NUR 101 Exam 3

A nurse is caring for a child with eczema. What are appropriate measures to take? Select all that apply A. Keep the child's fingernails cut short B. Put extra covers on the child to preserve warmth C. Try to identify what is in contact with the child's skin to cause the reaction and eliminate it D. Try to identify any dietary triggers for the reaction E. Keep the child's skin moist

A. Keep the child's fingernails cut short D. Try to identify any dietary triggers for the reaction E. Keep the child's skin moist

A client has burns over 20% of his body. They are mostly blisters, and areas where the dermis is visible. What degree of burns are they? A. First degree B. Second degree C. Third degree D. Unstageable

B. Second degree

A client is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men older than age 30? A. Septic arthritis B. Traumatic arthritis C. Intermittent arthritis D. Gouty arthritis

D. Gouty arthritis

A client with atopic dermatitis is prescribed medication for photochemotherapy. After administering medication for photochemotherapy, the nurse determines that the client understands the instructions based on which client statements? Select all that apply. A. "I must protect my skin and eyes from natural sunlight for 12 hours after taking this medication." B. "I will need to wear wraparound ultraviolet-protective sunglasses both indoors and outdoors, from the moment I take the medication until nightfall on the treatment day." C. "I will need to wear protective-wear wraparound ultraviolet-protective sunglasses after dark if I am under fluorescent lighting." D. "As long as I am inside behind a window glass I will not need to wear my protective glasses." E. "I will need to wear broad-spectrum sunscreen if I am outside."

A. "I must protect my skin and eyes from natural sunlight for 12 hours after taking this medication." B. "I will need to wear wraparound ultraviolet-protective sunglasses both indoors and outdoors, from the moment I take the medication until nightfall on the treatment day." C. "I will need to wear protective-wear wraparound ultraviolet-protective sunglasses after dark if I am under fluorescent lighting." E. "I will need to wear broad-spectrum sunscreen if I am outside." Explanation: Clients must avoid sun exposure even behind window glass for 12 hours after ingesting medication for photochemotherapy such as methoxsalen. Clients must protect their skin and eyes from natural sunlight for 12 hours after taking the tablets. During treatment, clients must wear wraparound ultraviolet-protective sunglasses both indoors and outdoors from the moment they take the tablets until nightfall on treatment day. After dark, the glasses must still be worn under fluorescent lighting, but are not necessary outside or with incandescent lamps. Clients should wear covering clothing and apply broad-spectrum sunscreens if outdoors.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. A. Reposition the client every 2 hours. B. Perform range-of-motion exercises. C. Use commercial soaps to keep the skin dry. D. Tuck bed covers tightly in the foot of the bed. E. Encourage the client to eat a well-balanced diet.

A. Reposition the client every 2 hours. B. Perform range-of-motion exercises. E. Encourage the client to eat a well-balanced diet. Explanation: To prevent pressure ulcer formation, the nurse should turn and reposition the client every 2 hours, perform range-of-motion exercises, avoid using commercial soaps that dry or irritate skin, avoid tucking covers tightly into the foot of the bed, and encourage the client to eat a well-balanced diet.

What information should a nurse provide to an aging client who wishes to avoid or delay osteoporosis? A. Be sure to take a high dose Calcium and Vitamin D supplement 3 times a day B. Be sure to eat a nutritionally complete diet and get weight bearing exercise such as walking daily. C. There is nothing that can delay aging of the skeletal system. Concentrate on installing safety devices to prevent falls D. Keep your feet up when seated to increase circulation.

B. Be sure to eat a nutritionally complete diet and get weight bearing exercise such as walking daily.

The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? A. Explain to the client what is happening and provide support. B. Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. C. Push the protruding organs back into the abdominal cavity. D. Ask the client to drink as much fluid as possible.

B. Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. Explanation: The nurse should first cover the wound with moistened gauze to prevent the organs from drying. Both the gauze and the saline solution must be sterile to reduce the risk of infection. The nurse should provide support that will reduce the client's anxiety, but covering the wound is the top priority. The organs should not be pushed back into the abdomen because doing so may tear or damage them. Evisceration requires emergency surgery; therefore, the nurse should place the client on nothing-by-mouth status immediately.

The nurse is caring for a young child who appears frightened. What activity can the nurse perform with the child to determine what the child is feeling? A. Play dominoes B. Draw pictures C. Read a story D. Watch a movie

B. Draw pictures

A nurse notes that a client has developed urticaria, pruritus and angioedema after taking a new medication. What is a priority consideration for the nurse in this case? A. Encourage the client to drink plenty of fluid B. Maintain the patient's airway C. Give a topical antihistamine for the itching and hives D. Administer prescribed anti-anxiety medication for the itching

B. Maintain the patient's airway

After a physician describes the surgical procedure for lumbar spinal fusion and its associated risks, the nurse provides a consent form for the client to sign. The client asks the nurse what the term "fusion" means and whether he'll lose a lot of blood during the procedure. Which action should the nurse take? A. Explain the surgical procedure and the typical blood loss associated with it. B. Notify the physician of the client's questions about the procedure before having the client sign the informed consent form. C. Request that the charge nurse answer the client's questions about the procedure. D. Inform the client that the operating room nurse can clarify any questions before the procedure.

B. Notify the physician of the client's questions about the procedure before having the client sign the informed consent form. Explanation: The physician performing the procedure (not the staff nurse or charge nurse) is responsible for making sure that the client understands the procedure, its risks, and its benefits before he signs the informed consent form. The nurse shouldn't explain the procedure; instead she should notify the physician of the client's lack of understanding. The nurse preparing the client for surgery, not the operating room nurse, is responsible for making sure that the informed consent form is signed before the client is transported to the operating room.

