exam 4 prep U

The nurse is planning teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?

As soon as possible, and before the surgical procedure

An 80-year-old client is being admitted for dehydration and syncope. The client is found to be hypotensive, and intravenous fluids are ordered. What are some teaching strategies that the nurse should review with this client?

Before ambulation the client should rise slowly and take mini breaks between lying, sitting, and standing.

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule.

The nurse's musculoskeletal assessment of a client reveals involuntary twitching of muscle groups. How would the nurse document this observation in the client's chart?

Fasciculations

Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure?

Fasciotomy

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority.

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection

Which nursing diagnosis is the most appropriate for a client with a strained ankle?

Impaired physical mobility

A client has been diagnosed with liver disease. The nurse would expect which skin variation?

Jaundice

A nurse is caring for a client who recently underwent a total hip replacement. What is the best action by the nurse for client care?

Limit hip flexion of the client's hip when the client sits up.

A nurse is performing a baseline assessment of a client's skin integrity. What are the priority assessments? Select all that apply.

presence of pressure ulcers on the client overall risk of developing pressure ulcers potential areas of pressure ulcer development

Which findings would be indicative of a nursing diagnosis of decreased cardiac output?

tachycardia; hemoglobin 10.9 gm/dL; BP 88/56

The nurse teaches the client who demonstrates herpes zoster (shingles) that

the infection results from reactivation of the chickenpox virus.

A client who suffered a stroke is too weak to move on his own. To help the client maintain skin integrity, the nurse should:

turn him frequently.

A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate?

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

A nurse is explaining the importance of sunlight on the skin to a client with decreased mobility who rarely leaves the house. The nurse would emphasize that ultraviolet light helps to synthesize what vitamin?

D

The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply.

Dehiscence Hematoma

A nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Prevent internal rotation of the affected leg.

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 indictors of an elevated serum calcium? Select all that apply.

a. Muscle weakness c. Anorexia and constipation e. Shortened QT interval f. Lack of muscle coordination

Which term refers to a blunt force injury to soft tissue?

contusion

The nurse is preparing the client with a right neck mass for magnetic resonance imaging (MRI). Which question should the nurse ask? Select all that apply.

"Are you wearing any jewelry?" "Have you removed your hearing aid?" "Do you have a pacemaker?"

The nurse is caring for a client who had a surgical amputation of the left leg related to complication from diabetes. The client asks the nurse, "If my leg is really gone, then why am I having such bad pain?" What is the best response by the nurse?

"It is called phantom pain and may come and go."

The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is:

"Leg exercises help prevent blood clots in your legs."

The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first?

Assess for bleeding.

The nurse is assessing a client for dietary factors that may influence her risk for osteoporosis. The nurse should question the client about her intake of what nutrients? Select all that apply.

Calcium Vitamin D

Which assessment findings would the nurse expect to find in the client with osteomyelitis?

Column B

During the first 24 hours after surgery, how often will the nurse evaluate the client's temperature?

Every 4 hours

A nursing instructor is preparing a class on pressure ulcers. Which of the following would the instructor most likely include as a possible risk factor? Select all that apply.

Immobility Anemia Increased moisture

A nurse is planning preoperative teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience? Select all that apply.

Increased fatty tissue prolongs elimination of anesthesia. Decreased ability to compensate for hypoxia increases the risk of an embolism. Loss of collagen increases the risk of skin complications. Reduced tactile sensitivity can lead to assessment and communication problems.

A client returns to the nursing unit following an open reduction with internal fixation of the right hip. Which nursing interventions would be appropriate for the prophylactic treatment of deep vein thrombosis? Select all that apply.

Increasing fluid intake Maintaining antiembolic stockings Administering enoxaparin

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?

Offer the client a bedpan or urinal.

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?

Outline the drainage with a pen and record the date and time next to the drainage.

Red bone marrow produces which of the following? Select all that apply.

Platelets White blood cells (WBCs) Red blood cells (RBCs)

A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care, the nurse should include assessment for which complications? Select all that apply.

