Final Exam questions
A client is alarmed that she has tested positive for MRSA following culture testing during her admission to the hospital. What should the nurse teach the client about this diagnostic finding? A) "There are promising treatments for MRSA, so this is no cause for serious concern." B) "This doesn't mean that you have an infection; it shows that the bacteria live on one of your skin surfaces." C) "The vast majority of clients in the hospital test positive for MRSA, but the infection doesn't normally cause serious symptoms." D) "This finding is only preliminary, and your doctor will likely order further testing."
B
A client is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The client is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A) "Actually, clients are only on bed rest for 2 to 3 days before they begin walking with assistance." B) "The physical therapist will likely help you get up using a walker the day after your surgery." C) "Our goal will actually be to have you walking normally within 5 days of your surgery." D) "For the first 2 weeks after the surgery, you can use a wheelchair to meet your mobility needs."
B
A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care? A) "Cover the cast with a blanket until the cast dries." B) "Keep your right leg elevated above heart level." C) "Use a clean object to scratch itches inside the cast." D) "A foul smell from the cast is normal after the first few days."
B
A client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, the client reports a new onset of pain at the surgical site. What is the nurse's best action? A) Administer pain medication as prescribed B) Assess the surgical site and the affected extremity C) Reassure the client that pain is a direct result of increased activity D) Assess the client for signs and symptoms of systemic infection
B
A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? A) Perform mechanical debridement to remove the exudate and prevent further infection. B) Inform the primary provider promptly because the graft may need to be removed. C) Perform ROM exercises to increase perfusion to the graft site & facilitate healing. D) Document this finding as an expected phase of graft healing.
B
A group of military nurses are reviewing the care of victims of biochemical terrorist attacks. The nurses should identify what agents as having the shortest latency? A) Viral agents B) Nerve agents C) Pulmonary agents D) Blood agents
B
A home care nurse is performing a visit to a client's home to perform wound care following the client's 5-week hospitalization for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? A) Psychosis B) Post-traumatic stress disorder C) Delirium D) Vascular dementia
B
A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture? A) Compression B) Compound C) Impacted D) Transverse
B
A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A) Perform chest physiotherapy once per shift and as needed B) Teach the client to perform deep breathing and coughing exercises C) Administer prophylactic antibiotics as prescribed D) Administer nebulized bronchodilators and corticosteroids as prescribed
B
A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care? A) Preventing skin breakdown B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure
B
A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A) Client is able to perform ADLs independently. B) Client is able to perform transfers safely. C) Client is able to weight-bear equally on both legs. D) Client is able to demonstrate full ROM of the affected hip.
B
A nurse is reviewing a client's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation? A) Straining during a bowel movement B) Bending down to put on socks C) Lifting items above shoulder level D) Transferring from a sitting to standing position
B
A nurse is triaging clients after a chemical leak at a nearby fertilizer factory. The guiding principle of this activity is what? A) Assigning a high priority to the most critical injuries B) Doing the greatest good for the greatest number of people C) Allocating resources to the youngest and most critical D) Allocating resources on a first come, first served basis
B
A nurse is undergoing debriefing with the critical incident stress management (CISM) team after participating in the response to a disaster. During this process, the nurse will do which of the following? A) Evaluate the care that he or she provided during the disaster. B) Discuss own emotional responses to the disaster. C) Explore the ethics of the care provided during the disaster. D) Provide suggestions for improving the emergency operations plan.
B
A nurse who is a member of the local disaster response team is learning about blast injuries. The nurse should plan for what event that occurs in the tertiary phase of the blast injury? A) Victims' pre-existing medical conditions are exacerbated. B) Victims are thrown by the pressure wave. C) Victims experience burns from the blast. D) Victims suffer injuries caused by debris or shrapnel from the blast.
B
A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A) "He's on a calorie-restricted diet in order to divert energy to wound healing." B) "His body has consumed his fat deposits for fuel because his calorie intake is lower than normal." C) "He actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat." D) "He lost many fluids while he was being treated in the emergency phase of burn care."
