbinafine are antifungal medications.

A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication would the nurse anticipate being prescribed?

Deferoxamine β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). The major complication of long-term transfusion therapy is hemosiderosis. To prevent organ damage from too much iron, chelation therapy with either deferasirox or deferoxamine may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as prophylaxis for postoperative deep vein thrombosis. Meropenem is an antibiotic. Metoprolol is a beta blocker used to treat hypertension.

The nurse is caring for a client diagnosed with osteomyelitis from a skeletal injury. Which mechanism of the disease process can result in necrosis of the bone?

Devascularization Osteomyelitis is an infectious process affecting the bone, bone marrow, and surrounding soft tissue. A microorganism gains entry into the blood and grows, causing increased pressure on the bone, leading to ischemia and ultimately necrosis as a result of devascularization. Infection of the bone occurs but is not specifically related to necrosis of the bone. Decreased bone mass and decreased bone density are also not related to necrosis of the bone.

When obtaining assessment data from a client with a microcytic normochromic anemia, which would the nurse question the client about?

Dietary intake of iron Microcytic normochromic anemias involve the presence of small, pale-colored red blood cells. Causes are iron deficiency anemia, thalassemia, and lead poisoning. The only choice that fits this description is option 2. Folic acid deficiency is caused by macrocytic normochromic cells; these are large red blood cells. Gastric surgery can result in vitamin B12 deficiency. Sickle cell anemia results in sickled cells and erythrocyte destruction.

A client is prescribed a liquid iron preparation that has the potential to stain the teeth. The nurse would instruct the client to take which action to prevent staining of the teeth?

Dilute the iron in juice, drink it through a straw, and rinse the mouth afterward. Liquid iron preparations will stain the teeth. The best advice for the client who needs liquid iron is to dilute the iron in juice or water, drink it through a straw, and rinse the mouth well afterward. Brushing before taking the liquid iron would not be of any benefit. The nurse would not instruct a client to take more than the prescribed amount.

The nurse is preparing to administer filgrastim by intravenous (IV) infusion. Which nursing action is the most appropriate for administering this medication?

Dilute the medication in 5% dextrose in water (D5W). Filgrastim may be administered by continuous IV infusion. It is diluted only with D5W when administered by the IV route. The solution would not be shaken. It would be stored in a refrigerator and needs to be discarded if it has been exposed to room temperature for more than 6 hours.

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition?

Disseminated intravascular coagulopathy (DIC) TSS is caused by infection and often is associated with tampon use. The client's clinical signs in this question are compatible with DIC, which is a complication of TSS. The nurse assesses the client at risk and notifies the primary health care provider promptly when signs and symptoms of DIC are noted. Although signs of bleeding may be seen with each of the conditions listed in the incorrect options, the initial diagnosis of TSS makes DIC the logical correct option.

The nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which nursing action would be appropriate?

Document the findings. A small amount of serous oozing is expected at the pin insertion site. The nurse would document the findings. It is not necessary to notify the PHCP. The nurse would not add or remove any weight from the client's traction setup because this would disrupt the alignment of the fracture.

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction would the nurse provide?

Drink 3000 mL of fluid a day. Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day, unless otherwise contraindicated. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth needs to contact the primary health care provider because this may indicate hypersensitivity.

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction would the nurse provide?

Drink 3000 mL of fluid a day. Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day, unless otherwise contraindicated. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth would contact the primary health care provider because this may indicate hypersensitivity.

A client with multiple sclerosis is receiving diazepam, a centrally acting skeletal muscle relaxant. Which finding, if noted during the nursing assessment, would indicate that the client is experiencing a side/adverse effect of this medication?

Drowsiness Incoordination and drowsiness are common side/adverse effects of diazepam. The remaining options are unrelated to the use of this medication.

A client with muscle spasms in the lumbar area of the spine has been started on cyclobenzaprine. The nurse would monitor for which most frequent side effect of the medication?

Drowsiness The most common side effects of cyclobenzaprine are drowsiness, dizziness, and dry mouth. This medication is a centrally acting skeletal muscle relaxant used in the management of muscle spasm due to a variety of conditions. Weakness, confusion, and excitability are less frequent central nervous system effects of cyclobenzaprine.

Etanercept is prescribed for a client with rheumatoid arthritis. The nurse would monitor the client for which side/adverse effect of the medication following administration?

Dyspnea Etanercept is an antiarthritic medication that is administered via the subcutaneous route. Side/adverse effects include heart failure (noted by manifestations of dyspnea and congested lung sounds on auscultation), hypertension or hypotension, pancreatitis, or gastrointestinal hemorrhage. Headache, dizziness, and abdominal discomfort are not side/adverse effects of the medication.

The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings would be listed in the care plan as a sign/symptom of fat embolism?

Dyspnea and chest pain The signs of fat embolism are associated with alterations in respiratory status or neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism. External rotation of the leg is indicative of the hip fracture itself. Fever and chills indicate signs of infection, and pallor, paresthesia, and pulselessness indicate signs of severe circulatory impairment

The nurse is conducting staff in-service training on von Willebrand's disease. Which would the nurse include as characteristics of von Willebrand's disease? Select all that apply.

Easy bruising occurs. Gum bleeding occurs. It is a hereditary bleeding disorder. Treatment and care are similar to that for hemophilia. The disorder causes platelets to adhere to damaged endothelium. Von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. Treatment and care are similar to measures implemented for hemophilia, including administration of clotting factors. An elevated creatinine level is not associated with this disorder.

The nurse is caring for a client who has just had a plaster leg cast applied to treat a fracture. The nurse would plan to prevent the development of compartment syndrome by performing which action?

Elevate the limb slightly. Compartment syndrome is prevented by controlling edema. Elevation of the extremity may lower venous pressure and slow arterial perfusion; thus, the extremity should not be elevated above the heart. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. It may also be necessary to bivalve or split the cast in half if compartment syndrome is suspected. Covering the limb with bath blankets and keeping the leg horizontal or in a dependent position would not be beneficial in controlling edema.

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?

Elevated on pillows continuously for 24 to 48 hours 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.

Dantrolene is prescribed for a client with spinal cord injury for discomfort caused by spasticity. Which finding would alert the nurse to a potential adverse effect associated with this medication?

Elevated temperature Dantrolene is a centrally acting muscle relaxant. Malignant hyperthermia is a rare but life-threatening adverse effect that can occur with use of this medication. Therefore, an elevated temperature would alert the nurse to this potential adverse effect.

Dantrolene is prescribed for a client experiencing discomfort caused by spasticity. In providing instructions to the client regarding the medication, what would the nurse emphasize?

Expect that periodic liver function studies will be required. Dantrolene is a skeletal muscle relaxant and can cause liver damage; the nurse would monitor results of the client's liver function studies. Baseline liver function studies are done before therapy starts, and regular liver function studies are performed throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. The remaining options are not related to the administration of this medication.

The 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.

Fatigue Morning stiffness 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 clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction?

Fluid overload Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The parents of a child with sickle cell disease would encourage fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury?

