Exam 1

A client who has fractured the radial head asks the nurse about factors that will promote bone healing. Which statements will the nurse include when responding to the client?

-Fractured bones require a good blood supply and adequate nutrition for healing. -Weight bearing stimulates healing of the long bones of the leg if the fracture is stabilized. -Immobilization of the fracture will promote healing by maximizing contact of bone fragments.

The nurse is caring for a patient with a total hip replacement. How will the nurse allow the patient to turn?

45 degrees onto the unoperated side if the affected hip is kept abducted.

every bed in the intensive care unit is occupied when a call comes in from the ED about admitting a patient who was critically injured in an explosion. Which patients will the manager evaluate as a possible transfer to a less acute unit?

A 40 year old patient with severe sepsis secondary to renal failure for whom the family has requested "no code" status. A 48 year old patient who was admitted for diabetic ketoacidosis whose blood glucose is now 150,g/dL A 40 year old patient admitted for an unintentional over dose of blood pressure medication who us now conscious and alert.

You are working in the ED triaging clients following a mass casuality event. You will identify which of the following clients as being most emergent?

A client who has a punctured artery.

The nurse is providing care for a cleint who is experiecing alcohol withdrawal. The client reports "I cannot fall or stay asleep." The nurse observes that the client is agitated, having difficulty falling asleep and crying uncontrollably, which confused speech and a tachycardic pulse. Which intervention will the nurse implement first?

Administer lorazepam as ordered by the health care provider.

A public health nurse is teaching a mother about vaccinations prior to obtaining informed consent for her clilds vaccination. What will the nurse cite as the most common adverse effect of vaccinations?

Alleregic reactions to the antigen or carrier solution.

A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue to the nurse. The nurse will know that in a legal proceeding the standard that will be used to dtermine if the nurse was negligent is which of the following?

Another staff nurse provides testimony about how a reasonabl, prudent nurse would have handled the situation.

A client who has suffered from a compound fracture (open fracture) is preparing for discharge home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response is appropriate?

Antibiotic therapy has been prescribes as a precaution because your bone was exposed to the environment at the time of your injury.

A high school student who was injured in a football game presents with knee pain with internal rotation of the foot. Which interventions are appropriate nursing actions.

Apply ice to the affected knee Apply a knee brace or wrap the affected knee. Elevate the affected leg.

An 80 year old client amitted to the ED with facial briuses and broken right wrist. Upon further assessment the nurse notes multiple bruises in various stages of healing. What is the best course of action by the nurse?

Asking the client whether they are experiencing abuse

Emergency medical technicians transport a client to the ED and inform the nurse that the client fell from a 2-story building. The comatose client has a large contusion on the left side of the chest, a hematoma in the left parietal area and a compound fracture of the left femur. The client was intubated and is maintaining an arterial oxygen saturation of 92% by pulse ox with a manual resuscitation bag. Which intervention by the nurse has the highest priority?

Assessing the left leg.

Administering an antibiotic medication to a client after the client has refused it is an example of which of the following?

Battery

A home care nurse assesses for disease complications in a client with bone cancer. Which laboratory value may indicate the presence of a disease complication?

Calcium level of 12.6 mg/dl

A client tells the nurse that he has a pain and numbness to his thumb, first finger and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic and the pain is increased while working. This may indicate that the client could possibly have what health problems?

Carpel tunnel syndrome

Whicgh of the following will the nurse identify as indicating that a client is experiencing airway obstruction?

Clutching of the neck Inability to speak Cyanosis Stridor

Which assessment finding will the nurse expect to find in the postoperative client with fat embolism syndrome?

Column B HR 116 RR 32 pH 7.50 Co2 30 HCO2 24 PaO2 55

A client is admitted to the orthopedic unit with a fracture femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications will the nurse monitor this client?

Compartment syndrome deep vein thrombosis fat embolism

A client presents to the ED following a motor vehicle collision. The client is suspected of having internal hemorrhage. The nurse assess the client for signs and symptoms of shock. Which are the signs and symptoms of shock?

Cool moist skin delayed capillary refill decreasing blood pressure increasing heart rate

The nurse recognizes what groups of people are at an increased risk for infection?

Debilitated clients Clients with impaired skin Older adults Malnourished clients.

You are working in an acute care setting and you volunteer to partcipate in a research study. You understand that research findings add to the scientific base of the nursing practice. Evidence based practice accomplishes which results?

Decrease health care costs thru standards of care. Establish best nursing practives Improve patient outcomes

You are teaching a group of newly hired nurses about the requirements for disaster planning. Which of the following statements by one of the newly hired nurses indicated an understanding of the teaching.

Disaster drills should be held on a regular basis.