B
A physician writes a prescription to discontinue skeletal traction on an orthopedic client. The nurse should anticipate what subsequent intervention? A) Application of a walking boot B) Application of a cast C) Education on how to use crutches D) Passive range of motion exercises
B
A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions? A) Wearing a mask and gown when starting an IV line B) Washing hands immediately after removing gloves C) Recapping all needles promptly after use to prevent needle-stick injuries D) Double-gloving when working with a client who has a blood-borne illness
B
An elite high school football player has been diagnosed with a shoulder dislocation. The client has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education? A) The need to take analgesia regardless of the short-term absence of pain B) The importance of adhering to the prescribed treatment and rehabilitation regimen C) The fact that he has a permanently increased risk of future shoulder dislocations D) The importance of monitoring for intracapsular bleeding once he resumes playing
B
An industrial site has experienced a radiation leak and workers who have been potentially affected are In route to the hospital. To minimize the risks of contaminating the hospital, managers should perform what action? A) Place all potential victims on reverse isolation. B) Establish a triage outside the hospital. C) Have hospital staff put on PPE. D) Place hospital staff on abbreviated shifts of no more than 4 hours.
B
The nurse is coordinating the care of victims who arrive at the ED after a radiation leak at a nearby nuclear plant. What would be the first intervention initiated when victims arrive at the hospital? A) Administer prophylactic antibiotics. B) Survey the victims using a radiation survey meter. C) Irrigate victims' open wounds. D) Perform soap and water decontamination.
B
The nurse is part of the health care team at an oncology center. A client has been diagnosed with advance metastatic cancer the prognosis is poor, but the client is not yet aware of the prognosis. How can the bad news best be conveyed to the client? A) Family should be given the prognosis first. B) The prognosis should be delivered with the client at eye level. C) The physician should deliver the news to the client alone. D) The appointment should be scheduled at the end of the day.
B
The nurse is preparing the client for mechanical debridement and informs the client that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from viable tissue B) Removal of eschar until the point of bleeding occurs C) Shaving of burned skin layers until bleeding occurs D) Early closure of the wound
B
What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis? A) To decrease nurses' susceptibility to healthcare-associated infections B) To decrease risk of transmission to vulnerable clients C) To eventually eradicate the influenza virus in the United States D) To prevent the emergence of drug-resistant strains of the influenza virus
B
What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? A) Administer analgesics as required B) Place a pillow between the client's legs when turning C) Maintain prone positioning at all times D) Encourage internal and external rotation of the affected leg
B
While assessing a client who has had knee replacement surgery, the nurse notes that the client has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this client? A) Risk for Infection B) Risk for Ineffective Peripheral Tissue Perfusion C) Unilateral Neglect Related to Hematoma D) Disturbed Kinesthetic Sensory Perception
B
A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the front of the left arm. What extent of burns does the client most likely have, measured as a percentage?
9%
A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response? A) "That's something that you and your doctor will likely talk about after your scars mature." B) "That is something for you to talk to your doctor about because it's not a nursing responsibility." C) "I know this is really important to you, but you have to realize that no one can make you look like you used to." D) "Unfortunately, it's likely that these scars will look like this for the rest of your life."
A
A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping
A
A client has returned to the post-surgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial post-surgical assessment were unremarkable but the client has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action? A) Apply a tourniquet B) Elevate the residual limb C) Apply sterile gauze D) Call the surgeon
A
A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit B) Hypokalemia, hypernatremia, decreased hematocrit C) Hyperkalemia, hypernatremia, decreased hematocrit D) Hypokalemia, hyponatremia, elevated hematocrit
A
A client is admitted to the burn unit after being transported from a facility a large distance away. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism
A
A client is being treated in the ED following a terrorist attack. The client is experiencing visual disturbances, nausea, vomiting, and behavioral changes. The nurse suspects this client has been exposed to what chemical agent? A) Nerve agent B) Pulmonary agent C) Vesicant D) Blood agent
A
A client is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Gastrointestinal hyper-motility C) Respiratory arrest D) Hypokalemia
A
A client is in a hospice receiving palliative care for lung cancer which has metastasized to the client's liver and bones. For the past several hours, the client has been experiencing dyspnea. What nursing action is most appropriate? A) Deliver a bolus of normal saline, as prescribed. B) Initiate high-flow oxygen therapy. C) Administer high doses of opioids. D) Administer bronchodilators and corticosteroids, as prescribed.