A client presents at the health care provider's office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The primary care provider diagnoses scabies. Which teaching points should a nurse review with the client? Select all that apply. A. The disease is only actively contagious when the lesions are open. B. Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. C. The most commonly infected areas are the hands, feet, and neck. D. Severe itching of the affected areas, especially at night, is a common finding. E. Only the infected individual needs to use the prescribed medication. F. All of the client's linens and clothing should be washed immediately in hot water.

B. Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. D. Severe itching of the affected areas, especially at night, is a common finding. F. All of the client's linens and clothing should be washed immediately in hot water. Explanation: Scabies is a contagious disorder caused by a tiny mite that burrows under the skin; it is transmitted by close person-to-person contact or contact with infected linens or clothing. It causes severe itching, especially at night, in addition to the familiar papular rash. All of the client's linens and clothing should be washed promptly in hot water to reduce the risk of reinfestation. Scabies is transmissible from the time of infection to the time the burrows and papules appear, which may occur several weeks afterward. It remains transmissible until eradicated by a prescription cream or an oral medication. Scabies is most commonly seen in the finger webs, flexor surface of the wrists, and the antecubital fossae. When a family member is diagnosed, all members of the family must be treated with medication, and their clothing and linens washed to prevent transmission and reinfestation.

Which of the following characteristics in a pigmented lesion would increase the suspicion that it might be malignant? Select all that apply. A. Both sides of the lesion appear the same B. The borders are irregular and notched C. The lesion has some areas with very dark color, but other areas are lighter D. The lesion is size of a dime. E. It has remained the same for months

B. The borders are irregular and notched C. The lesion has some areas with very dark color, but other areas are lighter D. The lesion is size of a dime.

A client has itching, red areas on his scalp. What would glowing white areas on the scalp seen under a Wood's lamp indicate? A. The client has head lice B. The client probably has a fungal infection of the scalp C. The client probably has a bacterial infection of the scalp D. The client is having an allergic reaction

B. The client probably has a fungal infection of the scalp

A nurse wants to assess the client for signs and symptoms of heat loss. What is an early sign that the client's body is trying to retain more heat than usual? A. The client will be flushed B. The hairs on the client's exposed skin will be standing upright C. The client will be pale D. The client will become confused

B. The hairs on the client's exposed skin will be standing upright

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should: A. remove any observable mites. B. wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious. C. apply a topical corticosteroid to the lesions. D. place the client on enteric precautions.

B. wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious. Explanation: To prevent the spread of scabies in other hospitalized clients, the nurse should wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Removing observable mites won't prevent infection in other clients. Treatment includes thoroughly washing the area and applying a scabicide. A topical corticosteroid may be applied after the scabicide is washed off, usually 12 to 24 hours later, to reduce itching, but it doesn't prevent the spread of scabies. This client doesn't require enteric precautions because the mites aren't found on feces.

The nurse has provided discharge instructions to a client. What statement made by the nurse can best help determine if the client understood the instructions? A. "Reread the instructions that I gave you." B. "Did you understand the instructions?" C. "Please repeat back in your own words the instructions I gave you." D. "I am going to give you questions regarding the instructions and I want you to answer them."

C. "Please repeat back in your own words the instructions I gave you."

A client who has been recently diagnosed with gout asks the nurse to explain why they need to take colchicine. What should the nurse base the response on? A. Colchicine increases estrogen levels in the bloodstream. B. Colchicine decreases the risk of infection. C. Colchicine decreases inflammation. D. Colchicine decreases bone demineralization.

C. Colchicine decreases inflammation. Explanation: The action of colchicine is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesn't decrease the risk of infection, increase estrogen levels, or decrease bone demineralization.

The community health nurse found an older adult client lying in the snow, unable to move the right leg because of a suspected fracture. What's the nurse's priority? A. Realign the fracture ends. B. Reduce the fracture. C. Immobilize the fracture in its present position. D. Elevate the leg on whatever is available.

C. Immobilize the fracture in its present position. Explanation: Initial treatment of obvious and suspected fractures includes immobilizing and splinting the limb. Any attempt to realign or rest the fracture at the site may cause further injury and complications. The leg may be elevated only after immobilization.

What is the priority consideration of a nurse caring for a client in the resuscitative phase of burn treatment? A. Recovery of function and scar managment B. Wound management and prevention of infection C. Preservation of airway and circulatory volume D. Pain management

C. Preservation of airway and circulatory volume

Which nursing diagnosis takes highest priority for a client with a compound fracture? A. Imbalanced nutrition: Less than body requirements related to immobility B. Impaired physical mobility related to trauma C. Risk for infection related to effects of trauma D. Activity intolerance related to weight-bearing limitations

C. Risk for infection related to effects of trauma Explanation: A compound fracture involves an opening in the skin at the fracture site. Because the skin is the body's first line of defense against infection, any skin opening places the client at risk for infection. Imbalanced nutrition: Less than body requirements is rarely associated with fractures. Although Impaired physical mobility and Activity intolerance may be associated with any fracture, these nursing diagnoses don't take precedence because they aren't as life-threatening as infection.

The client incurred a severe fracture of the tibia. An external fixator was applied. Daily pin site care is prescribed. What action will the nurse perform while providing pin site care? A. Don sterile gloves. B. Apply antibiotic ointment to the pin sites. C. Use a separate swab for each pin site. D. Scrub pin sites vigorously with cotton-tipped applicators.