A nurse is preparing a presentation to a local community group on disaster prepardness involving radiation exposure. Which of following will the nurse include when describing the factors that affect exposure?

Distance from the source Time of exposure Amount of shielding

A nurse is working with a group of disaster victims to reduce the psychological effects of the trauma. Which of the following will be LEAST helpful?

Encouraging the victims to watch television replays of the event.

A client with a right below the knee amputation us being transferred from the postanasthesia care unit to med surg. What is the highest priority nursing intervention by the receiving nurse?

Ensure that a large tourniquet is in the room

Patient experieinces fever and dyspnea and several hours after receiving the pneumococcus vaccine one day earlier. What is the nurses most appropriate action?

Ensure that the adverse reaction is reported.

A nurse is taking a health history on a client with musculoskeletal dysfunction. What will the nurse prioritize during this phase of the assessment?

Evaluating the effects of the musculoskeletal disorder on the clients function.

The nurse is providing care for a client who has had a below the knee amputation. The nurse enters the clients room and finds the client resting in bed with his residual limb supported on a pillow. What si the nurses most appropriate action?

Explain the risks of flexion contracture to the client.

A client with a history of allegience comes to the emergency dept. The nurse suspects anaphylasis based on which of the following?

Facial angioedema tachycardia generalized itching hypotension chest tighteness

Diagnostic tests shoe that a clients bone density has decreased over the past several years. The client asks the nurse what factors contribute to bone density decreasing. What will be the nurses best response?

For many people, lack of nutrition can cause a loss of bone density.

A client admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisining. The nurse caring for this client assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms will this nurse assess?

Hypotension Delirium Tachycardia Dysrhythmias

The puplic health nurse has een talking to a group of community members about sexually transmitted infections. Which statements by one of the participants demonstrates an understanding of methods during sexual intercourse to decrease the risk of a sexually transmitted infection?

I will make sure to was my genital area before and after having sexual intercourse

A nurse us caring for a client who has has a total hip replacement. The nurse is reviewing a health education prior to discharge. Which of the clients statements will indicate to the nurse that the client requires further teaching?

I will need my husband to assist me in getting off the low toilet seat at home.

There has been a radiation based terrorist attack and a client is experiencing vomiting, diarrhea, and shock after the attack. How will the clients likelihood of survival be characterized?

Improbable.

The nurse is caring for a client diagnosed with a chlamydia infection. The nurse teachers the client about disease transmission and advises the client to inform sexual partners of the infection. The client refuses, stating, "This is my business and I'm not telling anyone. Beside, chlamydia doesnt cause any harm like other STI's. "How will the nurse proceed?

Inform the health dept that this client contracted a chamydia infection. Eduacte the client about why it is important to inform sexual contacts so they can receive treatment.

which intervention will the nurse implement with the client who has an external fixator?

Inspect pin sites for signs of infection perform neurovascular assessment perform pin care as ordered supervise the client during transfers

You are working in the emergeny dept and caring for a client who has a compression fracture of the spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the clients family. Which of the following actions will you anticipate the neurosuregon taking?

Invoking implied consent.

When assessing a cleint with infectious diarrhea, which of the following will lead the nurse to suspect that the client is experiencing dehydration?

Lethargy Increased thirst Rapid, thready pulse Dry oral muous membranes Sunken eyes

During a disaster, the nurse sees a victim with a green triage tag. The nurse knows that the person has which type of injury?

Minor treatment can by delayed hours to days.

A nurse provides health teaching to the family of an older adult client who has trouble walking independently. The nurse reviews age related changes to the musculoskeletal system with the family. Which of the following statements will the nurse include in the teaching?

Muscle fibrosis increases Muscle atrophy Collagen decreases Intervertebral discs becomes thin.

A nursing student asks the nurse why older adults are at risk for falls. The best response by the nurse is:

Muscles atrophy with aging.

You are caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid med PRN. You are concerned that administering a dose of pain med might hasten the clients death. Which of the following ethical principles will you use to support the decision not to administer the medication

Nonmalificence.

A client presents to the ED with fever, chills, restlessness and limited movement of a fracture jaw. What complication will the nurse interpret as the findings?

Osteomyelitis

Which assessment findings indicate to the nurse that a client may have peripheral neurovascular dysfunction?

Pain Capillary refill of 4-5 seconds absence of feeling cool skin weakness in motion

A client with a short arm cast is suspected to have compartment syndrome. What actions will the nurse include in the plan of care?

Prepare to remove the cast. Provide support to the injured extremity to maintain limb alignment.

When describing the Emergency Operations to group of nurses working as part of a disaster response team, which of the following will be identified as its primary goal?