A
A client is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this client. What sequela of intra-articular fractures should the nurse describe regarding this client? A) Post-traumatic arthritis B) Fat embolism syndrome (FES) C) Osteomyelitis D) Compartment syndrome
A
A client on airborne precautions asks the nurse to leave his door open. What is the nurse's best reply? A) "I have to keep your door shut at all times. I'll open the curtains so that you don't feel so closed in." B) "I'll keep the door open for you, but please try to avoid moving around the room too much." C) "I can open your door if you wear this mask." D) "I can open your door, but I'll have to come back and close it in a few minutes."
A
A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? A) A patient-controlled analgesia (PCA) system B) Oral opioids supplemented by NSAIDs C) Distraction and relaxation techniques supplemented by NSAIDs D) A combination of benzodiazepines and topical anesthetics
A
A hospital's emergency operations plan has been enacted following an industrial accident. While one nurse performs the initial triage, what should other emergency medical services personnel do? A) Perform life-saving measures. B) Classify clients according to acuity. C) Provide health promotion education. D) Modify the emergency operations plan.
A
A major earthquake has occurred within the vicinity of the local hospital. The nursing supervisor working the night shift at the hospital receives information that the hospital disaster plan will be activated. The supervisor will need to work with what organization responsible for coordinating interagency relief assistance? A) Office of Emergency Management B) Local police and fire departments C) Centers for Disease Control and Prevention (CDC) D) American Red Cross
A
A man survived a workplace accident that claimed the lives of many of his colleagues several months ago. The man has recently sought care for the treatment of depression. How should the nurse best understand the man's current mental health problem? A) The man is experiencing a common response following a disaster. B) The man fails to appreciate the fact that he survived the disaster. C) The man most likely feels guilty about his actions during the disaster. D) The man's depression most likely predated the disaster.
A
A medical nurse is careful to adhere to infection control protocols, including hand washing. Which statement about hand washing supports the nurse's practice? A) Frequent hand washing reduces transmission of pathogens from one client to another. B) Wearing gloves is known to be an adequate substitute for hand washing. C) Bar soap is preferable to liquid soap. D) Waterless products should be avoided in situations where running water is unavailable.
A
A medical nurse is providing palliative care to a client with a diagnosis of end-stage chronic obstructive pulmonary disease (COPD). What is the primary goal of this nurse's care? A) To improve the client's and family's quality of life B) To support aggressive & innovative treatments for cure C) To provide financial support for the client and their family D) To help the client develop a separate plan with each health care team discipline
A
A nurse has been called for duty during a response to a natural disaster. In this context of care, the nurse should expect to do which of the following? A) Practice outside of her normal area of clinical expertise. B) Perform interventions that are not based on assessment data. C) Prioritize psychosocial needs over physiologic needs. D) Prioritize the interests of older adults over younger clients.