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

The nurse is assessing an older client who sustained a fall and exhibits a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition would the nurse anticipate?

Fracture of the femoral neck Typical signs after femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain or pain in the medial side of the knee. Moving the fractured extremity increases the pain significantly. The signs noted in the question are not associated with a fractured or dislocated knee or a fractured femur.

The nurse provides instructions to a client diagnosed with osteoporosis. Education about prevention of which complication is the most important?

Fractures Osteoporosis is a chronic, progressive metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility. The client is most likely to suffer fractures as a result of this disorder. The remaining options are not directly related to this disorder.

An older client is diagnosed with osteoporosis. The nurse plans to teach 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?

Fractures 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 primary health care provider (PHCP) writes a prescription for acetylsalicylic acid, or aspirin, for a client who was admitted to the hospital with joint pain from rheumatoid arthritis. The nurse contacts the PHCP to verify the prescription if which finding is noted in the assessment data?

Gastric ulceration Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its anti-inflammatory, antipyretic, and anticoagulant properties. Contraindications to the medication include gastrointestinal bleeding or ulceration, bleeding disorders, history of hypersensitivity to aspirin or other nonsteroidal anti-inflammatory medications, impaired hepatic function, and chicken pox or flu in children or teenagers. The items noted in options 1, 2, and 3 are not contraindications to this medication.

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?

Glaucoma Because cyclobenzaprine has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication.

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?

Glaucoma Because cyclobenzaprine has anticholinergic effects, it would be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine would be used only for a short time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication.

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply.

Heat Analgesics Muscle relaxers Intermittent traction Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the primary health care provider's preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled.

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication?

Hematocrit of 33% (0.33) Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is Male: 42% to 52% (0.42 to 0.52); Female: 37% to 47% (0.37 to 0.47). Therapeutic effect is seen when the hematocrit reaches between 30% and 33% (0.30 and 0.33). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L). Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin.

The nurse is monitoring a client who is receiving epoetin alfa for adverse effects of the medication. Which finding indicates a side/adverse effect?

Hypertension Epoetin alfa generally is well tolerated. The most significant adverse effect is hypertension, and its use is contraindicated in uncontrolled hypertension. Occasionally a tachycardia may occur as a side effect. This medication also may cause an improved sense of well-being.

The client in chronic kidney disease is receiving epoetin alfa. The nurse would monitor this client for which side/adverse effect of this medication?

Hypertension Epoetin alfa is generally well tolerated, although hypertension can occur and is the most significant adverse effect. Occasionally, tachycardia may also occur. It may also cause an improved sense of well-being. Fever, depression, and bradycardia are not adverse effects of this medication.

The nurse tells a client with leukemia who is receiving chemotherapy that allopurinol has been added to the medication list. When the client asks the purpose of the new medication, the nurse responds that the allopurinol is intended to prevent which problem?

Hyperuricemia Chemotherapy destroys cells, leading to the release of uric acid into the bloodstream. The client is then at risk of experiencing uric acid nephropathy, renal stones, and acute kidney injury. Allopurinol, an antigout medication, is used with chemotherapy to prevent or treat this complication of therapy. It also may be used in mouthwash following fluorouracil therapy to prevent stomatitis. Allopurinol is not used to treat nausea, diarrhea, or muscle spasms.

A client who sustained a severe sprain of the ankle is told by the primary health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions would the nurse anticipate will be included in the client's initial plan of care? Select all that apply.

Ice bags Elevation Compression bandage Reflex spasm of local muscles and swelling caused by rupture of local capillary beds can best be treated initially by remembering the acronym RICE, which stands for rest, ice, compression, and elevation. Heat and range-of-motion exercises are contraindicated because they would increase swelling.

Which teaching point is the priority when the nurse is teaching the client about caring for a plaster cast?

Immediately report any increase in drainage or interruption in cast integrity. Increases in drainage or interruption in cast integrity will affect healing and could lead to osteomyelitis. To apply a cast, the skin is washed and dried well. A stockinette is placed smoothly and evenly over the area to be casted, followed by a roll of padding. The plaster is then rolled onto the padding, and the edges are trimmed or smoothed if needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

The nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse would take which priority action?

Immobilize the right leg before moving the client. When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help needs to be called for if the client is not hospitalized, and a primary health care provider is called for the hospitalized client. The nurse would 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.

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?

Impaired tissue perfusion Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures needs to be reported to the primary health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse would make which interpretation about this finding?

Impaired venous return Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of "hot spots," which are areas of the cast that feel warmer to the touch than the rest of the cast.

A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority?

Inability to entertain self A manifestation of the inability to entertain self is expression of boredom by the client. The question does not identify difficulties with coordination, range of motion, or muscle strength, which would indicate lack of physical mobility. The question also does not relate to client feelings of inability to take responsibility for meeting basic health practices (inability to maintain health) or to lack of control.

The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse would include information about which types of fractures?

Incomplete An incomplete fracture is one that extends through only part of the thickness of the bone. These fractures usually are nondisplaced, meaning that the bone remains in the normal position. An open (or compound) fracture is one in which the fractured bone protrudes through the skin, disrupting soft tissue. A complete fracture is one that extends through the full thickness of bone and often is displaced, meaning that the bone moves out of normal position.

Allopurinol has been prescribed for a client with a diagnosis of gout. The nurse develops a list of instructions for the client regarding the use of this medication. Which measures would be included on the list? Select all that apply.

Increase fluid intake. Take the medication with food. Consume items to maintain an alkaline urine. Return to the health care clinic for liver and renal function tests. The client taking allopurinol needs to be instructed to return to the clinic for monitoring of liver and renal function studies, particularly during the first month of therapy because of the risk of hepatotoxicity and nephrotoxicity. The client would take the medication with food and needs to maintain an adequate fluid intake. The client needs to be instructed to maintain an alkaline urine and to avoid large doses of vitamin C.

What would the nurse anticipate when evaluating for the effects of raloxifene in an older client?

Increased bone density Raloxifene is an estrogen receptor modulator. It was developed to limit the side and adverse effects of estrogen while producing beneficial effects. The purpose of this medication is to increase bone mineral density. Leg tenderness or cramps can indicate deep vein thrombosis, which is an adverse effect of raloxifene. The modulating effects of this medication can lead to hot flashes and vaginal bleeding.

The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings would the nurse identify as early signs of possible fat embolism?

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

A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply.

Infection Recent injury Inflammation Redness and heat are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative disease is accompanied by pain, but there is no redness. Swelling may or may not occur. These symptoms are not specifically associated with delayed growth.

The nurse is discharging a client after an arthroscopy. The nurse needs to teach the client to watch for which potential complications? Select all that apply.

Infection Swelling Thrombophlebitis Increased joint pain related to mechanical injury Postoperative complications to watch for after an arthroscopy include infection, swelling, thrombophlebitis, and increased joint pain related to mechanical injury. Backache and decreased appetite are not included. Backache may be a result of lying on a hard table during the procedure, but it is not a complication. Decreased appetite is a normal reaction due to the effects of anesthesia and pain medications. The PHCP usually sees the client about 1 week after the procedure for follow-up care.

