352 Exam 2

Patients who are experiencing immobility often have which of the following emotions? (Select all that apply.) Helplessness Hunger Anger Anxiety Increased communication Improved self-worth

A, C, D

After administering a dose of promethazine to a patient with nausea and vomiting, what medication side effect does the nurse explain is common and expected? Tinnitus Drowsiness Reduced hearing Sensation of falling

B

During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development? Vitamins and minerals Protein and calcium Fats and carbohydrates Zinc and potassium

B

The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? Progressive leg exercises to obtain 90-degree flexion Early ambulation with full weight bearing on the left leg Bed rest for 3 days with the left leg immobilized in extension Immobilization of the left knee in 30-degree flexion to prevent dislocation

A

The nurse is preparing to administer celecoxib 200 mg PO for pain relief. Available are capsules containing 100 mg. How many capsules should the nurse administer? ________ capsules

2

The nurse is caring for a patient who complains of abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient is experiencing a decline in condition? Pallor and diaphoresis Ecchymotic peripheral IV site Guaiac-positive diarrhea stools Heart rate 90, respiratory rate 20, BP 110/60

A

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? Keep a wrench close or attached to the vest. Use the frame and vest to assist in positioning. Clean around the pins using betadine swab sticks. Loosen both sides of the vest to provide skin care.

A

The nurse is preparing to administer celecoxib to a patient. What medication taken by the patient should the nurse monitor for increasing the risk of adverse effects? Aspirin Scopolamine Theophylline Acetaminophen

A

The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse? Provide a light blanket. Encourage a hot shower. Monitor temperature every hour. Turn up the thermostat in the patient's room.

A

Following the initiation of a pain management plan, pain should be reassessed and documented on a regular basis as a way to evaluate the effectiveness of treatments. Pain should be reassessed at which minimum interval? With each new report of pain Before and after administration of narcotic analgesics Every 10 minutes Every shift

A, B

A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful? "Leg-raising exercises are necessary for several months." "I should not try to drive a motor vehicle for 2 to 3 weeks." "I will not have any restrictions now on hip and leg movements." "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

A

A patient complaining of nausea receives a dose of metoclopramide. Which potential adverse effect should the nurse tell the patient to report? Tremors Constipation Double vision Numbness in fingers and toes

A

A patient with osteoarthritis has been taking ibuprofen 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on what knowledge? Another NSAID may be indicated because of individual variations in response to drug therapy. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. The patient is probably not compliant with the drug therapy, and therefore the nurse must initially assess the patient's knowledge base and initiate appropriate teaching.

A

A postoperative patient has an order to receive morphine sulfate 4 mg IM every 3 to 4 hours prn for pain. On hand are prefilled syringes labeled morphine sulfate 10 mg/mL. How many milliliters should the nurse administer? 0.4 mL 0.55 mL 0.6 mL 0.75 mL

A

After administering acetaminophen with oxycodone (Percocet) for pain, which intervention would be of highest priority for the nurse to complete before leaving the patient's room? Ensure that the side rails are raised. Leave the overbed light on at low setting. Offer to turn on the television to provide distraction. Ensure that documentation of intake and output is accurate.

A

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? Reposition every 2 hours. Measure the size of the reddened area. Massage the area to increase blood flow. Evaluate the area later to see if it is better.

A

A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles' fracture after a skateboarding accident. Which nursing action is most appropriate? Elevate the right arm on two pillows for 24 hours. Apply heating pad to reduce muscle spasms and pain. Limit movement of the thumb and fingers on the right hand. Place arm in a sling to prevent movement of the right shoulder.

A

A 28-yr-old woman with a fracture of the proximal left tibia in a long leg cast and complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? Notify the health care provider immediately. Elevate the left leg above the level of the heart. Administer prescribed morphine sulfate intravenously. Apply ice packs to the left proximal tibia over the cast.

A

A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete? Gait and balance Speech and hearing Mental alertness Ability to follow directions

A

An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings? Use mirror therapy. Give opioid analgesics. Rebandage the residual limb. Show the patient the leg is gone.

