Test #5

The nurse suspects that a patient with an injured ankle is experiencing neurovascular compromise. What signs and symptoms did the nurse assess to come to this conclusion? Select all that apply. a. Pain b. Pulselessness c. Paralysis d. Peristalsis e. Pressure

A, B, C, E

Which laboratory test should the nurse include in the plan of care for a patient who may require a blood transfusion during the surgical procedure? a. Urinalysis b. Basic metabolic panel c. Arterial blood gas analysis d. Type and crossmatch

B

A patient with bilateral carpal tunnel syndrome (CTS) does not want to have surgery. What is this patient at risk for developing? a. Chronic pain b. Further nerve injury c. Infection d. Hematoma formation

A

A patient with bone cancer is admitted for treatment. What finding should the nurse expect to observe when assessing this patient? a. Limp b. Skin discoloration c. Muscle atrophy d. Dependent edema

A

A patient's bone density results are -2.7. For which potential health problem should the nurse instruct this patient? a. Fractures b. Muscle atrophy c. Pain d. Contractures

A

A nurse coordinates care for a client with a wet plaster cast. Which statement should the nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)? a. "Use a cloth-covered pillow to elevate the client's leg to promote drying." b. "Turn the client every 3 to 4 hours to promote cast drying." c. "Assess distal pulses for potential compartment syndrome." d. "Handle the cast with your fingertips."

A

A patient has a low level of thyroid stimulating hormone (TSH). How will this affect the musculoskeletal system? a. Reduces bone growth b. Promotes the number of osteoblasts c. Slows the rate of bone destruction d. Initiates the growth of bone

A

A patient is recovering from an arthrocentesis of the right knee. What should the nurse instruct the patient regarding care at home? a. Apply ice to the wound for the first 24 hours b. Avoid all weight bearing for three to five days c. Ambulate with crutches d. Elevate the extremity

A

A patient is seeking medical treatment for chronic low back pain. Which approach will help speed this patient's recovery? a. Regular exercise b. Spinal injections c. Transcutaneous electrical nerve stimulation (TENS) d. Nonsteroidal anti-inflammatory agents (NSAIDs)

A

A patient with Paget's disease is prescribed a bisphosphonate medication. Which additional medication should the nurse expect to be prescribed for this patient? a. Calcium with vitamin D b. Anticholinergic c. Thiazide diuretic d. Antihypertensive

A

The nurse requests an occupational therapy consultation for a patient with bilateral carpal tunnel syndrome. What is the reason for this consultation? a. Evaluate the work area b. Instruct on the use of splints c. Review the action of NSAIDs d. Instruct on hand exercises

A

The patient is transferred to the operating table. Which segment of the operative period is the patient currently experiencing? a. Intraoperative period b. Perioperative period c. Postoperative period d. Preoperative period

A

Which identifier should the nurse use during the initial time-out to determine the right patient? a. Date of birth b. Photo placed in the medical record c. Medical record number d. Middle name

A

Which is the priority action by the nurse when a patient discloses a medication allergy during the health history prior to a surgical procedure? a. Documenting the information on the patient's medical record. b. Asking the patient to describe the reaction that occurs c. Placing an alert bracelet on the patient prior to leaving the unit. d. Verifying the information with the patient's family members at the bedside

A

Which nursing action is appropriate when providing care to a patient who is exhibiting symptoms of a venous thromboembolism (VTE)? a. Administer prescribed heparin b. Monitor breath sounds c. Assess for malignant hyperthermia d. Hold prescribed opioid analgesics

A

Which personal protective equipment should the scrub nurse don to decrease the likelihood of an accidental splash injury during a surgical procedure? a. Eyewear b. Caps c. Gown d. Gloves

A

Which priority action should the circulating nurse anticipate during the emergence phase of general anesthesia? a. Securing the patient's airway b. Administering oxygen to the patient by face mask c. Maintaining the patient using balanced anesthesia d. Suctioning the patient to decrease incidence of aspiration

A

Which information should the postanesthesia care unit (PACU) nurse include in the hand-off that occurs with the medical-surgical nurse who will assume care? Select all that apply. a. Information regarding the surgical procedure b. Discussion of actual and/ or potential clinical issues, i.e. pain, changes in vital signs. c. Fluid intake and estimated blood loss d. Patient identification using one identifier e. Placement of intravenous (IV) lines and drains

A, B,

Which should the nurse ask the patient to verify during the initial time-out, the "pause for cause"? Select all that apply a. "Which procedure are you having done today?" b. "Have you signed your informed consent for the scheduled procedure?" c. "Is the information on your identification band correct?" d. "What is the name of your surgeon?" e. "Which side of the body is your procedure going to be completed on?"