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?

Injury to the brachial plexus nerves Crutches are measured so that the tops are two to three finger widths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.

The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform?

Inspect the skin at least every 8 hours for signs of irritation or inflammation. It is important for the skin to be assessed at least every 8 hours. Weights need to be no more than 5 to 10 lb (2.3 to 4.5 kg) to prevent injury to the skin and would always be freely hanging. Additionally, the amount of weight is prescribed by the health care provider. Once traction is applied, a correct balance is maintained at all times. Weights are not removed on a scheduled basis and are never removed without a prescription to do so.

A client has Buck's extension traction applied to the right leg. Which intervention would the nurse plan to prevent complications of the device?

Inspect the skin on the right leg. Buck's extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. There are no pins to care for with skin traction. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically prescribed by the primary health care provider.

The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan?

Inspect the skin under the boot at least every 8 hours. When possible, remove the belt or boot that is used for skin traction every 8 hours to inspect under the device for skin irritation and breakdown. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.

A 10-year-old child with hemophilia A has slipped on the ice and bumped the knee. The nurse would prepare to administer which prescription?

Intravenous infusion of factor VIII Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed, depending on the source of bleeding from the disorder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Factor X and iron are not used to treat children with hemophilia A.

A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint?

It has incompletely dislocated. A dislocation is the disruption of a joint to the extent that the articulating surfaces are no longer in contact. A subluxation is an incomplete dislocation of the joint surfaces. Because the disruption is less severe, healing time is less prolonged. A strain occurs when a muscle or ligament is used beyond the limit of its functional ability. It is characterized by overstretching of the muscle or ligament and also could involve tearing if the strain is more severe (i.e., second- or third-degree strain versus first-degree strain). A contusion is a soft tissue injury that results in hemorrhage into the involved tissue.

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?

It promotes reabsorption of blood from the injured tissue. 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 is preparing to administer filgrastim to a client with a diagnosis of agranulocytosis. The client asks the nurse about the purpose of the medication. Which information would the nurse include in the response regarding action of this medication?

It promotes the growth of neutrophils. Filgrastim is a granulocyte colony-stimulating factor produced by human recombinant DNA. It is administered to clients with agranulocytosis to promote the growth of neutrophils and enhance the function of mature neutrophils. Options 1, 2, and 3 are not actions of this medication.

The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include?

It will identify whether there is a joint injury and provide a route for surgical repair if indicated. 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.

The home health nurse is reviewing medications with a client receiving colchicine for the treatment of gout. The nurse evaluates that the medication is effective if the client reports a decrease in which measure?

Joint inflammation Colchicine is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client would report a decrease in pain and inflammation in the affected joints, as well as a decrease in the number of gout attacks. Headaches, blood glucose, and blood pressure are not associated with the use of this medication.

The nurse notes that a client has been taking colchicine. The nurse assesses the client for which finding that is an indication for the use of this medication?

Joint inflammation and pain Colchicine is classified as an antigout agent that interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client would report a decrease in pain and inflammation in the affected joints and a decrease in the number of gout attacks. The other options are incorrect.

The nurse is caring for a client with osteoarthritis. The nurse performs an assessment knowing that which clinical manifestations are associated with the disorder? Select all that apply.

Joint pain that diminishes after rest Joint pain that intensifies with activity The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Morning stiffness lasting longer than 30 minutes occurs in rheumatoid arthritis. Elevated white blood cell counts, platelet counts, and antinuclear antibody levels occur in rheumatoid arthritis.

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions would be included on the list? Select all that apply.

Keep small toys and sharp objects away from the cast. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. Contact the primary health care provider (PHCP) if the child complains of numbness or tingling in the extremity. While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the PHCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the PHCP would be notified.

Which cast care instructions would the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply.

Keep the cast clean and dry. Allow the cast 24 to 72 hours to dry. Keep the cast and extremity elevated. A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity need to be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The primary health care provider is notified immediately if circulatory impairment occurs.

The nurse is creating a plan of care for a client scheduled for a left total hip arthroplasty. Which interventions would the nurse include in the plan to prevent complications of the surgery? Select all that apply.

Keep the leg slightly abducted. Teach leg exercises to the client. Use aseptic technique for wound care. Prevent hip flexion beyond 90 degrees. A total hip arthroplasty (THA) is also known as a total hip replacement (THR). Postoperative complications can include dislocation, infection, venous thromboembolism, hypotension, bleeding, and infection. To prevent dislocation, the nurse needs to position the client correctly with the leg slightly abducted and prevent hip flexion beyond 90 degrees. Signs of dislocation such as acute pain, rotation, and extremity shortening need to be reported immediately to the surgeon. To prevent infection, the nurse needs to perform thorough hand washing and use aseptic technique for wound care and emptying of drains. To prevent venous thromboembolism, the client would wear elastic stockings and/or a sequential compression device per agency policy and surgeon prescription. The nurse would encourage fluid intake and teach the client leg exercises to promote circulation. Legs are not massaged; in addition, knee flexion is avoided for a prolonged period of time because these actions promote venous stasis and thromboembolism. The nurse would monitor vital signs at least every 4 hours and observe the client for bleeding. Any signs of complications are reported immediately to the surgeon.

Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder?

Kidney disease Colchicine is used with caution in older clients, debilitated clients, and clients with cardiac, kidney, or gastrointestinal disease. The disorders in options 1, 3, and 4 are not concerns with administration of this medication.

A client has skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse would assess which area as high risk for pressure and breakdown?

Left heel Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon. Scapulae and the back of the head are not common areas for pressure ulcers for this client. The right heel is elevated because of traction.

The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. What would the nurse instruct the client to do?

Lift the shoulder of the casted arm over the head periodically throughout the day. A stiff or frozen shoulder can develop as a complication of a cast on an upper extremity. The client needs to be instructed to lift the shoulder of the casted arm over the head periodically throughout the day to prevent this complication. The client would 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 lecturing to a group of clients who are at high risk for osteoporosis. The nurse would inform the clients about which most important measure?

Limit caffeine intake. Excessive caffeine intake can increase calcium loss in the urine. Protein deficiency may contribute to the incidence of bone demineralization. Activities such as walking and swimming may be beneficial and are appropriate to reduce the risk of fracture. Adequate vitamin D intake is necessary for the metabolism of calcium.

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding would be noted in this condition?

Limited range of motion in the affected hip In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip when the child is placed supine with the knees and hips flexed would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.

The nurse is assessing a dark-skinned client for signs of anemia. The nurse would focus the assessment on which structures? Select all that apply.

Lips Conjunctiva Mucous membranes Changes in skin color can be difficult to assess in the dark-skinned client. Color changes are most easily seen in areas of the body where the epidermis is thin and in areas where pigmentation is not influenced by exposure to sunlight. The nurse needs to assess the lips, conjunctiva, and oral mucous membranes for signs of anemia in the dark-skinned client. Signs of anemia are less easily observed in the tongue and earlobes.

A client experiencing spasticity as a result of spinal cord injury has a new prescription for dantrolene. Before administering the first dose, the nurse checks to see whether which baseline study has been done?