C. Use a separate swab for each pin site. Explanation: When providing care to the external fixator pin sites, the nurse uses a separate applicator for each pin site. This prevents introducing or transferring microorganisms from one pin site to another. It is not necessary to use sterile gloves to provide pin site care. Clean gloves are cost effective and protect the nurse from body fluids. Antibiotic ointment is not applied to the pin sites. The antibiotic ointment increases the risk of bacterial growth. The nurse gently cleans the pin sites with cotton-tipped applicators or presaturated swabs. The nurse cleans the site with a circular motion. Circular motion prevents moving microorganisms through the open skin area.

A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client? A. Charge nurse B. Physician C. Wound care nurse D. Risk management

C. Wound care nurse Explanation: The wound care nurse should be consulted for a treatment plan for this client. The charge nurse and physician should be informed, but the wound care nurse will be the resource person to institute a wound care protocol. Risk management should be informed if pressure ulcers are a continual problem.

The nurse is caring for a client who states "My knees are so stiff in the morning". Which nursing action may the healthcare provider order to alleviate the discomfort? A. apply cool compresses to the knees B. encourage adequate nutrition C. apply moist heat to the knees D. administer a narcotic analgesic

C. apply moist heat to the knees

The orthopedic nurse is providing discharge instruction to a surgical client. Which action, by the client, would demonstrate proper touchdown weight bearing? A. bearing full weight on the affected extremity B. bearing 30% to 50% of weight on the affected extremity C. bearing no weight on the extremity but allowing the extremity to touch the floor D. bearing no weight on the extremity and keeping the extremity elevated at all times

C. bearing no weight on the extremity but allowing the extremity to touch the floor Explanation: Touchdown weight bearing involves bearing no weight on the extremity but allowing the affected extremity to touch the floor. Full weight bearing allows for full weight to be put on the affected extremity. Partial weight bearing allows for 30% to 50% weight bearing on the affected extremity. Non-weight bearing refers to bearing no weight on the affected extremity.

The nurse is gathering data from a client with an abdominal incision and suspects there is a potential for delayed wound healing. Which observation most likely supports this finding? A. sutures dry and intact B. wound edges in close approximation C. purulent drainage on a soiled wound dressing D. sanguineous drainage in a wound-collection drainage bag

C. purulent drainage on a soiled wound dressing Explanation: Purulent drainage contains white blood cells, which fight infection. The sutures from a wound that is draining purulent secretions would pull away with an infection. Wound edges can't approximate in an infected wound. Sanguineous drainage indicates bleeding, not infection.

The nurse is making an initial visit to the home of a client who ambulates with a walker. Which finding should the nurse identify as a safety hazard when completing an assessment of the client's home? A. A fire extinguisher is stored in the hall closet. B. Nightlights are in the hallway between the bedroom and bathroom. C. The banister along the stairway is made of iron. D. Electrical cords are covered with a carpet.

D. Electrical cords are covered with a carpet. Explanation: During an initial home care visit, the home should be assessed for potential safety hazards. Covering electrical cords with a carpet could cause loose connections or frayed wires to go unnoticed, thus presenting a fire hazard that the nurse should address. A fire extinguisher is an important safety item, and storing it in a closet is acceptable as long as the client knows where it is and can access it quickly. Nightlights in the hallway between the bedroom and bathroom can help increase safety when ambulating at night. A banister along the stairway would ensure safety when ambulating on the steps. The material from which the banister is made does not affect safety.

Which nursing diagnosis would be the priority for a client who has just been admitted to the hospital with burns? A. body image disturbance B. risk for altered nutrition C. impaired social interaction D. impaired skin integrity

D. impaired skin integrity Explanation: Impaired skin integrity is the priority in the situation of the burned client because of the fluid and electrolyte loss and a high risk for infection. While body image, social interaction, and altered nutrition are all concerns, they are not necessarily potentially life threatening, unlike the impaired skin integrity.

A licensed practical nurse is assisting a triage nurse in the emergency department admit a client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned?

36% Explanation: The anterior and posterior portions of one leg amount to 18%. Because both legs are burned, the total is 36%.

A client is diagnosed with arthritis and wants to maintain an active lifestyle. Which exercises would the nurse recommend to the client? Select all that apply. A. swimming B. jumping rope C. bicycling D. running E. slow walking

A. swimming C. bicycling E. slow walking

Merkel's cells...?

Are tactile disks.

Sebacceous glands ...?

Create the oily substance that helps waterproof and soften skin and hair

Melanocytyes...?

Creates the substance that protects skin from the sun.

The nurse is testing the function of a client's cranial nerves. Which statement made by the nurse would indicate testing of cranial nerve IX (glossopharyngeal)? A. "Shrug your shoulders and turn your head." B. "Move and clench your jaw." C. "Swallow." D. "Stand with your eyes closed."

D. "Stand with your eyes closed."

Langerhans cells...?

Participate in immune and allergy responses.

Sudoriforous glands...?

Produce sweat

A crack in the skin is called a ___?

fissure

A flat dark colored lesion is called a ____?

macule

A raised lesion filled with white cells, bacterial and cellular debris is called a ___?

pustule

A raised lesion filled with serous fluid is called a ___?

vesicle

The health care provider has ordered for a child with an open femur fracture morphine sulfate 10 mg PO times one dose. The elixir on hand is 100 mg/5 mL. How many milliliters will the nurse administer? Record your answer using one decimal place.

0.5 mL

A client has just had total hip replacement surgery. The client's primary care provider orders 8,000 units of heparin to be administered subcutaneously. The label on the heparin vial reads "Heparin 10,000 units/mL." How many milliliters of heparin should the nurse draw up in the syringe to administer the correct dose? Record your answer using one decimal place.

0.8 mL Explanation: (1 mL/10,000 units) x 8000 units/dose = 0.8 mL/dose.