A

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful? "I will perform self-catheterization at least six times per day." "A reflex erection may cause an unsafe drop in blood pressure." "If I develop a severe headache, I will lie down for 15 to 20 minutes." "I can avoid this problem by taking medications to prevent leg spasms."

A

The nurse should question an order written for acetaminophen with oxycodone for a patient exhibiting which clinical manifestation? Severe jaundice Oral candidiasis Increased urine output Elevated blood glucose

A

The nurse should teach a patient to avoid which medication while taking ibuprofen? Aspirin Furosemide Nitroglycerin Morphine sulfate

A

The nurse teaches senior citizens at a community center how to prevent food poisoning at social events. Which community member statement reflects accurate understanding? "Pasteurized juices and milk are safe to drink." "Alfalfa sprouts are safe if rinsed before eating." "Fresh fruits do not need to be washed before eating." "Ground beef is safe to eat if cooked until it is brown."

A

The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? Arteriogram showing blood vessels Peripheral pulse palpation bilaterally Patches of black, indurated, cold tissue Bilateral pale, cool skin below the ankles

A

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F

A

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? Bradycardia Hypertension Neurogenic spasticity Bounding pedal pulses

A

Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia? Headache and rising blood pressure Irregular respirations and shortness of breath Decreased level of consciousness or hallucinations Abdominal distention and absence of bowel sounds

A

Which of the following is a priority for a nurse to include in a teaching plan for a patient who desires self-management and alternative strategies? Body alignment and superficial heat and cooling Patient-controlled analgesia (PCA) pump Neurostimulation Peripheral nerve blocks

A

Which patient is most at risk for the development of a pressure ulcer? An older patient who is septic, bedridden, and incontinent An obese woman with leukemia who is receiving chemotherapy A middle-aged thin man in a halo cast after a motor vehicle accident An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis

A

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? (Select all that apply.) Cleansing the wound Managing pain Applying a dry sterile dressing Using cold water in the bath

A, B

The nurse would explain to a patient that effective treatments for atopic pruritus include which treatments? (Select all that apply.) Oral steroids Topical steroids Oral antihistamines Topical antihistamines Topical petroleum ointment

A, B

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply.) Applying over-the-counter lotions to skin that is not broken Assisting the client with frequent turning to prevent pressure ulcers Covering the client who complains of being cold with more blankets Placing a sterile gauze pad over broken skin to contain drainage Assessing a patient complaining of an itching rash

A, B, C, D

While on a mission trip, the nurse is caring for a patient diagnosed with tetanus. The patient has been given tetanus immune globulin (TIG). What interprofessional care is appropriate (select all that apply.)? Administer penicillin. Administer polyvalent antitoxin. Control spasms with diazepam (Valium). Teach correct processing of canned foods. Provide analgesia with opioids (morphine). Prepare for tracheostomy for mechanical ventilation.

A, C, E, F

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, which recommendations should the nurse provide? (Select all that apply.) Wear sunglasses. Drink plenty of water. Eat plenty of foods high in vitamin K. Apply sunscreen 30 minutes prior to exposure. Consume fish oil and vitamin E.

A, D, E

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? Administer aspirin on a scheduled basis around the clock. Provide acetaminophen every 4 hours to maintain consistent blood levels. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. Provide drug interventions if complementary and alternative therapies have failed.

B

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? Apple Custard Popsicle Potato chips

B

A 65-year-old woman has fallen while sweeping her driveway, sustaining a tissue injury. She describes her condition as an aching, throbbing back. Which type of pain are these complaints most indicative of? Neuropathic pain Nociceptive pain Chronic pain Mixed pain syndrome

B

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? Serous Purulent Fibrinous Catarrhal

B

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? Pain level Intake and output Oxygen saturation Level of consciousness

B

A patient is receiving morphine sulfate via patient-controlled analgesia (PCA). What nursing action is most effective to reduce the risk of adverse effects? Instruct the patient not to push the button too frequently. Teach the caregiver not to push the button for the patient. Ask the patient to do deep breathing exercises every hour. Administer medications to prevent the occurrence of diarrhea.