Liver function studies Dantrolene is a skeletal muscle relaxant and can cause liver damage; therefore, the nurse would monitor the results of liver function studies. They would be done before therapy starts and periodically throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. The incorrect options are not specifically related to the administration of this medication.

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?

Liver function tests Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and throughout the treatment interval. Dantrolene is administered at the lowest effective dosage for the shortest time necessary.

The nurse is assessing for the presence of pallor in a dark-skinned client suspected of having anemia. What finding would the nurse look for?

Loss of normal red tones in the skin In dark-skinned clients, pallor results in the loss of normal red tones in the skin. A yellow-tinged skin could indicate jaundice. Bluish discoloration of the skin and an ashen-gray color could indicate cyanosis and circulatory compromise.

The nurse asks a nursing student about the uses of the medication dantrolene. The nursing student correctly states that dantrolene is used to manage hypermetabolism of skeletal muscle that occurs in which condition?

Malignant hyperthermia Dantrolene is a skeletal muscle relaxant. It is used to manage fulminant hypermetabolism of skeletal muscle that occurs in malignant hyperthermia crisis. Dantrolene relieves symptoms of malignant hyperthermia by blocking calcium release. It is not used for the conditions noted in options 1, 2, or 4.

The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis who is at risk for vitamin B12 deficiency. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.

Meat Liver Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of function of the parietal cells. The source of intrinsic factor is lost, which results in an inability to absorb vitamin B12, leading to development of pernicious anemia. Clients must increase their intake of vitamin B12 by increasing consumption of foods rich in this vitamin, such as meats and liver.

A client is seen in the primary health care provider's office for complaints of wrist pain. A diagnosis of carpal tunnel syndrome is made. In explaining this disorder to the client, the nurse states that it is caused by compression of which nerve?

Median Carpal tunnel syndrome is caused by excessive pressure on the median nerve as a result of injury, overuse, or disease. The peroneal nerve is in the leg. Trigeminal neuropathy results in facial pain, also known as tic douloureux. The spinal accessory nerve is a motor nerve impacting shoulder function.

Auranofin has been prescribed for a client with rheumatoid arthritis. The nurse provides instructions to the client about the medication and tells the client to notify the primary health care provider if which occurs?

Metallic taste in the mouth Auranofin is a gold preparation that is given orally rather than by injection. Gastrointestinal (GI) reactions including diarrhea, abdominal pain, nausea, and loss of appetite are common early in therapy but usually subside in the first 3 months. Early signs and symptoms of toxic reactions include a rash, purple blotches, pruritus, mouth lesions, and a metallic taste in the mouth. Signs and symptoms of toxic reactions are reported to the primary health care provider (PHCP).

A client with gout has begun to take allopurinol. The nurse informs the client that which medication may also be necessary during the beginning phase of medication therapy with allopurinol? Select all that apply.

Naproxen Colchicine Indomethacin Clients beginning medication therapy with allopurinol may also have to take colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs) because of the risk of an acute gouty attack after first starting allopurinol. Colchicine and NSAIDs help to prevent the acute gouty attack from occurring. Oxycodone and hydromorphone are opioid analgesics and do not assist in preventing an attack.

The nurse is reviewing the laboratory test results for a client who is receiving filgrastim. Which reported value would indicate an effective response to this medication?

Neutrophil count of 10,000 mm3 (10 × 109/L) Filgrastim is used to promote the growth of neutrophils and enhance the function of mature neutrophils. Treatment is continued until the absolute neutrophil count reaches 10,000 cells/mm3. Options 1, 2, and 3 are unrelated to the action of this medication.

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse would take which action?

Notify the primary health care provider (PHCP). Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 1, 2, and 3 are incorrect.

The nurse is caring for a client in skeletal traction. On assessing the pin sites, the nurse notes the presence of purulent drainage. Which nursing action is most appropriate?

Notify the primary health care provider. A small amount of clear fluid drainage is expected at pin insertion sites. Signs of infection such as inflammation, purulent drainage, and pain at the pin sites are not expected findings and would be reported to the primary health care provider. Options 1, 3, and 4 are inappropriate nursing actions for this client before cleaning a newly assessed potentially infected pin site; the site would be cultured before either cleaning it or putting medication on it.

A client who had a body cast applied 2 days earlier begins to complain of anorexia, nausea, and abdominal discomfort. The nurse would take which immediate action?

Notify the primary health care provider. The client who has been placed in a body cast is at risk for the development of cast syndrome. This results from pressure on the mesenteric artery and can lead to intestinal obstruction. The immediate action is to report the client's complaints to the primary health care provider (PHCP). Cast syndrome usually is treated with nasogastric decompression, intravenous therapy for hydration, and possibly application of a new cast. Testing the stool or administering an antacid or an antiemetic delays necessary interventions.

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 they will report which early symptom of compartment syndrome?

Numbness and tingling in the fingers 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 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 they would report which early symptom of compartment syndrome?

Numbness and tingling in the fingers 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.

A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history?

Open trauma to the left leg 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.

The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client?

Oral mucosa In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa and in areas of lighter melanization such as the abdomen and buttocks. Jaundice would best be noted in the sclera of the eye. Cyanosis is best noted on the palms of the hands and soles of the feet.

The nurse is assisting a primary health care provider (PHCP) in the examination of a 3-week-old infant with developmental dysplasia of the hip. What test or sign would the nurse expect the PHCP to assess?

Ortolani's maneuver In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's maneuver is a test to assess for hip instability and can be done only before 4 weeks of age. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum. Babinski's sign is abnormal in anyone older than 2 years of age and indicates central nervous system abnormality. The Moro reflex is normally present at birth but is absent by 6 months; if still present at 6 months, there is an indication of neurological abnormality. The palmar-plantar grasp is present at birth and lessens within 8 months.

The nurse is planning measures to increase bed mobility for a client in skeletal leg traction. Which item would the nurse consider to be most helpful for this client?

Overhead trapeze The use of an overhead trapeze is extremely helpful for a client to move about in bed and to get on and off the bedpan. This device has the greatest value in increasing overall bed mobility. Television and reading materials, although helpful in reducing boredom and providing distraction, do not increase bed mobility. A fracture bedpan is useful in reducing discomfort with elimination.

A client with a fractured femur who has had an open reduction-internal fixation is receiving ketorolac. Which assessment measurement will assist the nurse in determining the effectiveness of this medication?

Pain rating Ketorolac is a nonopioid analgesic and nonsteroidal anti-inflammatory agent. It acts by inhibiting prostaglandin synthesis and produces analgesia that is peripherally mediated. The nurse evaluates the effectiveness of this medication by using the pain rating scale with the client. Options 2, 3, and 4 are unrelated to the use of this medication.

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?

Pao2 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 analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child?

Partial thromboplastin time Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia.

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention would the nurse plan to perform?