The nurse is preparing to apply a moist dressing to a sacral pressure injury. Which is a priority action by the nurse? A. Medicate with analgesics one-half hour prior to the procedure. B. Have the client sign a consent form to perform the procedure. C. Document the procedure so that it will not be forgotten. D. Remove the necrotic tissue with forceps.

A. Medicate with analgesics one-half hour prior to the procedure.

A school nurse is performing a scoliosis screening on a group of students. Which student would most commonly develop this condition? A. 7-year-old girl B. 7-year-old boy C. 13-year-old girl D. 13-year-old boy

C. 13-year-old girl Explanation: Scoliosis is eight times more prevalent in adolescent girls than boys. Peak incidence is between ages 8 and 15. Therefore, a 13-year-old girl is at the highest risk. Seven-year-old boys and girls are at lower risk.

The nurse is preparing to administer allopurinol (Zyloprim) for a client with gout. Which of the information would the nurse include in the instructions? A. use aspirin to additionally relieve pain B. eat foods high in purine C. drink at least 3L of fluid each day D. alcohol may be used while taking this drug

C. drink at least 3L of fluid each day

The client calls the nurse in the clinic and states that the cast feels very rough around the edges and is scratching the skin. What is the best response by the nurse? A. Apply moleskin or pink tape around the edges. B. Elevate the limb above the level of the heart. C. Break off the rough area and file it down. D. Distribute pressure evenly.

A. Apply moleskin or pink tape around the edges. Explanation: To reduce the roughness of the cast, apply moleskin or pink tape around the rough edges. Elevating the limb will prevent swelling. Distributing pressure evenly will prevent pressure ulcers. Never break a rough area off the cast.

The nurse is observing a new graduate documenting care for a client. Which documentation error by the graduate requires the nurse to intervene? A. A nurse is documenting on the nurse's notes with a green pen. B. A nurse uses the approved facility abbreviation, "NPO." C. A nurse indicates the time and date of documentation entry. D. The note is signed using the nurse's first and last name and title.

A. A nurse is documenting on the nurse's notes with a green pen.

The nurse requests that a postoperative client dorsiflex the foot. While performing this task, the client reports having pain in the calf. Which potential complication of the immobility related to surgery does the nurse suspect has occurred? A. Deep vein thrombosis B. Fractured leg C. Muscle atrophy D. Dislocated hip

A. Deep vein thrombosis

A client states, "I feel bloated and have abdominal cramps." Which part of the assessment would the nurse perform first? A. Inspection B. Auscultation C. Percussion D. Palpation

A. Inspection

A client is undergoing an extensive diagnostic workup for suspected muscular dystrophy. The nurse knows that muscular dystrophy has many forms, but that one data collection finding is common to all forms. Which finding belongs in this category? A. Muscle weakness B. Cardiac muscle involvement C. Pseudohypertrophy of the calf muscles D. Muscle pain

A. Muscle weakness Explanation: Muscle weakness is common to all forms of muscular dystrophy. Cardiac muscle involvement and pseudohypertrophy of the calf muscles don't occur in all forms of muscular dystrophy. Muscle pain is rare with any form of muscular dystrophy.

The nurse is updating the "communication board" in the client's room. Which information would the nurse include? Select all that apply. A. The date B. The nurse's name C. The diagnosis D. The provider's name E. Results of current laboratory studies

A. The date B. The nurse's name C. The diagnosis

The nurse observes a client with facial burns and suspects smoke inhalation. Which observations lead the nurse to suspect this condition? Select all that apply. A. The facial burns B. Singed nasal hairs C. Soot around nares D. Soot-stained sputum E. Report of pain at the burn site

A. The facial burns B. Singed nasal hairs C. Soot around nares D. Soot-stained sputum

A client is prescribed hydroxyzine HCl (Atarax) for the treatment of pruritus. Which information should the nurse provide to the client? Select all that apply. A. The medication may cause drowsiness. B. Drink water, juice, and other fluids. C. Use sunscreen when exposed to the sun. D. Administer medication on an empty stomach. E. Discontinue medications 1 week before skin testing.

A. The medication may cause drowsiness. B. Drink water, juice, and other fluids. C. Use sunscreen when exposed to the sun.

The nurse is gathering data from a client with a loss of melanin production from age-related changes. What observation made by the nurse correlates with this change? A. White hair B. Freckles on the nose and cheeks C. Ridges on the skin surface D. Thickened areas on the palms and heels

A. White hair

The nurse observes facial wrinkling on a 35-year-old client. What questions should the nurse ask pertaining to this finding? Select all that apply. A. What type of moisturizer do you use? B. Do you smoke? C. Do you spend a lot of time outdoors? D. Did either of your parents wrinkle pr E. Do you drink alcohol?

B. Do you smoke? C. Do you spend a lot of time outdoors? D. Did either of your parents wrinkle pr

The nurse is documenting in the nurses' notes and realizes the entry is incorrect. Which is the appropriate action by the nurse? A. Use "white-out" to block out the entry. B. Draw one line through the entry, enclose it in parentheses, and document the error in charting. C. Draw a large X throughout the entire entry. D. Take out the paper the entry was written on and rewrite it.

B. Draw one line through the entry, enclose it in parentheses, and document the error in charting.

The nurse is preparing to bathe a client. The client states, "I feel embarrassed that I can't do this myself." Which action by the nurse can assist with maintaining the client's dignity? A. Avoid bathing the client until a family member comes in to do it. B. Provide as much privacy as possible during the bath. C. Administer sedation prior to giving the client a bath. D. Inform the charge nurse the client refuses the bath.

B. Provide as much privacy as possible during the bath.

The nurse is collecting data from a client admitted to the acute care facility. Which data obtained by the nurse would be documented as objective data? A. The client identifies severe itching on the leg. B. The client has a large sacral wound. C. A family member states that the client is confused. D. The client states, "I have been sick for 2 days."