B

A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? Warm, moist heat and massage Rest, ice, compression, and elevation Antipyretic and antibiotic drug therapy Active movement and exercise to prevent stiffness

B

Stephanie is a 70-year-old retired schoolteacher who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. Which of the following options should you suggest for her plan of care, considering her expressed wishes? Using a stationary exercise bicycle and free weights and attending a spinning class Using mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Drinking chamomile tea and applying icy/hot gel Receiving acupuncture and attending church services

B

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? 2 × 6 cm right calf abrasion with sanguineous drainage Left leg externally rotated and shorter than the right leg Stooped posture with a shuffling gait and slow movements Mild pain and minimal swelling of the right ankle and foot

B

The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? Recent knee trauma Debilitating joint pain Repeated knee infections Onset of frozen knee joint

B

The nurse is caring for a 63-yr-old woman taking prednisone (Deltasone) for Bell's palsy. Which statement by the patient requires correction by the nurse? "I can take the medication with food or milk." "The medication should be started 1 week after paralysis." "I can take acetaminophen with the prescribed medications." "Chances of a full recovery are good if I take the medication"

B

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? Central cord syndrome Spinal shock syndrome Anterior cord syndrome Brown-Séquard syndrome

B

The nurse is caring for a patient receiving morphine sulfate 10 mg IV push when necessary for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8/minute. Which medication would the nurse prepare to administer to treat these symptoms? Atropine Naloxone Protamine sulfate Neostigmine bromide (Prostigmin)

B

The nurse is caring for a patient receiving morphine sulfate via PCA. Which patient assessment data demonstrate the most therapeutic effect of this medication? Pain rating 3/10, awake and alert, respirations 24 Pain rating 2/10, awake and alert, respirations 18 Pain rating 2/10, drowsy but arousable, respirations 18 Pain rating 1/10, drowsy but arousable, respirations 16

B

The nurse is caring for a patient treated with IV fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, which food choice would be most appropriate? Iced tea Dry toast Hot coffee Plain yogurt

B

The nurse is caring for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention? Offer the patient an herbal supplement such as ginseng. Apply a cool washcloth to the forehead and provide mouth care. Take the patient for a walk in the hallway to promote peristalsis. Discontinue any medications that may cause nausea or vomiting.

B

The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement? "Proper care of the skin is important because the immobilized patient does not want to smell bad." "Proper care of the skin is important because the immobilized patient is at high risk for breakdown." "Proper care of the skin is important because the immobilized patient will have many visitors." "Proper care of the skin is important because the immobilized patient will be incontinent."

B

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? Local response Systemic response Infectious response Acute inflammatory response

B

The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 mL PO. The nurse will determine the medication was effective when which symptom has been resolved? Diarrhea Heartburn Constipation Lower abdominal pain

B

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? Keep the pressure ulcer clean and dry. Maintain protein intake of at least 1.25 g/kg/day. Use a 10-mL syringe to irrigate the pressure ulcer. Irrigate the pressure ulcer with hydrogen peroxide.

B

Which nursing intervention is most appropriate when preparing to administer an opioid analgesic agent to a patient in pain? Give the medication on an empty stomach. Count the number of doses on hand before administration. Give the medication with a glass of juice or other cold beverage. Assess the patient for allergies to aspirin before administration.

B

he patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication? Zolpidem Ondansetron Dexamethasone Morphine sulfate

B

The postoperative patient is receiving epidural fentanyl for pain relief. For which common side effects should the nurse monitor the patient (select all that apply.)? Ataxia Itching Nausea Urinary retention Gastrointestinal bleeding

B, C, D

The patient's neuropathic pain is not well controlled with the opioid analgesic prescribed. What medications may be added for a multimodal approach to treat the patient's pain (select all that apply.)? Fentanyl Antiseizure drugs β-Adrenergic agonists Tricyclic antidepressants Nonsteroidal antiinflammatory drugs

B, D

A 68-yr-old patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and caregiver to assist with bowel evacuation (select all that apply.)? Drink more milk. Eat 20-30 g of fiber per day. Use oral laxatives every day. Limit caffeinated beverages. Drink 1800 to 2800 mL of water or juice. Establish bowel evacuation time at bedtime.