A
A nurse has reported for a shift at the burn unit in a large university hospital. Which client is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female client burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire
A
A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A) Sodium deficit (hyponatremia) B) Decreased prothrombin time (PT) C) Potassium deficit (hypokalemia) D) Decreased hematocrit
A
A nurse is caring for a client who is postoperative day 1 right hip replacement. How should the nurse position the client? A) Keep the client's hips in abduction at all times B) Keep hips flexed at no less than 90 degrees C) Elevate the head of the bed to high Fowler's D) Seat the client in a low chair as soon as possible
A
A nurse is participating in the planning of a hospital's emergency operations plan. The nurse is aware of the potential for ethical dilemmas during a disaster or other emergency. Ethical dilemmas in these contexts are best addressed by which of the following actions? A) Having an ethical framework in place prior to an emergency B) Allowing staff to provide care anonymously during an emergency C) Assuring staff that they are not legally accountable for care provided during an emergency D) Teaching staff that principles of ethics do not apply in an emergency situation
A
A nurse is planning the care of a client who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions? A) Improving the client's level of function B) Helping the client come to terms with limitations C) Administering medications safely D) Improving the client's adherence to treatment
A
A nurse is planning the care of a client who will require a prolonged course of skeletal traction. When planning this client's care, the nurse should prioritize interventions related to what risk nursing diagnosis? A) Risk for Impaired Skin Integrity B) Risk for Falls C) Risk for Imbalanced Fluid Volume D) Risk for Aspiration
A
A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? A) Risk for Infection B) Risk for Ineffective Role Performance C) Risk for Perioperative Positioning Injury D) Risk for Powerlessness
A
A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A) Client is likely experiencing a delayed onset of respiratory complications B) The client has likely developed a systemic infection C) The client's respiratory complications are likely related to psychosocial stress D) The client is likely experiencing an anaphylactic reaction to a medication
A
A nurse who provides care in a busy ED is in contact with hundreds of clients each year. The nurse has a responsibility to receive what vaccine? A) SARS-CoV-2 vaccine B) Human Papillomavirus (HPV) vaccine C) Clostridium difficile vaccine D) Staphylococcus aureus vaccine
A
A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A) Education about home safety B) Education about safe storage of chemicals C) Education about workplace health threats D) Education about safe driving
A
An adult client in the ICU has a central venous catheter in place. Over the past 24 hours, the client has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the client's care may have increased susceptibility to CLABSI? A) The client's central line was placed in the femoral vein. B) The client had blood cultures drawn from the central line. C) The client was treated for vancomycin-resistant enterococcus (VRE) during a previous admission. D) The client has received antibiotics and IV fluids through the same line.
A
An adult oncology client has a diagnosis of bladder cancer with metastasis and the client has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting? A) The client and family should be viewed as a single unit of care. B) Persistent symptoms of terminal illness should not be treated. C) Each interdisciplinary team member should develop an individual plan of care. D) Terminally ill clients should die in the hospital whenever possible.
A
An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells
A
During a health education session, a participant asks the nurse how a vaccine can protect from future exposures to diseases against which she is vaccinated. What would be the nurse's best response? A) The vaccine causes an antibody response in the body. B) The vaccine responds to an infection in the body after it occurs. C) The vaccine is similar to an antibiotic that is used to treat an infection. D) The vaccine actively attacks the microorganism.
A
Emergency department (ED) staff members have been trained to follow steps that will decrease the risk of secondary exposure to a chemical. When conducting decontamination, staff members should remove the client's clothing and then perform what action? A) Rinse the client with water. B) Wash the client with a dilute bleach solution. C) Wash the client Chlorhexidine. D) Rinse the client with hydrogen peroxide.
A
Family members are caring for a client with HIV in the client's home. What should the nurse encourage family members to do to reduce the risk of infection transmission? A) Use caution when shaving the client. B) Use separate dishes for the client and family members. C) Use separate bed linens for the client. D) Disinfect the client's bedclothes regularly.
A
The ED staff has been notified of the imminent arrival of a client who has been exposed to chlorine. The nurse should anticipate the need to address what nursing diagnosis/problem? A) Impaired gas exchange B) Decreased cardiac output C) Chronic pain D) Excess fluid volume
A
The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? A) Knots in the rope should not be resting against pulleys. B) Weights should rest against the bed rails. C) The end of the limb in traction should be braced by the footboard of the bed. D) Skeletal traction may be removed for brief periods to facilitate the client's independence.