B. The client has a large sacral wound.

The nurse is documenting the care provided to a client. Which statements would the nurse need to consider when documenting? Select all that apply. A. The nurse should only document if there is a change in the client's condition. B. The nurse should document the information clearly and legibly. C. The nurse should only document accurate information and not assumptions. D. The nurse should document frequently. E. The nurse should use a black pen if manual entry is required.

B. The nurse should document the information clearly and legibly. C. The nurse should only document accurate information and not assumptions. D. The nurse should document frequently. E. The nurse should use a black pen if manual entry is required.

A client informs the nurse that a bookshelf fell on the client's toe and the toenail fell off. The client asks the nurse when to expect the toenail to regrow. Which response by the nurse is best? A. "You will not have regrowth of that toenail." B. "You should have a new nail in about 3 months." C. "You should have a new nail in about 12 to 18 months." D. "The nail will be back in about 2 weeks."

C. "You should have a new nail in about 12 to 18 months."

What nursing action is essential in order to prevent heat loss through evaporation? A. Apply blankets. B. Move a space heater closer to the client. C. Dry the client with a towel when perspiring. D. Apply a warm cloth to the forehead.

C. Dry the client with a towel when perspiring.

An older adult client is admitted to the hospital with intact skin. Prior to discharge, the nurse observes a decubitus ulcer on the sacrum but no documentation describes its presence or preventative measures taken. Which outcome does the nurse anticipate? A. The client will be discharged home with instructions for the family to dress the wound. B. The nurses that have been assigned to care for the client will be terminated. C. Payment for care may be denied by third-party payers. D. There is no penalty since skin impairment occurs in all older adults.

C. Payment for care may be denied by third-party payers.

The nurse is changing a dressing for a client with a burn to the back of the left leg. Which information should the nurse avoid documenting in the chart? A. The wound is pink around the edges. B. The wound has no drainage or odor. C. The client must not have felt the hot object burning the leg. D. The client states, "My pain is a 3 on a 1-10 scale."

C. The client must not have felt the hot object burning the leg.

A client is diagnosed with primary osteoporosis. Which nursing intervention should be included when the nurse is assisting with the plan of care? A. placing items within reach of the client B. installing bars in the bathroom to prevent falls C. maintaining optimal calcium and vitamin D intake D. using a professional alert system in the home in case the client falls when alone

C. maintaining optimal calcium and vitamin D intake Explanation: Primary prevention of osteoporosis includes maintaining optimal calcium and vitamin D intake. Using a professional alert system in the home, installing bars in bathrooms to prevent falls, and placing items within reach of the client are all secondary and tertiary prevention methods.

Which activity in a child with muscular dystrophy should a nurse anticipate difficulty with first? A. breathing B. sitting C. standing D. swallowing

C. standing Explanation: Muscular dystrophy usually affects postural muscles of the hip and shoulder first. Swallowing and breathing are usually affected last. Sitting may be affected, but a child would have difficulty standing before having difficulty sitting.

A client lacks the DNA-repair enzyme that helps reverse UV damage. Which information related to this lack of enzyme would the nurse include when teaching the client? A. Wear sunglasses when outdoors. B. Avoid any activities that involve the outdoors. C. Apply aloe vera after a sunburn. D. Closely check the skin for new or changes in moles.

D. Closely check the skin for new or changes in moles.

A child has been treated for head lice but has remaining nits attached to the hair shaft. Which instruction would the nurse provide to the parent? A. Apply petroleum jelly. B. Apply a hair cap to smother them. C. Soak the hair in water. D. Comb the hair with a fine tooth comb.

D. Comb the hair with a fine tooth comb.

When asking a client sensitive personal questions related to admission, which action would the nurse take to avoid dehumanizing the client? A. Do not maintain eye contact with the client when asking the questions. B. Rapidly go through the questions so that the client doesn't have time to become embarrassed. C. Tell the client not to answer anything the client does not want to answer. D. Develop rapport and trust with the client prior to beginning the interview.

D. Develop rapport and trust with the client prior to beginning the interview.

A client developed angioedema after taking prinivil (Lisinopril). Which priority nursing action is essential when caring for this client? A. Start an IV. B. Insert an indwelling catheter. C. Apply antipruritic lotion. D. Maintain a patent airway.

D. Maintain a patent airway.

A client is scheduled for an invasive diagnostic procedure. The nurse observes that the client is unable to sit still, is sweating, has an elevated blood pressure and heart rate, and has trouble breathing. What anxiety level does the nurse notify the healthcare provider that the client is experiencing? A. +1 B. +2 C. +3 D. Panic

D. Panic

The nurse is obtaining a pulse oximetry reading and vital signs for a client with pneumonia. Which finding would the nurse report immediately to the healthcare provider? A. Temperature of 98 °F B. Heart rate of 72 C. Respiratory rate of 16 D. Pulse oximetry of 89%

D. Pulse oximetry of 89%

A client asks the reason for being placed in traction prior to surgery. Which response by the nurse is most appropriate? A. Traction will help prevent skin breakdown. B. Traction helps with repositioning while in bed. C. Traction allows for more activity. D. Traction helps to prevent trauma and overcome muscle spasms.

D. Traction helps to prevent trauma and overcome muscle spasms. Explanation: Traction prevents trauma and overcomes muscle spasms. Traction doesn't help in preventing skin breakdown, repositioning the client, or allowing the client to become active.

A client who's being discharged with an arm cast wants to shower at home. The nurse demonstrates how to shower without getting the cast wet. For which reason is this important? A. A wet cast can cause a foul odor. B. A wet cast will weaken or decompose. C. A wet cast is heavy and difficult to maneuver. D. It's all right to get the cast wet; just use a hair dryer to dry it off.