B, D, E

22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is most appropriate? Insert a rectal stimulant suppository. Teach the patient to gradually increase intake of high-fiber foods. Assess bowel movements for frequency, consistency, and volume. Instruct the patient to avoid all caffeinated and carbonated beverages.

C

A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? "I probably won't be able to play soccer for 6 to 8 months." "They will have me do range of motion with my knee soon after surgery." "I can't wait to get this done now so I can play soccer for the next tournament." "I will need to wear an immobilizer and progressively bear weight on my knee."

C

A 25-yr-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? Prevent urinary tract infection. Monitor the patient every 15 minutes. Encourage him to verbalize his feelings. Teach him about using the gastrocolic reflex.

C

A 42-yr-old man underwent amputation below the knee on the left leg after a recent heavy farm machinery accident. Which intervention should the nurse include in the plan of care? Sit in a chair for 1 to 2 hours three times each day. Dangle the residual limb for 20 to 30 minutes every 6 hours. Lie prone with hip extended for 30 minutes four times per day. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

C

A 74-yr-old female patient with osteoporosis is diagnosed with gastroesophageal reflux disease (GERD). Which over-the-counter medication to treat GERD should be used with caution? Sucralfate Cimetidine Omeprazole Metoclopramide

C

A child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone? Physiological bonding and growth Speech and hearing development Intellectual and psychomotor function Childhood play interaction

C

A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. Which side effect of this medication should the nurse try to prevent with oral intake and medication? Diarrhea Agitation Constipation Urinary incontinence

C

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? Increased platelet count Increased blood urea nitrogen Increased number of band neutrophils Increased number of segmented myelocytes

C

A patient asks the nurse why a dose of hydromorphone (Dilaudid) by IV push is given before starting the medication via PCA. Which response is most appropriate? "PCA will never be effective unless a loading dose is given first." "The IV push dose will enhance the effects of the PCA for the next 8 hours." "The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA." "PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim."

C

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? Frequent examination of the character and quantity of exudate Monitoring for signs and symptoms of local or systemic infections Assessment of the patient's circulation distal to the location of the dressing Assessment of the range of motion of the ankle and the patient's activity tolerance

C

After administration of a dose of metoclopramide, which patient assessment finding would show the medication was effective? Decreased blood pressure Absence of muscle tremors Relief of nausea and vomiting No further episodes of diarrhea

C

An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? Dress it with an absorbent dressing for exudate. Handle the wound gently and let it dry out to heal. Debride the nonviable, eschar tissue to allow healing. Use negative-pressure wound (vacuum) therapy to facilitate healing.

C

The nurse determines a patient has experienced the beneficial effects of therapy with famotidine when which symptom is relieved? Nausea Belching Epigastric pain Difficulty swallowing

C

The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? Pain Left knee stiffness Left knee infection Left knee instability

C

The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? Uses an elevated toilet seat Sits with feet flat on the floor Maintains hip in adduction and internal rotation Verifies need to notify future caregivers about the prosthesis

C

The nurse is providing care for a patient diagnosed with Guillain-Barré syndrome. Which assessment should be the nurse's priority? Pain assessment Glasgow Coma Scale Respiratory assessment Musculoskeletal assessment

C

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? The wound will be stapled together until it heals. The healing will contract the area to close the wound. The wound will be left open and heal from the edges inward. The wound will be sutured after the current infection is controlled.

C

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? Notify the health care provider. Document the fistula formation. Assess the patient and vaginal drainage. Have the UAP apply a dressing to the vagina.

C

When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient's respiratory rate drops down to or below which parameter? 16 breaths/min 14 breaths/min 12 breaths/min 10 breaths/min

C

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? White blood cell (WBC) count of 8000/ìL; temperature of 101?5? F White blood cell (WBC) count of 4000/ìL; temperature of 100?5? F White blood cell (WBC) count of 8500/ìL; temperature of 98.4?5? F White blood cell (WBC) count of 16,500/ìL; temperature of 98.8?5? F

C

Which assessment is of highest priority for the nurse to complete before administration of morphine? Pain rating Blood pressure Respiratory rate Level of consciousness

C

Which clinical manifestation should the nurse attribute to adverse effects of morphine sulfate administered via PCA? Diarrhea Urinary incontinence Nausea and vomiting Increased blood pressure