Perform sterile dressing changes. Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Clinical manifestations include constant bone pain unrelieved by rest that worsens with activity; swelling, tenderness, and warmth at the infection site; restricted movement of the affected part; and fever, night sweats, chills, restlessness, nausea, and malaise. Option 2 is the correct option, as treatment of osteomyelitis often includes surgical debridement and requires sterile dressing changes. Option 1 is incorrect, as osteomyelitis is an infection and applying ice to the area will not help any swelling and may cause vasoconstriction. Option 3 is incorrect, as movement worsens the pain and some immobilization of the affected limb (e.g., splint, traction) is usually indicated. Option 4, measuring leg circumference daily, is not necessary.

The nurse has suggested specific leg exercises for a client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client performing which action?

Performing active range of motion to the right ankle and knee Active range of motion to the right ankle and knee would disrupt skeletal traction of the right lower leg. The client may pull up using the trapeze, perform active range of motion with uninvolved joints, and do isometric muscle-setting exercises (i.e., quadriceps- and gluteal-setting exercises). The client also may flex and extend the feet. These exercises are within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion.

The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action would the nurse take?

Petal the cast edges with adhesive tape. 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 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. The nurse plans for which most appropriate intervention?

Petal the cast edges with appropriate material. 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 is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What would the nurse include in the teaching? Select all that apply.

Physical therapy Knee immobilizer Aspiration of joint fluid Anti-inflammatory medications The anterior cruciate ligament (ACL) runs diagonally in the middle of the knee. Injury to the ACL can result in a partial tear, a complete tear, and an avulsion. Treatment measures for this injury include physical therapy, use of a knee immobilizer or hinge brace, aspiration of joint fluid if an effusion occurs, ambulation with crutches, anti-inflammatory medications, rest, ice, and possibly reconstructive surgery.

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual limb and expects to note which finding?

Pink color to the skin flap Following above-the-knee amputation, the nurse's primary focus is to monitor for signs indicating that there is sufficient tissue perfusion and no hemorrhage. The skin flap at the end of the residual (remaining) limb would be pink in a light-skinned person and not discolored (lighter or darker than other skin pigmentation) in a dark-skinned person. The area would be warm but not hot. If the area is hot, this could indicate inflammation or infection. The incision would be clean and dry with no serous or other fluid leaking from it. There should be a pulse at the closest proximal pulse point. If no pulse is felt, the nurse would assess for a pulse using a Doppler. If no pulse is detected using the Doppler device, this could indicate lack of perfusion, and the surgeon would need to be notified.

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?

Place a clock and calendar in the client's room. An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and would not be applied unless specifically prescribed; agency policies and procedures need to be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed?

Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. The nurse can best assist the client in skeletal traction with repositioning by providing a trapeze on the bed frame for the client's use. Although a drawsheet is helpful and client movement may be more easily facilitated with four nurses, these actions will not promote repositioning by the client. Encouraging the client to push with the unaffected leg on the bed mattress for repositioning may cause skin breakdown on the unaffected heel area.

The nurse is caring for a client on postoperative day 1 following left above-knee amputation. Which is the priority nursing action at this time?

Position the residual limb flat on the bed. Edema of the residual limb may be controlled by elevating the foot of the bed for the first 24 hours after surgery, although this practice is controversial. Some providers avoid this practice because of the risk of hip and knee flexion contracture. Either way, after the first 24 hours, the residual limb is placed flat on the bed to reduce hip and knee contracture. Edema is also controlled by residual limb wrapping techniques.

A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse would explore which item next?

Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection Clients who receive cadaver bone may worry about contracting human immunodeficiency virus or hepatitis or another infection from the cadaver bone. To ease their fear, clients need reassurance and information about the donor screening that is done. The level of pain that will be experienced in the postoperative period and the availability of assistance for the client after discharge should be included as part of the basic preparation of the client for surgery. Administering antianxiety medication is used as a last measure if other reassuring measures are not effective.

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?

Presence of a "hot spot" on the cast 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 needs to be notified if any of these are noted. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema.

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection?

Presence of a "hot spot" on the cast 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 would 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.

The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which would be an abnormal finding?

Presence of fasciculations Fasciculations are fine-muscle twitches that are not normally present. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal. Muscle strength is graded from (paralysis) to (normal power). Symmetrical muscle movement is a normal finding.

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions would the nurse plan to promote client safety? Select all that apply.

Provide the client with a soft toothbrush. Instruct the client to use an electric razor. Monitor all secretions for frank or occult blood. Fibrinogen is produced by the liver and is necessary for normal clotting. A client who has insufficient levels is at risk for bleeding. The PT is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client's risk for bleeding is also increased. A soft toothbrush, an electric razor, and monitoring secretions for evidence of bleeding are measures that provide for client safety.

A client with a hip fracture asks the nurse what is involved with Buck's (extension) traction, which is being applied before surgery. The nurse would provide which information to the client?

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

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 would provide which information to the client?

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

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

Pyrexia Elevated white blood cell count Elevated erythrocyte sedimentation rate Bone scan impression indicative of infection 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.

A client with a muscle injury has difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?

Raised toilet seat A raised toilet seat is useful if the client does not have the mobility or ability to flex the hips. A walker would provide stability for the client during ambulation. A slider board is used in transferring a client from a bed to a stretcher or wheelchair. Adaptive eating utensils may be beneficial if the client has partial paralysis of the hand.

Laboratory studies are performed for a child suspected to have iron-deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic In iron-deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in children with iron-deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

Epoetin alfa by the subcutaneous route is prescribed for a client. What is the most appropriate nursing action?

Refrigerate the medication until used. Epoetin alfa would be refrigerated at all times. The bottle would not be shaken, and the medication would not be frozen because this will affect the chemical composition. Syringes with a ⅚-inch (1.5-cm) needle are used for subcutaneous injection. A 1½-inch (3.8-cm) needle may be used for intramuscular injection.

The nurse has instructed an assistive personnel (AP) in how to ambulate a client with a musculoskeletal injury. Which actions by the AP support a clear understanding of the appropriate steps to carry out this task safely? Select all that apply.

Remove clutter that may interfere with ambulation. 2Assist the client in applying nonskid shoes before ambulation. 3Instruct the client to sit up on the bedside and dangle before ambulation. 4Observe the client for dizziness during ambulation and report immediately. When delegating the task of ambulation to an AP, the nurse would ensure that the AP understands instructions before ambulation, including making sure that clutter is removed in the area of ambulation; assisting the client in applying nonskid shoes before ambulation; instructing the client to sit up on the bedside and dangle before ambulation; and observing the client for dizziness and reporting this finding immediately. The client would not experience nausea, dizziness, or diaphoresis or become pale during ambulation under normal conditions.

The nurse is reviewing a pediatrician's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record would the nurse question? Select all that apply.

Restrict fluid intake. Give meperidine, 25 mg intravenously, every 4 hours for pain. Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.

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?

Restricting fluids 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 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 would the nurse take?

Rewrap the residual limb with an elastic compression bandage. 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 one 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.

The home health nurse is caring for a client who is taking probenecid. The client has been instructed to restrict the diet to low-purine foods. Which food item would the nurse instruct the client to avoid?

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

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?