A
The nurse is helping to set up Buck's traction on an orthopedic client. How often should the nurse assess circulation to the affected leg? A) Within 30 minutes, then every 1 to 2 hours B) Within 30 minutes, then every 4 hours C) Within 30 minutes, then every 8 hours D) Within 30 minutes, then every shift
A
The nurse places a client in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection? A) Mode of transmission B) Agent C) Susceptible host D) Portal of entry
A
The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A) Increased warmth of the calf B) Decreased circumference of the calf C) Loss of sensation to the calf D) Pale-appearing calf
A
A client's rapid cancer metastases have prompted a shift from active treatment to palliative care. When planning this client's care, the nurse should identify what primary aim? A) To prioritize emotional needs B) To prevent and relieve suffering C) To bridge between curative care and hospice care D) To provide care while there is still hope
A or B unsure
A 91-year-old client is slated for orthopedic surgery and the nurse has integrated gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A) Administration of prophylactic antibiotics B) Total parenteral nutrition (TPN) C) Use of a pressure-relieving mattress D) Use of a Foley catheter until discharge
C
A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding? A) Obtain an order to reduce the rate of the client's IV fluid infusion B) Report the client's early signs of acute kidney injury (AKI) C) Recognize that the client is experiencing an expected onset of diuresis D) Administer sodium chloride as prescribed to compensate for this fluid loss
C
A client has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? A) Inadequate vitamin D intake B) Bleeding at the injury site C) Inadequate immobilization D) Venous thromboembolism . .. (VTE)
C
A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the client to keep the wound site in a dependent position B) Administer PRN analgesia as prescribed C) Assess the client's peripheral pulses distal to the dressing D) Assist with passive range-of-motion exercises to "set" the new dressing
C
A client is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur? A) Russell traction B) Dunlop traction C) Buck's extension traction D) Cervical halter
C
A client is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the client's need for exercise? A) Performing gentle leg lifts with both legs B) Performing massage to stimulate circulation C) Encouraging frequent use of the over-bed trapeze D) Encouraging the client to logroll side to side once per hour
C
A client is reporting pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the client states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome
C
A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Hypotension D) Sudden agitation
C
A group of disaster survivors is working with the critical incident stress management (CISM) team. Members of this team should be guided by what goal? A) Determining whether the incident was managed effectively B) Educating survivors on potential coping strategies for future disasters C) Providing individuals with education about recognizing stress reactions D) Determining if individuals responded appropriately during the incident
C
A nurse has had contact with a client who developed smallpox and became febrile after a terrorist attack. This nurse will require what treatment? A) Watchful waiting B) Treatment with colony-stimulating factors (CSFs) C) Vaccination D) Treatment with ceftriaxone
C
A nurse is caring for a client in skin traction. In order to prevent bony fragments from moving against one another, the nurse should caution the client against performing what action? A) Shifting one's weight in bed B) Bearing down while having a bowel movement C) Turning from side to side D) Coughing without splinting
C
A nurse is caring for a client who has a leg cast. The nurse observes that the client uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A) Allow the client to continue to scratch inside the cast with a pencil but encourage him to be cautious B) Give the client a sterile tongue depressor to use for scratching instead of the pencil C) Encourage the client to avoid scratching, and obtain a prescription for an antihistamine if severe itching persists D) Obtain a prescription for a sedative, such as lorazepam , to prevent the client from scratching
C
A nurse is caring for a client who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the client does what action to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable B) Use supplementary oxygen when transferring or mobilizing C) Increase fluid intake and perform prescribed foot exercises D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon
C
A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent joint ossification
C
A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome
C
A nurse is preparing to administer a client's scheduled dose of subcutaneous heparin. To reduce the risk of needle-stick injury, the nurse should perform what action? A) Recap the needle before leaving the bedside. B) Recap the needle immediately before leaving the room. C) Avoid recapping the needle before disposing of it. D) Wear gloves when administering the injection.