Pneumonia Skin breakdown Sepsis Delirium

The emergency department nurse teaches clients with sports injuries to remember the acronym PRICE. This acronym stands for which combination of treatments?

Protection, rest, ice, compression, elevation

The nurse is assessing the skin of an older adult. Which finding will the nurse identify as an expected age-related change? Select all that apply.

Sagging Wrinkles Lentigines Overlapping skin folds

The nurse is caring for a client who developed a pressure injury as a result of decreased mobility. The nurse on the previous shift has provided client teaching about pressure injuries and healing promotion. The nurse determines that the client has understood the teaching by observing the client:

avoid placing body weight on the healing site.

What areas of the body may be examined when bone densitometry is done? Select all that apply.

hip spine wrist

Which is not a category of medications used for treatment of the skin?

inhaled steroids

A client undergoes an open reduction of a femur fracture, and returns to the orthopedic unit with a cast in place. What is the rationale for frequently assessing the client's pedal pulses?

maintaining adequate circulation

The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements? Select all that apply.

"I took my Coumadin as usual last evening." "I took two aspirins for joint pain this morning."

Upon reporting to work and receiving report, a nurse has been assigned to provide care for three clients. Each of the clients has called out to the nurses' station requesting assistance. Which client should the nurse see first?

A 32-year-old male, who had a plaster cast applied to his leg 2 hours ago, who complains that the cast feels as if it's getting tighter

A nurse is providing care to a patient who is receiving chemotherapy. The nurse notes that the patient has lost most of the hair on her head. The nurse documents this finding as which of the following?

Alopecia

A client is having repeated tears of the joint capsule in the shoulder, and the health care provider orders an arthrogram. What intervention should the nurse provide after the procedure is completed? Select all that apply.

Apply a compression bandage to the area. Administer a mild analgesic. Inform the client that a clicking or crackling noise in the joint may persist for a couple of days.

The nurse is taking care of a client with lower motor neuron destruction. How would the nurse document on the electronic health record the muscle tone in the client's lower legs?

Atonic

A client recovering from surgery asks, "When can I go home?" The nurse responds by stating which of the following activities must be completed before discharging home? Select all that apply.

Be independent with toileting Ambulate a functional distance Get in and out of bed unassisted

The nurse is assessing a client who was a victim of a house fire. Which finding indicates to the nurse that the client may have carbon monoxide poisoning?

Cherry red lips

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply.

Deep vein thrombosis Compartment syndrome Fat embolism

Which of the following activities are nursing activities in the preoperative phase of care? Select all that apply.

Discussing and reviewing the advanced directive document Establishing an intravenous line Beginning discharge planning

A nurse is inspecting the area of contusion and notes numerous areas of bruising. How would the nurse document this finding?

Ecchymosis

The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.

Evaluate the client's level of pain, using a numeric value pain scale. Ask the client whether the wound bed or surrounding skin itches. Palpate the client's skin for moisture, temperature, and texture. Measure and assess the client's wound bed, size, edges, and margins.

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and body mass index increase the risk for what complication in the postoperative period?

Infection

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 would the nurse include in the teaching? Select all that apply.

Intervertebral discs become thin. Muscles atrophy. Muscle fibrosis increases. Collagen increases

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity

Which statements describe open reduction of a fracture? Select all that apply.

It is performed in the operating room. The bone is surgically exposed and realigned. The client usually receives general or spinal anesthetic.

A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan?

Maintaining correct body alignment

The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways the nurse might help alleviate the client's anxiety? Select all that apply.

Make sure the client understands what will happen during surgery. Listen empathetically to the client's concerns about the procedure. Review the client's postoperative goals following the procedure. Ask the client if he would like to speak with a clergyperson.

A client is suspected of developing an allergy to an environmental substance and has been given a patch test. During the test, the client develops fine blisters, papules, and severe itching. The nurse knows that this is indicative of what strength reaction?