Separation of the wound edges 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 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 surger

Separation of the wound edges Clients with diabetes mellitus are more prone to wound infection, wound separation, 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.

Which tests can be used to diagnose gout? Select all that apply.

Serum uric acid level Synovial fluid aspiration 24-hour urine uric acid level Diagnostic tests for gout include serum uric acid level and 24-hour urine uric acid level, as well as synovial fluid aspiration and x-ray of the affected areas. Renal ultrasound, bone marrow biopsy, and urinalysis with culture are not specifically associated with gout; they test for a variety of other conditions.

The nurse is caring for a client admitted for a fractured hip that was sustained from a fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted?

Shortening and external rotation Signs of a hip fracture include shortening and deformity. The affected leg externally rotates as a result of discontinuation of the femur and loss of alignment and muscle control. The remaining options are not findings associated with a fractured hip.

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse would expect to find which sign or symptom in the client as a result of the anemia?

Shortness of breath with activity The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Muscle cramps are an unrelated finding. Increased respiratory rate is not an associated finding.

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful?

Showing the client the cast cutter and explaining how it works Individuals may be fearful of having a cast removed because of misconceptions about the cast-cutting blade. The nurse would show the cast cutter to the client before it is used and explain that they may feel heat, vibration, and pressure. The cast cutter resembles a small electric saw with a circular blade. The nurse needs to reassure the client that the blade does not cut like a saw but instead cuts the cast by vibrating side to side. The remaining options will increase the client's fear about the procedure.

The nurse is creating a plan of care for a client in skin traction. Which frequent assessment would the nurse include in the plan as a priority intervention?

Signs of skin breakdown 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 would monitor for which priority finding in this client?

Signs of skin breakdown 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 enters the hospital emergency department with a nosebleed. On assessment, the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action?

Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. The initial nursing action for a client with a nosebleed is to sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. Inserting nasal packing or preparing a nasal balloon is not an appropriate initial intervention. These interventions are used when conservative measures fail. Placing the client in a semi-Fowler's position would promote swallowing blood, which is not helpful because of the risk of vomiting and resultant aspiration.

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.

Sitting using a lumbar roll or pillow Standing with one foot on a step or stool The client needs to avoid positions or activities that place strain on the lower back. The client needs to 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 needs to not lean forward without bending the knees, stand in one position for long periods, or lift anything above elbow level.

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?

Slightly elevating the foot of the bed 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.

A client is receiving baclofen for muscle spasms because of a spinal cord injury. Which side/adverse effect related to this medication would the nurse monitor the client for?

Slurred speech Side/adverse effects of baclofen include drowsiness, dizziness, weakness, and nausea. Others include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Paradoxical central nervous system excitement and restlessness can occur, along with slurred speech, tremor, dry mouth, nocturia, and impotence.

The home health nurse is providing dietary instructions to a client who is taking probenecid for the treatment of gout. Which food would the nurse instruct the client to continue to eat?

Spinach Probenecid inhibits the reabsorption of uric acid by the kidney and promotes excretion of uric acid in the urine. Clients taking this medication are instructed to limit excessive purine intake. High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast.

The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states the ankle was twisted. Based on these findings, which condition does the nurse determine the client has most likely experienced?

Sprain A sprain is an injury to a ligament caused by a wrenching or twisting motion. Signs and symptoms include pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on a muscle. Manifestations include soreness and pain with muscle use. Typical signs and symptoms of fracture are variable but include pain, loss of function in the affected area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis.

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention would the nurse take?

Stay with the victim and encourage the victim to remain still. With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse would 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.

The nurse is preparing to administer filgrastim to the client. Which route of administration would the nurse determine is the most appropriate for this medication?

Subcutaneous Filgrastim is a granulocyte colony-stimulating factor produced by human recombinant DNA technology. It is given by subcutaneous injection or continuous intravenous infusion.

A client with chronic kidney disease has a medication prescription for epoetin alfa. The nurse would plan to administer this medication by which method?

Subcutaneously Epoetin alfa is erythropoietin that has been manufactured through the use of recombinant DNA technology. It is used to treat anemia in the client with chronic kidney disease. The medication may be administered subcutaneously or intravenously as prescribed.

The nurse is preparing home care instructions for the parents of a 10-year-old child with hemophilia. Which sport activity would the nurse suggest for this child?

Swimming Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Children with hemophilia need to avoid contact sports and to take precautions with other sports, such as wearing elbow and knee pads and helmets. The safe activity for them is swimming.

The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA?

Systemic symptoms such as fatigue, anorexia, and weight loss In clients diagnosed with RA, systemic symptoms such as fatigue, anorexia, weight loss, and nonspecific aching and stiffness may appear before joint manifestations. RA is characterized by chronic joint pain of variable intensity, which is more severe on rising in the morning. The age of onset for RA is most commonly between 30 and 50 years of age. A complaint of pain that is more severe after activity and asymmetrical joint pain associated with past injuries to the joint are more commonly seen in osteoarthritis.

A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse would plan to carefully monitor the client for which signs/symptoms?

Tachycardia and hypotension 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?

Tachycardia, hypotension 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 teaching a client who will be discharged on alendronate about the medication. Which would be included in the teaching plan? Select all that apply.

Take the medication at the same time daily. Take the medication on an empty stomach. Remain upright for 30 minutes following ingestion. Alendronate is a bisphosphonate that is used to prevent or treat osteoporosis. The medication needs to be taken in the morning at the same time. In the presence of any solid food, essentially none of the alendronate is absorbed. Even coffee or orange juice can decrease absorption by 60%. Thus, taking the medication on an empty stomach is a priority. The client needs to remain upright for 30 minutes after ingestion to prevent esophagitis. The presence of muscle pain is not associated with alendronate.

Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions on administration of the medication. Which instruction would the nurse provide?

Take the medication with a full glass of water after rising in the morning Precautions need to be taken with the administration of alendronate to prevent gastrointestinal adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client would not eat or drink anything for 30 minutes following administration and needs to not lie down after taking the medication.

Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions on administration of the medication. Which instruction would the nurse provide?

Take the medication with a full glass of water after rising in the morning. Precautions need to be taken with the administration of alendronate to prevent gastrointestinal adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client is not to eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.

Which intervention would the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace?

Tell the client to inspect the environment for safety hazards. The client must inspect the environment for safety hazards. The client is instructed in the importance of avoiding prolonged sitting and standing. Powders and lotions would not be used because they may irritate the skin. The client needs to be taught to loosen the brace during meals and for 30 minutes after each meal. The client may have difficulty eating if the brace is too tight. Loosening the brace after each meal will allow adequate nutritional intake and promote comfort.

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?

Temperature of 101.6° F (38.7° C) orally The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F (38.7° C) should be reported.

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?

Temperature of 101.6° F (38.7° C) orally The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F (38.7° C) would be reported.

The nurse is caring for a client diagnosed with a rotator cuff lesion. The nurse assesses the client knowing that the client most likely has which structure affected?