C
A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse should focus on which of the following groups? A) Preschool-aged children B) Adults with diabetes and/or kidney disease C) Older adults with compromised health status D) Infants under the age of 12 months
C
A young client is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the client is uncharacteristically confused. What diagnostic test should be performed on this client? A) Electrolyte assessment B) Electrocardiogram C) Arterial blood gases D) Abdominal ultrasound
C
An elderly client's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? A) The presence of leg shortening B) The client's complaints of pain C) Signs of neurovascular compromise D) The presence of internal or external rotation
C
The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation
C
The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a client receiving skeletal traction. What nursing intervention best addresses this risk? A) Encourage independence with ADLs whenever possible B) Monitor the client's nutritional status closely. C) Teach the client to perform ankle and foot exercises within the limitations of traction D) Administer clopidogrel as prescribed
C
The nurse is caring for a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting? A) Using antibacterial soap when bathing clients with MRSA B) Conducting culture surveys on a regularly scheduled basis C) Performing hand hygiene before and after contact with every client D) Using aseptic housekeeping practices for environmental cleaning
C
The nurse is caring for a client who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction B) Have the client reposition himself independently C) Protect the affected leg from internal rotation D) Keep the hip flexed by placing pillows under the client's knee
C
The organization of a client's care while receiving palliative care is based on interdisciplinary/interprofessional collaboration. How does interdisciplinary/ interprofessional collaboration differ from multidisciplinary practice? A) It is based on the participation of clinicians without a team leader. B) It is based on clinicians of various backgrounds integrating separate plans of care. C) It is based on communication, cooperation and collaboration between disciplines. D) It is based on medical expertise and client preference with the support of nursing.
C
There has been a radiation-based terrorist attack and a client is experiencing vomiting, diarrhea, and shock after the attack. How will the client's likelihood of survival be characterized? A) Probable B) Possible C) Improbable D) Extended
C
While developing an emergency operations plan (EOP), the committee is discussing the components of the EOP. During the post-incident response of an emergency operations plan, what activity should take place? A) Deciding when the facility will go from disaster response to daily activities B) Conducting practice drills for the community and facility C) Conducting a critique and debriefing for all involved in the incident D) Replacing the resources in the facility
C
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
C, D, E
A nurse is emptying an orthopedic surgery client's closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse's best action? A) Aspirate a small amount of drainage for culturing B) Advance the drain 1 to 1.5 cm C) Irrigate the drain with normal saline D) Inform the surgeon of this finding
D
A nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, which of the following would be most important as part of the recovery phase? A) Assess for signs of electrolyte imbalances B) Administer IV fluids as prescribed C) Develop a teaching plan for home safety D) Assess the client's psychosocial state
D
A nurse is providing discharge education to a client who is going home with a cast on his leg. What topic should the nurse emphasize in the teaching session? A) Using crutches efficiently B) Exercising joints above and below the cast, as prescribed C) Removing the cast correctly at the end of the treatment period D) Reporting signs of impaired circulation
D
A nurse who works in the specialty of palliative care frequently encounters issues and situations that constitute ethical dilemmas. What issue has most often presented challenging ethical issues, especially in the context of palliative care? A) Increased cultural diversity B) Staffing shortages in health care and questions concerning quality of care C) Increased costs of health care coupled with inequalities in access D) Ability of technology to prolong life beyond meaningful quality of life
D
A workplace explosion has injured 21 workers. A 40-year-old man has full thickness burns over 80% of his body. The man is unconscious but breathing. How would this person be triaged? A) Green B) Yellow C) Red D) Black
D
An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? A) The length of time since the burn B) The location of burned skin surfaces C) The source of the burn D) The total body surface area (TBSA) affected by the burn
D
An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? A) Apply ice burn site for 5 to 10 minutes. B) Wrap the client's affected extremity in ice until help arrives. C) Apply an oil-based substance to the burned area until help arrives. D) Wrap cool towels around the affected extremity intermittently.
