Altered Mobility
The nurse is caring for a client who has a C5 complete cervical fracture following a motor vehicle accident. The client is in cervical traction with skeletal tongs. For each body system, select the appropriate nursing interventions for a client in cervical traction.
Skin --> inspect and clean pin sites Musculoskeletal --> passive ROM exercises Pulmonary --> Incentive spirometry every hour
The nurse is caring for a client with a complete C7 spinal cord injury who reports a severe headache. Vital signs are P 55, BP 210/112, and RR 22. Place the nursing actions in the correct priority order.
The client is showing signs and symptoms of autonomic dysreflexia. Nursing interventions include first raising the head of the bed to lower blood pressure and determining the cause (the most common cause is bladder distention, then bowel rectal distention). Once the source of stimulation is identified, resolve it (unkinking the urinary catheter tubing). The bladder will then empty. The nurse should continually monitor blood pressure and administer medications if ordered.
Which tasks can be delegated to an unlicensed assistive personnel (UAP)? Select all that apply. Evaluate the client's ability to transfer to the chair. Turn and reposition the client every 2 hours. Ensure that the client's heels are raised off the bed. Monitor for redness and swelling of the client's calves. Instruct the client on proper walker use. Complete a fall risk assessment every shift.
Turn and reposition the client every 2 hours. Ensure that the client's heels are raised off the bed.
The nurse is caring for a client who has inflammation of the wrists and hands bilaterally. The nurse observes subcutaneous nodules and ulnar deviations on both hands. Which treatment does the nurse anticipate will be prescribed? Select all that apply. Use of hot or cold compresses Exercise program Methotrexate therapy Weight reduction program Physical therapy
Use of hot or cold compresses Methotrexate therapy Physical therapy
Based on these assessment findings, the client is at greatest risk for developing ____ as evidenced by _______.
compartment syndrome pain
The nurse is caring for a client following a motor vehicle accident who sustained a left femur fracture. The following data is found during the assessment. Vital signs T 98.4 °F (36.9 °C), BP 132/84, RR 28, P 110, and pulse oximetry reading 88% on room air. The client is reporting shortness of breath and is oriented to person and time, but appears anxious and restless. The nurse observes petechiae on the chest and neck. Pedal pulses are +2 bilaterally with brisk capillary refill. Based on these assessment findings, the client is most at risk for developing _____ as evidenced by _______.
impaired gas exchange altered blood flow
For each potential nursing action, indicate whether the action is indicated, nonessential, or contraindicated. Place the traction weights on the bed. Inspect the skin every 2 hours. Clean traction pins every shift. Assess the client's pedal pulse every day. Encourage use of the incentive spirometer every 2 hours. Assess vital signs every hour. Monitor blood glucose every 2 hours.
Contraindicated Indicated Indicated Contraindicated Indicated Nonessential Nonessential
The nurse is providing discharge education to a client who is 1 day postoperative from a right total hip replacement. Which statement made by the client indicates a need for further teaching? "I will use an elevated toilet seat at home." "I will sit in chairs that have arms." "I can put on my own shoes once I return home." "I should use a pillow between my legs when I sleep."
"I can put on my own shoes once I return home."
The nurse is educating a client about rheumatoid arthritis. Which statement made by the client indicates the teaching has been effective? "I may need to rest my legs frequently and use my cane more often." "After I complete my first dose of methotrexate, I should see therapeutic effects." "I can stop taking the corticosteroid medication once I start to feel better." "I should not use hot or cold compresses on my sore joints."
"I may need to rest my legs frequently and use my cane more often."
The nurse is providing discharge education to a client with an ankle sprain. What statement made by the client indicates the teaching has been effective? "I should place ice directly on my skin to relieve pain." "I cannot bear weigh on the injured ankle for 12 weeks." "I should elevate my leg on two pillows." "When I wrap my ankle, I should start from the knee side and wrap distally."
"I should elevate my leg on two pillows."
The nurse receives shift report on four clients. Place the clients in the order in which they should be assessed from the highest priority to the lowest priority.