Moderately positive

The PACU nurse is caring for a client who had minimally invasive knee surgery. Which actions are the responsibility of the nurse in the PACU? Select all that apply.

Monitoring the safe recovery from anesthesia Answering family questions about recovery Providing light nourishment Assessing the operative site for hemorrhage

The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse?

Notify the primary care provider immediately.

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

Red, swollen skin with inflammation spreading to surrounding tissues

The nurse is assessing a patient at risk for the development of a pressure ulcer. What laboratory test will assist the nurse in determining this risk?

Serum albumin

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply.

Stable blood pressure Sufficient oxygen saturation Adequate respiratory function

A client is admitted to the ED reporting severe abdominal pain and vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that they need surgery. When can the client most likely anticipate that the surgery will be scheduled?

Without delay

A client has a fractured femur and is being seen in the emergency department. The nurse assessing the area notices there is a grating sound that is suspected to be bone ends moving over one another. This would be called:

crepitus.

The nurse is planning an education program for women of childbearing years. What does the nurse recognize as the primary prevention of osteoporosis?

Ensuring adequate calcium and vitamin D intake

Which of the following are the major hormonal regulators of calcium homeostasis? Select all that apply.

Parathormone Calcitonin

A client seeks medical attention for a new skin condition. Which finding indicates to the nurse that the client is experiencing contact dermatitis? Select all that apply.

Pruritus Burning Papules Vesicles

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

Absence of feeling Capillary refill of 4 to 5 seconds Cool skin Pain Weakness in motion

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

When assessing a patient's skin, the nurse would use palpation to assess which of the following?

Turgor

A client recovering from surgery develops a cough. Which additional finding(s) would the nurse assess to determine if the client is developing atelectasis? Select all that apply.

crackles decreased breath sounds

Each bone is composed of cells, protein matrix, and mineral deposits. Which type of bone cell works to repair a bone fracture?

osteocytes

A client in the postanesthesia care unit (PACU) develops a blood pressure of 180/90 mm Hg. Which assessment will the nurse complete to determine the cause of the blood pressure findings? Select all that apply.

pain hypoxia bladder distention

The nurse is caring for a client with cellulitis of the left foot. Which treatment will the nurse expect to be prescribed for this client? Select all that apply.

Administer cephalexin Elevate the extremity Apply cool packs every 2 to 4 hours Apply graduated compression stocking to the foot

A client has undergone a leg amputation. What teachings should the nurse offer such a client to prevent abduction deformity? Select all that apply.

Advise the client to use a trochanter roll. Advise the client to adduct the stump so it presses against the other leg when the client is lying on the stomach.

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply.

Chills Crackles Tachypnea

Pressure ulcers are caused by:

Extrinsic factors

A client is scheduled for a bone scan. A bone scan may be ordered to detect metastatic bone lesions, fractures, and certain types of inflammatory disorders. Which nursing considerations are correct in preparing a client for a bone scan? Select all that apply.

Inform the client that the radiopaque isotope will be administered intravenously. Ensure that the client does not have any allergies to the isotope. Encourage the client to drink fluids to help distribute and eliminate the isotope.

Inspection of the skin is an important part of nursing assessment. Interpretation of abnormalities is based on an understanding of structure and function. The nurse is aware that the epidermis, especially the stratum cornea, has many vital functions. What are some of these functions? Select all that apply.

Provides an effective barrier to water loss Contains lipids that resist penetration by microbes Produces keratin, the hardening ingredient of the nails

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing?

The client

A nurse is working in the postanesthesia unit (PACU). What evidence indicates that a client is ready for discharge from the PACU? Select all that apply.

The client is arousable, but falls back to sleep rapidly. The client has a blood pressure within 10 mm Hg of the baseline.

In anticipation of a client's scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client?

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

A nurse is performing discharge teaching for an elderly client diagnosed with osteoporosis. Which statement about home safety should the nurse include?

"Most falls among the elderly occur in the home. These clients should remove throw rugs and install bathroom grab bars."

