med surg coursepoint test-2

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."

an older adult patient had a hip replacement. when should the patient begin with assisted ambulation with a walker

24 hours

in a client with a dislocation, the nurse should initially perform neurovascular assessments a minimum of every 15 minutes until stable. which complication does the assessments help the nurse to monitor?

compartment syndrome

a client who has fallen and injured a hip cannot place weight on the leg and is in significant pain. after radiographs indicate intact but malpositioned bones, what would the physician diagnose

dislocation

the nurse has instructed the client to use a peak flow meter. the nurse evaluates client learning as satisfactory when the client....

exhales hard and fast with a single blow

a client with a fracture develops compartment syndrome that requires surgical intervention. what treatment will the nurse most likely prepare for client

fasciotomy

nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient 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 patient is likely demonstrating symptoms of what complication?

fat embolism syndrome

The nurse assesses a patient after total right hip arthroplasty and observes a shortening of the extremity, and the patient complains of severe pain in the right side of the groin. What is the priority action of the nurse?

notify the health care provider

The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing

obtain culture

a clients fracture was reduced by surgically exposing the bone and realigning it. what type of treatment does the nurse identify this as?

open reduction

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

partial pressure of arterial oxygen (PaO2)

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?

promote the clients highest possible level of function

a nurse is caring for a client who has a leg cast. nurse observes the client using pencil to scratch the skin under his cast. how should the nurse respond to this observation?

provide a fan to blow cool air into the cast to relieve itching

the nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. when planning care for this patient, what does the nurse understand is the main goal of treatment?

providing sufficient oxygen to improve oxygenation

which nursing intervention is essential in caring for a client with compartment syndrome

removing all external sources of pressure, such as clothing and jewelry

the home care nurse is monitoring a client discharged home after resolution of a pulmonary embolus. for what potential complications should the home care nurse be most closely monitoring this client?

residual effects of compromised oxygenation

a nurse is planning the care of a client with emphysema who will soon be discharged. what teaching should the nurse prioritize in the plan of care?

setting realistic short and long term goals

which is an inaccurate principle of traction

skeletal traction is interrupted to turn and reposition the client

a nurse is developing a teaching plan for an adult client with asthma. which teaching point should have the highest priority in the plan of care that the nurse is developing

take prescribed medications as scheduled

a nurse is admitting a new client who has been admitted with a diagnosis of COPD exacerbation. how can the nurse best help the client achieve the goal of maintaining effective oxygenation

teach the client strategies for promoting diaphragmatic breathing

a nurse is caring for a client receiving skeletal traction. due to the clients severe limits on mobility, the nurse has identified a risk for atelctasis or pneumonia. what intervention should the nurse provide in order to prevent these complications?

teach the client to perform deep breathing and coughing exercises

a nurse is developing the teaching portion of a care plan for a client with COPD. what would be the most important component for the nurse to emphasize

Chronic inhalation of indoor toxins can cause lung damage

an unresponsive client has a plaster cast applied to the right lower leg 8 hours ago. when moving the client, the nurse notices an indentation on the posterior lower portion of the cast. what is the best action by the nurse?

Notify the physician

a nurse is caring for a client with status asthmaticus. which medication should the nurse prepare to administer?

an inhaled beta 2 adrenergic agonist

a client with a fractured femur is placed in skeletal traction. which intervention will increase client independence when moving in bed?

apply a trapeze to the bed frame

the nurse is preparing to suction a client with an endotracheal tube. what should be the nurses first step in the suctioning process?

assess the client's lung sounds and SaO2 via pulse oximeter

which action would be most important postoperatively for a client who has had a knee or hip replacement

assisting in early ambulation

a client with COPD is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for.....

atelectasis

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

bending down to put on socks

the nurse is caring for a client in the ICU who is receiving mechanical ventilation. which nursing measure is implemented in an effort to reduce the clients risk of developing ventilator associated pneumonia

cleaning the clients mouth with chlorhexidine daily

a client who is undergoing skeletal traction reports pressure on bony areas. which action would be most appropriate to provide comfort for the client

changing the clients position within prescribed limits

a nurse is working with a 10 year old client who is undergoing a diagnostic workup for suspected asthma. which signs and symptoms are consistent with a diagnosis of asthma? select all that apply.

chest tightness, wheezing, cough

a client withh COPD expresses a desire to quit smoking. the first appropriate response from the nurse is......

have you tried to quit smoking before?

which factor may contribute to compartment syndrome?

hemorrhage

a nurse is planning the care of a client who has undergone orthopedic surgery. what main goal should guide the nurses choice of interventions

improving the clients level of function

The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

increased warmth of the calf

a client is postoperative immediately following a total laryngectomy. the clients respirations are 32 bpm, shallow, and noisy. the tracheostomy pad is moist with mucus. pulse oximetry is 88%. the clients eyes are wide open, and the client appears apprehensive. what is a priority nursing concern?

ineffective airway clearance

Which nursing diagnosis is of highest priority for a client with a compound fracture?

infection related to effects of trauma

which of the following factors contribute to the underlying pathophysiology of chronic obstructive pulmonary disease(SATA)

inflamed airway obstructs airflow mucus secretions block airway over inflated alveoli impair gas exchange

a client with COPD is admitted to the medical surgical unit, to help this client maintain a patent airway and achieve maximal gas exchange, the nurse should.

instruct the client to drink at least 2 L of fluid daily

the nurse is caring for a clinet who had a surgical amputation of the left leg related to complications 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?

its called phantom pain and it may come and go

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 clients hip when the client sits up

a client has a history of COPD, following a coughing episode, the client reports sudden and unrelieved shortness of breath. which of the following is the most important for the nurse to assess?

lung sounds

a client has undergone an extrenal fixation. which actions would be the priority for this client

maintaining pin care

the nurse is providing instructions to the client who is being prepared for skeletal traction. which statement by the client indicates teaching was effective

metal pins will go through my skin to the bone

a rehabilitation nurse is working with a client who has had a below the knee amputation. in order to determine the client's ability to be an active participant in self car, the nurse should prioritize assessment of what variable?

the clients attitude

which statements would be considered appropriate interventions for a client with an endotracheal tube (SATA)

the cuff is deflated before tube is removed cuff pressures should be checked every 6-8 hours humidified oxygen should always be introduced through the tube

for a client with advanced COPD, which nursing action best promotes adequate gas exchange

using a venturi mask to deliver oxygen as ordered

a nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. the nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by.....

using the minimal leak technique with cuff pressure less than 25 cm H2O

a client with a severe exacerbation of chronic pulmonary disease requires reliable and precise oxygen delivery. which mask will the nurse expect the health care provider to prescribe?

venturi mask