Adam Nguyen Harold Stockmeyer Betty Jones Anita Franklin
The nurse is caring for an older adult with osteoporosis who has been admitted for a left hip fracture. The nurse is developing the plan of care for the client. Match the client problem on the left with the most appropriate nursing intervention.
Altered mobility --> strength training Pain (acute) --> cool or warm compresses Unable to dress self --> Referral to OT Constipation --> Ensure adequate fluid intake Stage 1 Pressure ulcer --> Turn and reposition every 2 hours Risk of DVT --> TED stockings
The nurse is caring for a client who has sustained a left ulnar fracture. The client's fracture was reduced (external fixation) and placed in a plaster cast. The client reports increased pain, and numbness and tingling in the left fingers. For each potential nursing intervention, click to specify whether the intervention is indicated, non-essential, or contraindicated. Elevate the arm on two pillows Perform a neurovascular assessment of the hand Apply ice to the cast Perform passive range of motion exercises Notify the healthcare provider
Contraindicated Indicated Nonessential Indicated
For each client, select the assessment findings that indicate an increased risk for altered mobility.
Betty Jones --> Glaucoma, Depression, Rheumatoid arthritis Adam Nguyen --> Motor vehicle accident; left tibia and fibula fracture Harold Stockmeyer --> Parkinson's disease, Hyperlipidemia
The nurse is assessing a client with a fractured left femur. Based on the assessment findings below, click to specify if the finding is consistent with the complication of fat embolism syndrome, compartment syndrome, or venous thromboembolism. Respiratory rate 22 Toes cool touch Petechiae on chest Redness right calf Heart rate 115 Decreased sensation in the right foot Pain rating 10/10 on the Numerical Rating Scale Edema right calf
Fat Emboli Syndrome Compartment Syndrome Fat Emboli Syndrome VTE Fat Embolism Syndrome Compartment Syndrome Compartment Syndrome VTE
The nurse is creating a plan of care for a client with a complete T4 spinal cord injury. Move the symptoms of autonomic dysreflexia to the boxes on the right.
Nausea BP 210/106 HR 52 Sudden severe headache
The nurse is assessing a client with left tibia and fibula fractures following a motor vehicle accident. For each assessment finding, click to specify if the finding should be reported as emergent, non-urgent, or not reported to the healthcare provider. The client reports tenderness. The client's skin is pink and warm to the touch. The client can move all their toes. The client's capillary refill on the left toes is greater than three seconds. The client reports pain of an 8/10 on the Numerical Rating Scale. The client cannot distinguish between a sharp touch and a dull touch on the left lower leg. The client is alert and oriented to person, place, time, and situation.
Not Reported Not Reported Not Reported Emergent Non-Urgent Emergent Not Reported
The nurse is preparing to teach a client about diagnostic testing to determine if the client has a hip fracture. Which diagnostic tests will the nurse include in teaching? Select all that apply. Dual-energy x-ray absorptiometry Electromyogram (EMG) Radiograph (x-ray) Magnetic resonance imaging (MRI) scan Computed tomography (CT) scan Arthroscopy Arthrocentesis
Radiograph (x-ray) Magnetic resonance imaging (MRI) scan Computed tomography (CT) scan
Betty Jones is a 71-year-old client admitted to the hospital for a right hip fracture. She has a history of osteoporosis. The nurse is providing a report to another nurse during the client's transfer from acute care to rehabilitation. The nurse giving the report must provide a ______ report to ensure ________.
thorough continuity of care
01/22/YY @ 1430 Received client post motorcycle accident. Vital signs: Temp 99.1 °F (37.3 °C),BP 134/76, P 98, and RR 18. Client is alert and oriented x 4. Client unable to wiggle toes on right foot. Client reports pain 8/10 on the Numerical Rating Scale. Capillary refill < 2 seconds. Client reports decreased sensation in toes.
unable to wiggle toes Client reports pain 8/10 on the Numerical Rating Scale decreased sensation