B. A wet cast will weaken or decompose. Explanation: A wet cast will weaken or decompose. A foul odor is a sign of infection. It's never appropriate to get a cast wet.

Which of the following is NOT a principle of good body mechanics? A. Keep the center of gravity over the base of support B. Keep a load to be carried close to the center of gravity C. Tighten your back muscles to lift D. A person should have a wide base of support

C. Tighten your back muscles to lift

What test is most commonly used to determine the state of the skeletal system? A. Bone Scan B. PET scan C. MRI D. X-ray

D. X-ray

A nurse is caring for a client with a pressure ulcer on the sacrum. When educating the client about dietary intake, which foods should the nurse plan to emphasize? A. legumes and cheese B. whole-grain products C. fruits and vegetables D. lean meats and low-fat milk

D. lean meats and low-fat milk

While assessing a client, a nurse notes a stage I pressure ulcer on the client's left hip. How should the nurse report this finding? A. Document the size, extent, and location of the wound in the client's medical record. B. Inform the client's family of the pressure ulcer. C. Notify a physician immediately. D. Report the finding to a nurse-manager immediately.

A. Document the size, extent, and location of the wound in the client's medical record.

A nurse is caring for a client who has lost 30% of his skin due to trauma. The nurse knows that the compromised integumentary system has the following implications for the client: (Select all that apply.) A. Extra care will need to be taken to preserve normothermia in the client. B. The client will need exercise to preserve muscle mass. C. The client will need to have fluid balance carefully monitored. D. The client will need to cough and deep breathe to prevent pneumonia. E. The client will need to be protected against infection.

A. Extra care will need to be taken to preserve normothermia in the client. C. The client will need to have fluid balance carefully monitored. E. The client will need to be protected against infection.

A nurse is asked by a young client how to keep her skin young looking for longer. What can the nurse recommend? Select all that apply. A. Protect skin from the sun B. Use the most expensive moisturizer they can afford C. Avoid smoking D. Take several showers a day E. Eat a balanced diet and drink plenty of fluids

A. Protect skin from the sun C. Avoid smoking E. Eat a balanced diet and drink plenty of fluids

A client is experiencing residual limb pain following a surgical amputation to the right lower extremity below the knee. Which action by the nurse would help alleviate the pain? A. instruct the client to "move? the missing limb B. apply ice to the residual limb C. encourage the client to discuss feelings of loss D. present reality and do not support the delusion of sensation

A. instruct the client to "move? the missing limb

An older adult client is admitted to the acute care facility. Which nursing action is a priority to help with the prevention of falls? A. perform a fall risk assessment B. have restraints in the room if the client tries to get out of bed C. obtain a walker for ambulation D. inform the client not to get out of bed without assistance

A. perform a fall risk assessment

The nurse is collecting data from several clients at the clinic. Which client does the nurse determine is most likely receive the Zostavax vaccine for the prevention of shingles? A. 24-year old client that will be traveling out of the country B. 6-month-old infant having surgery to repair a cleft lip C. 62-year-old client that had a mild case of shingles 4 years previously D. 38-year-old pregnant client that has gestational diabetes

C. 62-year-old client that had a mild case of shingles 4 years previously Explanation: The Centers for Disease Control and Prevention (CDC) recommends that anyone 60 years of age or older receive the shingles vaccine, even if they have had a previous case of shingles to prevent reoccurrence of the virus. The other clients are not at greater risk for the development of shingles.

The nurse is reinforcing education to parents of an infant about burn prevention. Which instructions should be reinforced regarding burns from tap water? A. Set the water-heater temperature at 130° F (54.4° C) or less. B. Run the hot water first, then adjust the temperature with cold water. C. Before putting the infant in the tub, test the water with a hand. D. Supervise an infant in the bathroom, only leaving the infant for a few seconds if needed.

C. Before putting the infant in the tub, test the water with a hand. Explanation: Instruct the parents to fill the tub with water first, then test all of the water in the tub with a hand for hot spots. The cold water should be run first and then adjusted with hot water. Water heaters should be set at 120° F (48.9° C). Never leave a infant alone in the bathroom, even for a second.

Which characteristic of the fascia can cause it to develop compartment syndrome? A. It is highly flexible. B. It is fragile and weak. C. It is unable to expand. D. It is the only tissue within the compartment.

C. It is unable to expand. Explanation: Compartment syndrome occurs because the fascia can't expand. It isn't flexible or weak. The compartment contains blood vessels and nerves.

A nurse is caring for a hypothermic patient and is trying to prevent the client from losing heat in any way. What is a way for the nurse to prevent heat loss by conduction? A. Turn off the fan B. Dry the client off C. Put insulating fabric between the client and the surface under them. D. Cover the exposed skin of the client

C. Put insulating fabric between the client and the surface under them.

Which nursing intervention is essential in caring for a client with compartment syndrome? A. Keeping the affected extremity below the level of the heart B. Wrapping the affected extremity with a compression dressing to help decrease the swelling C. Removing all external sources of pressure, such as clothing and jewelry D. Starting an I.V. line in the affected extremity in anticipation of venogram studies

C. Removing all external sources of pressure, such as clothing and jewelry Explanation: Nursing measures should include removing all clothing, jewelry, and external forms of pressure (such as dressings or casts) to prevent constriction and additional tissue compromise. The extremity should be maintained at heart level (further elevation may increase circulatory compromise, whereas a dependent position may increase edema). A compression wrap, which increases tissue pressure, could further damage the affected extremity. There is no indication that diagnostic studies would require I.V. access in the affected extremity.