Tendon Lesions of the rotator cuff often involve the supraspinatus tendon of the shoulder. Although the entire joint is painful, the etiology does not involve nerves, ligaments, or synovial fluid. Usually the problem involves one or more of the tendons and muscles in the musculotendinous cuff. It most often is the result of minor repeated traumas or degenerative changes in the older client or the result of severe trauma in the younger client.

The nurse in the hospital emergency department is assessing a client with an open leg fracture. The nurse would inquire about the last time the client had which done?

Tetanus vaccine With an open fracture, the client is at risk for the development of osteomyelitis, gas gangrene, and tetanus. The nurse assesses for the date of the last tetanus immunization to ensure that the client has tetanus prophylaxis. The remaining options are unrelated to the current situation identified in the question.

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?

The client assists in self-care as much as possible. 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 needs to 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 home care nurse has instructed a client with a ligament injury to the knee how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait?

The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. In a three-point gait the client is instructed to simultaneously move both crutches and the affected leg forward and then to move the unaffected leg forward. Option 1 identifies a swing-through gait. Options 3 and 4 identify a four-point gait.

The nurse is obtaining a health history from a client and is assessing for risk factors associated with osteoporosis. The nurse would be most concerned if which data were obtained? Select all that apply.

The client reports that they don't exercise much at all. The client reports that they smoke a few cigarettes a day. The client reports that they are taking phenytoin to treat a seizure disorder. The client reports that they take a daily low dose of prednisone to treat a chronic respiratory condition. Risk factors associated with osteoporosis include a sedentary lifestyle, cigarette smoking, excessive alcohol consumption, chronic illness, and long-term use of anticonvulsants and furosemide. Another risk factor associated with osteoporosis includes a diet that is deficient in calcium. Options 1, 2, 3, and 5 are risk factors associated with osteoporosis.

The nurse is preparing to teach a client with a leg cast applied to treat a fracture how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment would include which information?

The client's vital signs, muscle strength, and previous activity level Vital signs provide a baseline to determine how well the client will tolerate activity. Assessing muscle strength will help determine whether the client has enough strength for crutch walking and whether muscle-strengthening exercises are necessary. Previous activity level will provide information related to the tolerance of activity. The remaining options also are components of the assessment, but physiological needs take precedence over psychosocial needs.

The nurse is planning to teach proper use of a thoracolumbosacral orthosis to a client who has had spinal fusion with instrumentation. The nurse would include which teaching point in the discussion with the client?

The device is applied before getting out of bed in the morning. 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 needs to be secure but not overly loose or tight. The brace would not irritate the skin with proper fitting. Always follow the primary health care provider's activity prescriptions.

The nurse is caring for a client admitted for a torn meniscus. What is the focus of the nurse's immediate assessment?

The knee A meniscus is an interarticular fibrocartilage that partially or completely separates the components of a joint. The knee is a common area for meniscal tears because it is frequently injured as a result of falls and sports injuries; therefore, options 1, 3, and 4 are incorrect.

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client?

The need for sensory stimulation A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment would also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.

A client is having a plaster cast placed on the lower extremity that will extend from mid-thigh to the center of the foot. Which instruction would be given to the client before hospital discharge?

The need to notify the primary health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale Numbness, swelling, and cool, pale skin are findings that indicate a state of neurovascular compromise. This can lead to significant problems and potential loss of the limb. Although teaching the client how to petal the edge of a cast is commonly done to keep the edges from crumbling, this is not the priority at this time. Chemical reaction occurs while a plaster cast dries, causing the cast to be warm. This effect can last from 24 to 48 hours, depending on how long it takes for the cast to dry. It is inappropriate to place any objects under the edge of the cast because such maneuvers can result in tissue injury and consequent infection.

The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)?

The neurological and respiratory systems The early signs of the complication of fat embolism include changes in the client's mental status and signs of impaired respiratory function as a result of impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairments are likely to be secondary to impaired respiratory function. Effects on the endocrine system usually are not seen. The client's mobility status is unrelated to the signs of fat embolism.

An older client with rheumatoid arthritis has been instructed by the primary health care provider to take ibuprofen 400 mg orally (PO) three times daily. The home care nurse reading the medication prescription knows that the instruction has been effective when the client states the instructed dose is which?

The normal adult dose For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dose for an older client is 400 to 800 mg three or four times daily. The other options are incorrect.

The nurse is reviewing the primary health care provider's prescriptions for an adult client who has been admitted to the hospital after a back injury. Carisoprodol is prescribed for the client to relieve the muscle spasms. The primary health care provider has prescribed 350 mg to be administered 4 times a day. What would the nurse conclude?

The prescription is the normal adult dosage. The normal adult dosage for carisoprodol is 350 mg orally 3 to 4 times daily.

The nurse is planning to teach the client with below-the-knee amputation about care to prevent skin breakdown. Which point would the nurse include in developing the teaching plan?

The socket of the prosthesis must be dried carefully before it is used. A residual limb sock must be worn at all times to absorb perspiration and is changed daily. The residual limb is washed, dried, and inspected for breakdown twice each day. The socket of the prosthesis is cleansed with a mild detergent and rinsed and dried carefully each day. A harsh bactericidal agent would not be used.

?A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess

The white blood cell counts and platelet counts Infection and pancytopenia are adverse effects of etanercept. Laboratory studies are performed before and during medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste and loss of appetite are not common adverse effects of this medication.

A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess?

The white blood cell counts and platelet counts Infection and pancytopenia are adverse effects of etanercept. Laboratory studies are performed prior to and during medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste and loss of appetite are not common signs of adverse effects of this medication.

The nurse is providing care for a client admitted 3 days ago with a severe left ankle contusion. The nurse determines that heat application to the area has been effective if which has occurred?

There is reabsorption of blood noted at the injured site. 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 prevent infection or abscess formation.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

Thick, yellow drainage from the pin sites The nurse needs to monitor for signs of infection, such as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse needs to correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse would compare any findings to baseline findings to determine whether there were any changes.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

Thick, yellow drainage from the pin sites The nurse would monitor for signs of infection such as inflammation, purulent (thick white or yellow) drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse would correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse would compare any findings to baseline findings to determine if there were any changes.

The nurse is collecting data related to a client's risk factors associated with osteoporosis. Which data would the nurse include? Select all that apply.

Thin body build Smoking history Postmenopausal age Chronic corticosteroid use Family history of osteoporosis A high intake of dairy products is not associated with osteoporosis because dairy products are high in calcium. Other than low calcium intake, other risk factors for osteoporosis include a thin body frame, sedentary lifestyle, cigarette smoking, excessive alcohol intake, chronic illness, long-term use of corticosteroids, postmenopausal age, and a family history of osteoporosis.

The nurse is giving medication instructions to a client who is receiving dantrolene sodium. Which statement by the client indicates that the educational session was effective?

This medication acts directly on the skeletal muscle to relieve spasticity." Dantrolene sodium acts directly on skeletal muscle to relieve muscle spasticity. The primary action is the suppression of calcium release from the sarcoplasmic reticulum. This in turn decreases the ability of the skeletal muscle to contract.

The home care nurse is visiting a client who sustained a severe muscle sprain to the back. Carisoprodol is prescribed for the client. The nurse provides instructions to the client regarding the medication and would teach the client to take which measure?