A client has been involved in a motor vehicle collision. Radiographs indicate a fractured humerus; the client is awaiting the casting of the upper extremity and admission to the orthopedic unit. Other than the bone, what physical structures could be affected by this injury?

All options are correct.

The nurse in the postanesthesia care unit (PACU) is preparing to receive a client from the operating room. The nurse knows that which information would need to be communicated?

Allergies Surgical procedure Estimated blood loss Medical comorbidities Anesthetic agents used

The nurse is preparing a client for surgery. The client reports being nervous and not really understanding the surgical procedure or its purpose. What is the most appropriate action for the nurse to take?

Call the health care provider to review the procedure with the client.

Which intervention would the nurse implement with the client in skeletal traction? Select all that apply.

Ensure the pins or wires are covered with caps. Position trapeze within the client's reach. Instruct the client on isometric exercises for immobilized extremity.

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

Have the client lay on the back with the head elevated

A nurse is caring for a client who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the client faces a high risk of what infectious complication?

Osteomyelitis

The nurse is performing an assessment for a patient who may have peripheral neurovascular dysfunction. What signs does the patient present with that indicate circulation is impaired? (Select all that apply.)

Pale, cyanotic, or mottled color Cool temperature of the extremity More than 3-second capillary refill

A nurse is preparing to perform the physical assessment of a newly admitted client. During which of the following components of the assessment should the nurse wear gloves? Select all that apply.

Palpation of a rash on the client's trunk Palpation of a lesion on the client's upper back

The nurse notes that a client who uses a wheelchair for long periods after recovering from an amputation has a reddened area over the coccyx. Which teaching will the nurse provide to the client to relieve the pressure? Select all that apply.

Perform push-ups. Move from side to side. Shift weight in the chair. Complete half push-ups.

A client is admitted with cellulitis and experiences a consequent increase in white blood cell count. During what process will pathogens be engulfed by white blood cells that ingest foreign particles?

Phagocytosis

The nurse is providing preoperative teaching to a client scheduled for surgery. Place in order the instructions the nurse will provide the client to perform diaphragmatic breathing. Use all options.

Place bed in at 30- to 45-degree angle. Place the hands on the front of the lower ribs. Breathe out gently and fully to feel the ribs sink downward. Take a deep breath through the nose and mouth to make the abdomen rise. Hold the breath for a count of five. Exhale and let all the air out through the nose and mouth. Repeat the exercise 15 times with a rest after each group of five. Practice this breathing twice a day before the surgery.

The nurse is caring for an older adult client in the postanesthesia care unit. The client begins to awaken and responds to their name, but is confused, restless, and agitated. Which principle should guide the nurse's subsequent assessment?

Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

Reorient the client. Assess for hypoxia. Assess urine output.

A nurse is developing a plan of care for an 85-year-old woman who is bedridden following a stroke. Which of the following would the nurse be least likely to include in the plan of care for this patient to reduce her risk for pressure ulcers?

Repositioning the patient about once a shift

The nurse is admitting a client to the medical-surgical unit after a diagnosis of cellulitis of the calf. What factor(s) does the nurse know impact the processes of inflammation, repair, and replacement? Select all that apply.

Severity of the injury Condition of the host Nature of the injury

The nurse is doing preoperative client education with a client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client?

Stop smoking as soon as possible before the scheduled surgery to enhance pulmonary function and decrease infection.

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs you that the client has a reddened, macerated area at the base of the sacrum. What would the nurse suspect is going on with the client?

They have the beginning of a pressure sore.

Which of the following are associated with compartment syndrome? Select all that apply.

Trauma from accidents Surgery Casts Tight bandages Crushing injuries

A client recovering from surgery is at risk for respiratory complications. The nurse knows which action(s) could improve a client's respiratory status? Select all that apply.

Turn and reposition the client. Instruct the client to yawn frequently. Coach the client to take deep breaths and cough. Remind the client to use the incentive spirometer every 2 hours.

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities?

Ulceration

The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action?

Walk or perform weight-bearing exercises