Protection of the community

Cleint bleeding profusely from numerous deep laceration on top of his head, right side of his face and forehed. You need to appluy pressure on the apporpriate pressure point. Which of the following will the nurse use of the following pressure points

Proximal which is the pressure point on the right temple

The nurse us taking a class on chemical disasters with the local emergency response team. What toxins will the nurse be learning about?

Pulmonary agents Vesicant agents-blistering agents nerve agents blood agents-cyanide

The nurse is caring for clients in the emergency dept who have been admitted from the area surrounding a nuclear power plant. There had been a small explosion at the plant and a small amount of radiation has escaped. The nurse knows that this is what type of disaster?

Radiologic

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures the nurse will encourage what actions?

Regular bone density testing use of rails for prevention precautions high calcium diet weight bearing exercise

The nurse is conducting a musculoskeletal assessment on a client documented to have rheumatoid arthritis. Which will the nurse anticipate finding when inspecting the clients fingers?

Soft subcutaneous nodules along the tendons

A nurse is collaborating with a physical therapist to plan the care of a client with osteomyelitis. Which priority principle will guide the management of activity and mobility in this client?

Stress on the weakened bone must be avoided.

A nurse is caring for a client with a bone tumor. The nurse is providing education to help the client reduce the risk for pathologic fractures. What will the nurse teach the client?

Support the affected extremity with external supports such as splints.

The nurse suspects an older adult is experiencing heat stroke based on which assessment findings?

Tachycardia Hypotension Temperature 105 degrees Delirium Hot dry skin

A nurse is performing discharge teaching for an elderly client with osteoporosis. Which instruction about a calcium supplement will the nurse include?

Take the supplement with meals or orange juice.

You are caring for a client whose family member requests to view the clients medical record. Which of the following responses will you make?

The client must provide permission to share the records with you.

A rehabilitation nurse is working with a client who has had a below the knee amputation. In order to determine the clients ability to be an active participant in self care. the nurse will prioritize assessment of what variable?

The clients attitude.

A client is being prepared for a total hip arthroplasty and the nurse is providing relevant education. The nurse will explain what expectation for activity following hip replacement?

The physical therapist will likely help you get up using a walker the day after your surgery.

Identify the area on the figure where the nurse will assess for kyphosis?

Thoracic

A hospitals emergency operations plan has been enacted following as industrial accident. While one nurse performs the initial triage, what willl the other emergency medical services personnel do?

Transport clients Perform life saving measures

You are reviewing the informed consent for a client who is preoperative. Which of the following actions will you take?

Verify the client understands the surgical procedure. confirm that the consent is voluntary. validate the signiture is authentic

A nurse us providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse will encourage participants to ensure that they consume the recommended intake of what nutrients?

Vitamin D Calcium

The older client asks the nurse how best to maintain strong bones. What is the best response?

Weight bearing exercises can strengthen bones

The nurse is scheduled to administer tetanus diphtheria and pertussis (Tdap) vaccine to a client at the clinic. The client states " I had a reaction that last time I got an immunization." What action will the nurses first take?

Withhold the immunization.

Which interventions will a nurse implement as part of initial pain relief for the client with a cast?

administer analgesics elevate the involved part apply cold packs

Hypercalcemia is a dangerous complication of bone cancer. Therefore, nursing assessment includes evaluation of symptoms that require immediate treatment. Which of the following are signs/symptoms that are indicators of an elevated serum calcium?

altered mental status muscle weakness lack of muscle coordination anorexia and constipation

When teaching a client how to prevent low back pain as a result of lifting, the nurse will instruct the client to:

avoid overreaching

A nurse is caring for an older client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge?

client is able to perform transfers safely.

A client who had a total hip replacement was discharged home and developed acute groin pain in the affected leg, shortening of the leg, and limited movement of the fractured leg. The nurse interprets these findings as indicating which complication?

dislocation of the hip

A nurse is caring for a client who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse will teach the client to monitor closely for what postprocedural complication?

fever

A nurse who was working as part of an emergency response team for a mass casuality incident is engaging in a critical indicent stress management program. Key components of this program include the following:

field support debriefing defusing follow up education

To reduce the incidence of complications in a client in traction, which intervention should be included in the care plan?

increase fiber intake

The nurse is assessing a clients gait. What assessments indicate the client has a normal gait?

knee flexion smoothness

A client return to the nursing unit following an open reduction with internal fixation of the right hip. Which nursing interventions will be appropriate for the prophylactic treatment of deep vein thrombosis?

maintaining antiembolic stockings increasing fluid intake administering enoxaparin

A 75 year old client had surgery for a left hip fracture of the femur head yesterday. When completing the plan of care, the nurse will include assessment for which complications?

skin breakdown pneumonia sepsis delirium

An 82 year old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives aline and hasnt been eating or drinking properly. When assessing the client for dehydration, the nurse will expect to find:

tachycardia orthostatic hypotension