A client has widespread itching of the skin. The doctor has diagnosed an allergic reaction and given a prescription for an anti-anxiety medication and anti-histamine. In addition to drug teaching, what suggestions can the nurse give to help the client deal with the itching? The nurse can also suggest all of the following EXCEPT: A. Use bath oil or soothing starch solution in cooler water for bathing B. Avoid scented skin products and laundry detergent C. Take hot baths with soap D. Wear clothes in natural fabrics that breathe.

C. Take hot baths with soap

The nurse completes a wet-to-dry dressing change on a client's lower extremity wound. When should the nurse document the dressing change? A. the next time they access the client's record to update vital signs B. just before the end of the shift, prior to giving a report C. as soon as they finish performing the dressing change D. immediately prior to the next dressing change

C. as soon as they finish performing the dressing change Explanation: The nurse should document the dressing change as soon as it is completed. This ensures accuracy in documentation, especially related to wound descriptors. Waiting to access the client's chart when documenting vitals or at the end of a shift is not best practice and often leads to charting errors. Waiting until the next dressing change is not appropriate and can also lead to charting errors.

The nurse is interviewing a client during admission to the hospital and the client gives information that is unclear to the nurse. What statement made by the nurse best demonstrates "seeking clarification?" A. "I don't know what you are talking about." B. "What did you say?" C. "We can move on to something else." D. "Would you please explain what you meant?"

D. "Would you please explain what you meant?"

A nursing student wonders why he gets all sweaty during a nursing exam. What should his friends tell him? A. Eccrine sweat glands are triggered to secrete more during times of mental stress B. He needs more exercise C. He needs more iron D. Apocrine sweat glands are triggered to increase secretions during times of stress

D. Apocrine sweat glands are triggered to increase secretions during times of stress

A client has been diagnosed with a terminal illness and is crying. What statement made by the nurse is a barrier for further communication? A. "Everything will be ok. It's out of your hands." B. "I am here if you would like to talk." C. "Is there anything that I can do for you or questions that I can answer?" D. "This must be difficult for you."

A. "Everything will be ok. It's out of your hands."

A client is having abdominal pain. What open-ended statement can the nurse use to find out more about the client's condition? A. "Tell me more about how you feel." B. "Rate your pain on a scale of 1-10." C. "Point with one finger to where your pain is located." D. "What medication are you taking?"

A. "Tell me more about how you feel."

A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status? A. The LPN speaks directly to the physician. B. The LPN informs the RN when a wound heals. C. The LPN informs the RN only if a wound worsens. D. The RN communicates daily with the LPN about the condition of each resident.

D. The RN communicates daily with the LPN about the condition of each resident. Explanation: It's within the scope of LPN practice to communicate with the physician; however, the RN should communicate daily with the LPN about the condition of each nursing home resident. The RN should be kept abreast of all changes in clients' conditions as they occur.

The nurse is caring for a client who has had a lower extremity amputation. Which intervention by the nurse will best prevent hip contractures? A. change drains using aseptic technique B. elevate the foot of the bed C. inspect the limb for signs of infection D. do not place a pillow under the residual limb

D. do not place a pillow under the residual limb

After treatment of compartment syndrome, a client reports experiencing paresthesia. Which symptoms should the nurse monitor? A. fever and chills B. change in range of motion (ROM) C. pain and blanching D. numbness and tingling

D. numbness and tingling Explanation: Paresthesia is described as numbness and tingling. It doesn't include pain or blanching and isn't associated with fever and chills or change in ROM.

A client is being prepared for surgery and states, "I am so scared and nervous." Which action by the nurse will help alleviate the anxiety felt by the client? A. Allow the client to express feelings. B. Inform the client there is no time to have second thoughts. C. Tell the client that there is nothing to worry about. D. Inform the client that if unable to calm down, the surgery will be canceled.

A. Allow the client to express feelings.

A college student living in the dormitory comes to the school health clinic stating, "I think I have ringworm on the bottom of my foot." What education should the nurse reinforce after treatment to prevent reoccurrence? Select all that apply. A. Be sure to wear shower shoes when using a public shower. B. Change socks at least once a day. C. Wear shoes that prevent air from circulating around the feet. D. Keep skin clean and dry. E. Do not cut toenails short.

A. Be sure to wear shower shoes when using a public shower. B. Change socks at least once a day. D. Keep skin clean and dry. Explanation: Students in a college dormitory share a common shower room and makes the shower area a hazard for catching ringworm and shower shoes should be worn. Socks and underwear should be changed at least once daily and especially if they are damp. Wearing shoes that allow the air to circulate freely around the feet can help prevent ringworm. Keeping skin clean and dry is important in the prevention of ringworm. Fingernails and toenails should be kept clean and short.

The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication of this condition? A. Bone fracture B. Loss of estrogen C. Negative calcium balance D. Dowager's hump

A. Bone fracture Explanation: Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause — not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

What is true of bones? A. Bones are constantly being remodeled B. Once mature, bones remain constant unless damaged C. There are no living cells in bone, just the remains of dead ones. D. The only malignancies found in bone are metastases from other body sites.