D
Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? A) Impacted B) Compound C) Compression D) Greenstick
D
The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? A) Apply skin emollients as prescribed after granulation has occurred B) Keep injured areas immobilized whenever possible to promote healing C) Administer oral or IV corticosteroids as prescribed D) Encourage physical activity and range-of-motion exercises
D
The nurse is caring for a client who has terminal lung cancer and is unconscious. Which assessment finding would most clearly indicate to the nurse that the client's death is imminent? A) Mottling of the lower limbs B) Slow, steady pulse C) Bowel incontinence D) Increased swallowing
D
The nurse is preparing to admit clients who have been the victim of a blast injury. The nurse should expect to treat a large number of clients who have experienced what type of injury? A) Chemical burns B) Spinal cord injury C) Meningeal tears D) Tympanic membrane rupture
D
When assessing clients who are victims of a chemical agent attack, the nurse is aware that assessment findings vary based on the type of chemical agent. The chemical sulfur mustard is an example of what type of chemical warfare agent? A) Neuro toxin B) Blood agent C) Pulmonary agent D) Vesicant
D
An older adult client experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply. A) Loss of visual acuity B) Adverse medication effects C) Slowed reflexes D) Hearing loss E) Muscle weakness
A, B, C, E
A client has sustained a long bone fracture and the nurse is preparing the client's care plan. Which of the following should the nurse include in the care plan? A) Administer vitamin D and calcium supplements as prescribed B) Monitor temperature & pulses of affected extremity C) Perform passive range of motion exercises as tolerated D) Administer corticosteroids as prescribed
B
A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The client has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding? A) Inform the primary provider promptly B) Document this as an expected assessment finding C) Limit the client's fluid intake to 2 L for the next 24 hours D) Administer a loop diuretic as prescribed
B
A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action? A) Taking an opioid analgesic as prescribed B) Applying a cold pack to the injured site C) Performing passive ROM exercises D) Applying a heating pad to the affected muscle
B
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? A) Cellulitis B) Septic arthritis C) Sepsis D) Osteomyelitis
D
A client is admitted to the ED who has been exposed to a nerve agent. The nurse should anticipate the STAT administration of what drug? A) Amyl nitrate B) Dimercaprol C) Erythromycin D) Atropine
D
A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A) Pain B) Fluid balance C) Anxiety and fear D) Airway management
D
A client is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions? A) Use of a cardiopulmonary bypass machine B) Postoperative blood salvage C) Prophylactic blood transfusion D) Autologous blood donation
D
A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? A) Standard precautions only B) Droplet precautions C) Standard and contact precautions D) Standard and airborne precautions
D
A client was exposed to a dose of more than 5,000 rads of radiation during a terrorist attack. The client's skin will eventually show what manifestation? A) Erythema B) Ecchymosis C) Desquamation D) Necrosis
D
A client who has been exposed to anthrax is being treated in the local hospital. The nurse should prioritize what health assessments? A) Integumentary assessment B) Assessment for signs of hemorrhage C) Neurologic assessment D) Assessment of respiratory status
D
A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A) Maximize the efficiency of care B) Ensure that the client's health care is holistic C) Facilitate the client's adjustment to a new body image D) Promote the client's highest possible level of function
D
A client with a fractured femur is in balanced suspension traction. The client needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do? A) Place slight additional tension on the traction cords B) Release the weights and replace them immediately after positioning C) Reposition the bed instead of repositioning the client D) Maintain consistent traction tension while repositioning
D
A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? A) Warm the client's foot and determine whether circulation improves B) Reposition the client with the affected foot dependent C) Reassess the client's neurovascular status in 15 minutes D) Promptly inform the primary provider
D
A nurse is caring for a client who has had a plaster arm cast applied. Immediately post-application, the nurse should provide what teaching to the client? A) The cast will feel cool to touch for the first 30 minutes. B) The cast should be wrapped snuggly with a towel until the client gets home. C) The cast should be supported on a board while drying. D) The cast will only have full strength when dry.
D
A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching? A) "I'll need to keep several pillows between my legs at night." B) "I need to remember not to cross my legs. It's such a habit." C) "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D) "I will need my husband to assist me in getting off the low toilet seat at home."
D
A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity Intolerance B) Anxiety C) Ineffective Coping D) Acute Pain
D
A nurse is caring for a client who is in skeletal traction. To prevent the complication of skin breakdown in a client with skeletal traction, what action should be included in the plan of care? A) Apply occlusive dressings to the pin sites B) Encourage the client to push up with the elbows when repositioning C) Encourage the client to perform isometric exercises once a shift D) Assess the pin insertion site every 8 hours
D