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

A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need which intervention?

To have a window cut in the cast A window may be cut in a dried cast to relieve pressure in an area of a bony prominence, to assess pulses, to relieve discomfort, or to remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling, to facilitate taking radiographs, or to make a half-cast for use as an intermittent splint. The use of an air splint is not indicated. Padding is not placed on top of a cast.

The nurse is providing dietary instructions to a client with osteoporosis and is discussing appropriate food items to include in the diet. Which food items would the nurse recommend as being high in calcium? Select all that apply.

Tofu Salmon Spinach Sardines Foods high in calcium include milk and milk products, dark green leafy vegetables, tofu and other soy products, sardines, salmon with bones, and hard water. Options 1, 2, 4, and 5 are all foods that are high in calcium. Peaches are high in vitamins A and C.

A client is diagnosed with iron-deficiency anemia, and ferrous sulfate is prescribed. The nurse would tell the client that it would be best to take the medication with which food?

Tomato juice Ferrous sulfate is an iron preparation, and the client is instructed to take the medication with orange juice or another vitamin C-containing product or a product high in ascorbic acid to increase the absorption of the iron. Among the options presented, tomato juice is highest in vitamin C and ascorbic acid. Milk and eggs inhibit absorption of iron.

The nurse determines that a client's skeletal traction needs correction if which observation is made?

Traction ropes rest against the footboard. Traction ropes must hang free of the bed. The remaining options are observations that indicate correct use of the traction setup.

The nurse is reviewing the prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply.

Transfusions Splenectomy Corticosteroid medication Immunosuppressive agents Idiopathic autoimmune hemolytic anemia is a decrease in the number of red blood cells due to increased destruction by the body's defense (immune) system. It is an acquired disease that occurs when antibodies form against a person's own red blood cells. In the idiopathic form of this disease, the cause is unknown. Idiopathic autoimmune hemolytic anemia is treated with corticosteroids. Other treatments that may be prescribed as necessary include transfusions, splenectomy, and, occasionally, immunosuppressive medications. Radiation therapy is not used to treat this disorder.

A client has been prescribed cyclobenzaprine for the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse would withhold the medication and question the prescription if the client has a concurrent prescription for which medication?

Tranylcypromine The client would not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors such as tranylcypromine or phenelzine within the last 14 days. Otherwise, the client could experience hyperpyretic crisis, seizures, and possibly death. The medications in the remaining options are not contraindicated.

The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply.

Twisting of the spine Hyperflexion of the spine Herniation of an intervertebral disk 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.

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?

Uric acid level of 9.0 mg/dL (0.54 mmol/L) 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 (0.48 mmol/L); a normal value for a male ranges from 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L) and for a female, from 2.7 to 7.3 mg/dL (0.16 to 0.43 mmol/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.

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?

Uric acid level of 9.0 mg/dL (540 mcmol/L) In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia. A normal value ranges from 2.7 to 8.5 mg/dL (160-501 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.

The nurse has a prescription to administer a dose of iron by the intramuscular route to the client with anemia. What are the most appropriate nursing actions? Select all that apply.

Use a Z-track method. Aspirate for blood after the needle is inserted. Use an air lock when drawing up the medication. Change the needle after drawing up the dose and before injection. An air lock and a Z-track method are both used when administering iron by the intramuscular route. Proper technique includes changing the needle after drawing up the medication but before giving it to prevent staining of skin. After insertion of the needle, the nurse would aspirate for 5 to 10 seconds. If no blood returns with aspiration, the medication is injected slowly. The ventrogluteal site is the preferred site, and proper identification of appropriate landmarks is essential. The site would not be massaged after injection because massaging could cause staining of the skin.

The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse would include which in the plan of care?

Use a fracture pan for bowel elimination. A fracture pan is designed to be used for clients with body or leg casts. A client with a spica cast (body cast) involving a lower extremity cannot bend at the hips to sit up; therefore, a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care.

The nurse has taught a client with a below-the-knee amputation about prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client makes which statement?

Use a mirror to inspect all areas of the residual limb each day. Following amputation, the client needs to inspect all surfaces of the residual limb daily for irritation, blisters, or breakdown. The other options are incorrect. The client needs to wear a clean woolen residual limb sock each day. Nylon is a synthetic material that does not allow the best air circulation and holds in moisture. The stump is cleansed daily with a gentle soap and water and is dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils, creams, and lotions also are avoided because they are too softening to the skin for safe prosthesis use.

The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented?

Use a raised toilet seat. The client who has had an insertion of a femoral head prosthesis needs to use a raised toilet seat. The client would avoid putting on socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion. The client needs to sit in chairs that have arms to provide assistance in rising from the sitting position. The client also needs to maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg would not be adducted, internally rotated, or flexed more than 90 degrees.

The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply.

Use night-lights. Remove scatter rugs. Use staircase railings. Place hand rails in the bathroom. Home modifications to reduce the risk for falls include railings on all staircases, ample lighting, the removal of scatter rugs, and the placement of hand rails in the bathroom. Removing wall-to-wall carpeting is unnecessary as long as it is in good condition.

A client newly diagnosed with gout has been prescribed allopurinol. The nurse would be concerned if the client was also currently taking which medication?

Warfarin Allopurinol is an antigout medication that may increase the effect of oral anticoagulants. Warfarin sodium is an anticoagulant; if this medication was prescribed for the client, the nurse would verify the prescription. The dosage of warfarin may need to be decreased. Digoxin is a cardiac glycoside. Adenosine is an antidysrhythmic. Ergonovine maleate is an antimigraine medication.

The nurse is providing medication instructions to a client with multiple sclerosis receiving baclofen. Which information would the nurse include in the instructions?

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

The nurse is developing a plan of care for a client in Buck's traction. The plan of care would include assessing the client for which finding indicating a complication associated with the use of this type of traction?

Weak pedal pulses 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, options 3 and 4, findings of redness or drainage at the pin sites, are incorrect. Hypotension is not directly associated with the use of this type of traction.

A client who has rheumatoid arthritis has begun treatment with anakinra and has received the first injection. What finding would indicate that the primary health care provider (PHCP) needs to be notified and that the medication would be discontinued?

White blood cell count of 12,000 mm3 (12 × 109/L) and a temperature of 99.9° F (37.7° C) Leukocytosis and a slight temperature elevation can indicate an infection in a client on a biological response modifier. These findings warrant PHCP notification and possible discontinuation of the medication. Irritation and erythema are common and can be decreased by rotating the injection sites. Arthritic medications often are given with other medications, such as a tumor necrosis factor inhibitor. Arthritic symptoms often do not lessen early in the treatment.

The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period?

Within 20 to 30 minutes of application A fiberglass cast is made of water-activated polyurethane material that is dry to the touch within minutes and reaches full rigid strength in about 20 minutes. Accordingly, the client can bear weight on the cast within 20 to 30 minutes. The remaining options are incorrect.

The community health nurse is planning an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse would instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk?

Yogurt 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.