A, C, D, E

The nurse suspects that a home care patient recovering from hip replacement surgery is developing osteomyelitis. What findings caused the nurse to come to this conclusion? Select all that apply. a. Pain unrelieved by rest b. Tenderness, redness and warmth at the surgical site. c. Fever d. Bone deformity e. Progressive muscle weakness

A,B,C

Which tasks can the nurse assign to the unlicensed assistive personnel (UAP) who is assisting with providing care to postoperative patients on a medical-surgical unit? Select all that apply. Select one or more: a. Assisting with patient exercises b. Administering pain medication as ordered by the health-care provider c. Documenting the assessment completed by the nurse d. Reporting when a patient cannot complete exercises e. Conducting discharge teaching

A,D

A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? a. "Provide pin care by using alcohol wipes to clean the sites." b. "Ensure that the weights remain freely hanging at all times." c. "Remove the traction when re-positioning the client." d. "Assess the client's skin when performing a bed bath."

B

A patient is suspected of having osteoporosis. Which diagnostic test should the nurse expect to be prescribed for this patient? a. Bone scan b. DEXA scan c. CT scan d. MRI

B

A patient recovering from surgery to repair a fractured femur is experiencing extreme pain and pulselessness. What should the nurse expect to be prescribed for this patient? a. Limb CT scan b. Fasciotomy c. Anticoagulant therapy d. Intravenous fluids

B

A patient with severe hip pain is diagnosed with osteoarthritis (OA). What information should the nurse provide to the patient about this disease process? a. "OA causes an overgrowth of cartilage in the joints." b. "OA causes a decrease in joint fluid that affects the cartilage." c. "OA causes joint fluid to become bluish-white in color." d. "OA causes a build of fluid in the joints, hindering movement."

B

The medical-surgical nurse is providing care to a postoperative patient who is experiencing an elevated temperature. Which laboratory value should the nurse monitor to gather more information? a. Platelet count b. White blood cell (WBC) count c. Red blood cell (RBC) count d. Serum glucose

B

The nurse is evaluating a patient's musculoskeletal system. Which approach should be used to determine joint mobility? a. Posture b. Range of motion c. Gait d. Palpation of muscle tone

B

The nurse is preparing material about back pain for a community health fair. What should be included as a reason why this pain occurs most frequently in the lumbar region of the spine? a. It is the most rigid area of the spine. b. It is the most inflexible area of the spine. c. It contains peripheral nerves. d. The lumbar region supports the weight of the upper body and anchors the weight of the lower body.

B

Which is the priority nursing action when providing patient care during the preoperative phase of care? a. Obtaining informed consent b. Completing a preoperative checklist c. Ensuring NPO status d. Monitoring vital signs

B

Which patient diagnosis would contraindicate the use of massage at a complementary and alternative medicine (CAM) therapy? a. Depression b. Direct tumor sites c. Osteoporosis d. Fibromyalgia

B

While playing tennis a patient fell and fractured the right elbow. For which treatment should the nurse prepare this patient? a. Pressure dressing b. Cast c. Splint d. External fixator

B

Which is included in the scope of practice for the circulating registered nurse (RN)? Select all that apply. a. Obtaining informed consent b. Assisting the Certified Registered Nurse Anesthetist (CRNA) with patient monitoring. c. Labeling patient samples and sending for analysis d. Conducting the initial assessment e. Documenting information pertinent to the surgical procedure

B, C, D, E

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? Select all that apply. a. Slight redness and itching at the incision site b. Sudden and severe headache c. Incisional bulging d. Surgical discomfort e. Clear drainage on the dressing

B, C, E

A 70-year-old patient is diagnosed with a low energy fracture. What most likely caused this injury to occur? a. Bicycle accident b. Contact sport c. A fall d. Motor vehicle collision

C

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Change the settings based on range of motion. b. Remind the client to do quad-setting exercises. c. Raise the lower siderail on the affected side. d. Assess the distal circulation in 30 minutes.

C

A nurse overhears another nurse say, "That patient is asking for pain medication again. He is constantly on the call bell, always reporting how severe his pain is, and I think he is just drug-seeking. I am going to make him wait the full 4 hours before I give this medication again." Which action by the nurse is the most appropriate in this situation? a. Informing the charge nurse of what was overheard b. Ignoring the situation because the patient is not this nurse's responsibility c. Reminding the nurse, in private, that the sensation of pain is whatever the patient says it is d. Reprimanding the nurse and completing an incident or variance report

C

A patient is treated for a second-degree sprain. Which patient statement indicates that teaching about care has been ineffective? a. "I should take pain medication as directed." b. "I should elevate my leg." c. "I should expect the leg to feel numb." d. "I should apply ice."