C

Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? Urinary catheterization Check for bowel impaction Elevate the head of the bed Administer intravenous hydralazine

C

Which patient would be at highest risk for developing oral candidiasis? A 74-yr-old patient who has vitamin B and C deficiencies A 22-yr-old patient who smokes 2 packs of cigarettes per day A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks A 58-yr-old patient who is receiving amphotericin B for 2 days

C

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to perform which actions? (Select all that apply.) Bathe and dry the skin vigorously to stimulate circulation. Keep the head of the bed elevated 30 degrees. Offer nutritional supplements and frequent snacks. Turn the patient at least every 2 hours. Maintain a cooler environment when bathing.

C, D

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? Take the antibiotic until the wound feels better. Take the analgesic every day to promote adequate rest for healing. Be sure to wash hands after changing the dressing to avoid infection. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. Notify the health care provider of redness, swelling, and increased drainage.

C, D

When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (select all that apply.)? Apply ice directly to the skin. Apply heat to the ankle every 2 hours. Administer antiinflammatory medication. Compress ankle using an elastic bandage. Rest and elevate the ankle above the heart. Perform passive and active range of motion.

C, D, E

The patient with peripheral facial paresis on the left side is diagnosed with Bell's palsy. What should the nurse teach regarding self-care (select all that apply.)? Administration of antiseizure medications Preparing for a nerve block to manage pain Administration of corticosteroid medications Surgery if conservative therapy is not effective Dark glasses and artificial tears to protect the eyes A facial sling to support the muscles and facilitate eating

C, E, D

A patient has been prescribed a nonsteroidal antiinflammatory medication (NSAID). Which effect should the nurse instruct the patient to immediately report? Blurred vision Nasal stuffiness Urinary retention Black or tarry stools

D

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? Adhesion Contractions Keloid formation Excess granulation tissue

D

A patient learns about rehabilitation for a spinal cord tumor. Which statement by the patient reflects appropriate understanding of this process? "I want to be rehabilitated for my daughter's wedding in 2 weeks." "Rehabilitation will be more work done by me alone to try to get better." "I will be able to do all my normal activities after I go through rehabilitation." "With rehabilitation, I will be able to function at my highest level of wellness."

D

Postoperative surgical patients should be given alternating doses of acetaminophen and which medication throughout the postoperative course, unless contraindicated? Antihistamine Local anesthetic Opioids Nonsteroidal anti-inflammatory drug (NSAID)

D

The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate? Promote vitamin C and calcium intake in the diet. Provide passive range of motion to all of the joints q4hr. Keep the left leg in extension and abduction to prevent contractures. Encourage isometric quadriceps-setting exercises at least four times a day.

D

The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN? Assess skin integrity around the traction boot. Determine correct body alignment to enhance traction. Remove weights from traction when turning the patient. Monitor pain intensity and administer prescribed analgesics.

D

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? Fever and chills Increased blood pressure Increased respiratory rate General malaise and fatigue

D

The patient is a documented abuser of opioids and just had surgery. The nurse is concerned about the high dose of opioid analgesic prescribed for this patient. What is the best action for the nurse to take? Remember that pain can be observed in patients. Relieve this patient's pain to avoid adverse consequences. Be sure the patient is really in pain before giving the analgesic. This patient has the right to appropriate assessment and management of pain.

D

The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? Administer enoxaparin (Lovenox). Provide range-of-motion exercises. Apply sequential compression boots. Immobilize the fracture preoperatively.

D

The patient is receiving fentanyl patch for control of chronic cancer pain. What should the nurse observe for in the patient as a potential life-threatening adverse effect of this medication? Hypertension Pupillary dilation Urinary incontinence Decreased respiratory rate

D

This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? "No one is available to assist and accompany the patient." "The cast is not dry yet, and it may be damaged while using crutches." "Rest, ice, compression, and elevation are in process to decrease pain." "Excess edema and complications are prevented when the leg is elevated for 24 hours."

D

When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? Impaired urinary elimination related to tetraplegia Risk for impaired tissue integrity related to paralysis Disabled family coping related to the extent of trauma Ineffective airway clearance related to cervical spinal cord injury

D