C

A patient recovering from total knee replacement surgery develops osteomyelitis. What teaching should the nurse prepare as a priority for this patient? a. Debridement of the wound b. Antibiotic therapy c. Removal of the knee prosthesis d. Pain management

C

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Breathing b. Cardiac rhythm c. Airway d. Bleeding

C

After requesting a narcotic pain medication, the patient refuses it after the nurse prepares the injection. What is the nurse's best initial response? a. Explain to the patient the need to manage pain effectively. b. Have another registered nurse witness the proper discarding of the drug. c. Ask the patient the reason for his refusal. d. Notify the physician and ask for a different type of pain medication.

C

The nurse is conducting a medication assessment for a preoperative patient. Which action by the nurse is appropriate for the patient who is prescribed warfarin? a. Tapering the drug two days prior to surgery b. Assessing for hyperglycemia c. Monitoring blood pressure d. Obtaining a baseline ECG

C

The nurse is obtaining a pain history. The patient reports pain in the right ear. Which response by the nurse is the most appropriate? a. "Do you have anything else that hurts?" b. "Is the pain minor?" c. "Tell me more about the pain and what you do for it when it hurts." d. "I will note that in the record. Is there anything else I should know?"

C

The nurse is providing care to a postoperative patient who is experiencing pain. The patient rates the pain at a 4 on a 1 to 10 numeric pain assessment scale. Which prescribed medication should the nurse administer to this patient? a. Fentanyl b. Hydromorphone c. Ibuprofen d. Morphine

C

The patient has pain in the lower back that radiates down the leg as the result of a herniated disk compressing the sciatic nerve that began 4 months ago. When documenting this patient's pain, which term will the nurse use? a. Acute neuropathic pain b. Acute visceral pain c. Acute somatic pain d. Chronic neuropathic pain

C

The patient has requested a PRN medication for nausea. Which of the following should the nurse do first? a. Explain the specific purpose of the medication. b. Offer dry crackers and ice chips if not contraindicated. c. Check to see when the medication was given last, and make sure the time interval is up. d. Ask the patient about his allergies.

C

The postoperative patient displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low blood pressure. The nurse suspects which postoperative complication? a. Pneumonia b. Atelectasis c. Hypovolemia d. Pulmonary embolism

C

Which action by the nurse is the most appropriate when initiating guided imagery with a patient as a method to control pain? a. Suggesting a healing place or person where the patient will focus their attention on. b. Asking the patient to passively listen to music that they find enjoyable and relaxing. c. Asking the patient to begin by closing their eyes and focusing on an image and taking full diaphragmatic/abdominal breaths. d. Asking the patient to use progressive muscle relaxation exercises.

C

Which term should the nurse document for a patient who is having surgery for the removal of the gallbladder? a. Amniocentesis b. Hysterectomy c. Cholecystectomy d. Episiotomy

C

A patient recovering from a traumatic amputation is experiencing phantom limb pain. What should the nurse expect to be included in the treatment plan for this patient? a. Rigid splint b. Ice compresses c. Elevate stump on a pillow d. Gabapentin

D

An older patient asks what can be done to prevent bone fractures. What should the nurse suggest to this patient? a. Increase the intake of water b. Limit exposure to the sun c. Increase frequency of rest periods d. Engage in weight-bearing exercise

D

The blood pressure of a patient recovering from total hip replacement surgery is dropping. What should the nurse suspect is occurring with this patient? a. Development of a postoperative infection b. Pain medication overdose c. Development of a deep vein thrombosis d. Blood loss

D

The nurse is caring for a patient who is experiencing acute chest pain that is rated as a 9 on a 0 to 10 pain scale. Based on this data, which medication does the nurse plan to administer? Select one: a. Ibuprofen b. Naproxen c. Acetaminophen d. Morphine

D

The nurse is caring for a patient with unrelenting low back pain caused by a herniated disk. What instruction should the nurse provide to this patient to help with the pain? a. Reduce the intake of fluids b. Sit with the legs elevated c. Limit activity until the pain subsides d. Bend at the knees with a straight back

D

The nurse is completing the preoperative checklist on the night shift in preparation for the patient's surgery, scheduled for 0800. Which tasks could the nurse complete at this time? a. Documenting the time of last voiding b. Administering preoperative medication c. Removing the prosthesis d. Checking the medical record for the history, physical, and signed informed consent

D

The nurse notes that a 55-year-old female patient's bone density test has changed from -1.2 to a current level of -2.5. What could be the reason for this change? a. Poor nutritional status b. Immobility c. Chronic diseases d. Loss of estrogen

D

The nurse notes that a patient recovering from surgery to repair a torn meniscus has a blood pressure of 158/90 mm Hg. This finding would suggest that the nurse also assess the patient for which condition? a. Infection b. Hemorrhage c. Edema d. Pain

D

Which nursing action will provide the patient with the most pain relief after abdominal surgery? a. Allow the patient to "sleep off" the anesthesia, and then offer pain medication. b. Wait until the patient can describe the pain specifically. c. Assess the pain level every 4 hours around the clock. d. Offer pain relief before the patient complains of pain.

D