A. Bones are constantly being remodeled

The infection control team has identified a 25% infection rate on the orthopedic floor. The nursing staff members are asked to record their care activities by recording them in a log to help identify the cause of the high infection rate. Which of the following care activities should be recorded in the activity log? A. Hand washing between client contacts B. Clean glove use when applying sterile dressings C. Sterile gown use when changing clients' linens D. Wearing a mask when changing sterile dressings

A. Hand washing between client contacts Explanation: The best way to stop the spread of infection is by hand washing between each client contact. Therefore, the nursing staff should record each time they wash their hands. Recording this activity heightens the staff's awareness of hand washing, reinforces its importance, and helps determine whether lack of hand washing is at the root of the problem. The nurse should wear clean gloves to remove a dressing and then put on sterile gloves to apply a sterile dressing. A clean gown, not a sterile gown, should be worn when soiling of the nurse's clothing is likely during a linen change. A mask isn't required for all sterile dressing changes.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? A. Ineffective airway clearance related to edema of the respiratory passages B. Impaired physical mobility related to the disease process C. Impaired skin integrity related to disease process D. Risk for infection related to breaks in the skin

A. Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process is not appropriate because burns are not a disease. Impaired skin integrity related to disease process is not the priority and Risk for infection related to breaks in the skin may be appropriate, but they do not command a higher priority than Ineffective airway clearance because they do not reflect immediately life-threatening problems.

A client is having multiple symptoms associated with an alteration in muslce function. Which diagnostic tests should the nurse prepare the client for? Select all that apply. A. creatinine kinase B. electromyogram C. lumbar puncture D. muscle biopsy E. electrocardiogram

A. creatinine kinase B. electromyogram D. muscle biopsy

An older client in for an annual check-up is concerned because their skin has some brown spots, and some areas that have lost their usual color. What teaching can the nurse provide the client? A. These are "liver spots" and mean the client should have his liver checked. B. These changes in pigmentation are a normal part of aging C. These are freckles caused by sun exposure D. The client needs to use a lightening cream

B. These changes in pigmentation are a normal part of aging

A child was found unconscious at home and brought to the emergency department by the fire and rescue unit. While collecting data, the nurse observes cherry-red mucous membranes, nail beds, and skin. Which cause is the most likely explanation for the child's condition? A. Aspirin ingestion B. Carbon monoxide poisoning C. Hydrocarbon ingestion D. Spider bite

B. Carbon monoxide poisoning Explanation: Cherry-red skin changes are seen when a child has been exposed to high levels of carbon monoxide. Nausea and vomiting and pale skin are symptoms of aspirin ingestion. A hydrocarbon or petroleum ingestion usually results in respiratory symptoms and tachycardia. Spider-bite reactions are usually localized to the area of the bite.

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require? A. Strict isolation B. Contact isolation C. Respiratory isolation D. Enteric isolation

B. Contact isolation Explanation: A client with rabies requires contact isolation because the disease is highly transmissible through close or direct contact. Rabies isn't transmitted through the air, eliminating the need for strict isolation, which aims to prevent transmission of highly contagious or virulent infections spread by both air and contact. Respiratory isolation, used to prevent transmission only through the air, isn't sufficient for a client with rabies. Enteric isolation is inappropriate because rabies isn't transmitted through direct or indirect contact with feces.

The nurse is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it is meant to protect? A. air-fluidized bed B. ring or donut C. gel flotation pad D. water bed

B. ring or donut Explanation: Rings or donuts are not to be used because they restrict circulation. An air-fluidized bed contains beads that move under an airflow to support the client, thus reducing shearing force and friction. Gel pads redistribute with the client's weight. The water bed also distributes pressure over the entire surface.

A client with a sacral pressure ulcer is limited to 2 hours of sitting in a chair twice per day. She is scheduled for physical therapy three times per day and dressing changes twice per day. How can a nurse best coordinate this client's care? A. Ask the physician if physical therapy can be changed to twice a day, so the client will only need to get out of bed twice a day. B. Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session. C. Request bedside physical therapy for all three session, so the client can get out of bed when she wants. D. Ask the physician to discontinue physical therapy until the client has no activity limitations.

B. Coordinate physical therapy with getting the client out of bed for breakfast and dinner; then request bedside physical therapy for the third session. Explanation: The nurse should attempt to coordinate physical therapy with getting the client out of bed for breakfast and dinner. She should then request bedside physical therapy for the third session until the client has no activity limitations. She shouldn't ask the physician to change the physical therapy schedule because doing so could jeopardize her plan of care. Coordinating her activities optimizes the client's ability to participate in physical therapy because she can go to the physical therapy department for therapy. Discontinuing therapy sessions places the client at risk for complications associated with immobility.

A nurse is caring for a client who sustained a gunshot wound to the leg during a jewelry store robbery. The client is in police custody and receiving treatment in the emergency department. A member of the media asks the nurse about the client's condition. How should the nurse respond? A. Ask security to escort the media to the client care area to interview the client. B. Notify the nursing supervisor so she can obtain a formal statement from the physician about the client's condition for the media. C. Contact the physician to receive an update on the client's condition and then inform the media. D. Meet with the media in the lobby and inform them of the client's condition.

B. Notify the nursing supervisor so she can obtain a formal statement from the physician about the client's condition for the media. Explanation: The nurse should contact the nursing supervisor, who can contact the physician for a formal statement and then inform the media. It is a violation of the client's privacy to escort media to the client care area. The staff nurse shouldn't speak to the media herself.

A client suffered a stroke that affected the left side of the body. Which nursing action will assist with the prevention of contractures of the lower extremities? A. apply heat to the extremities B. position the client as if standing C. Apply sequential compression devices to the lower extremities D. stand the client on both feet several times a day

B. position the client as if standing

The nurse is caring for a client postoperatively who has had cervical decompression. Which symptom(s) reported by the client would the nurse immediately report to the primary care provider? Select all that apply. A. reports of discomfort when moving B. reports of change in sensation of arms C. difficulty breathing D. difficulty moving arms E. no bowel movement for 2 days

B. reports of change in sensation of arms C. difficulty breathing D. difficulty moving arms

The nurse is preparing to perform wound care for a client. What action should the nurse prioritize before changing the dressing? A. put on gloves B. wash hands thoroughly C. slowly remove the soiled dressing D. observe the dressing for the amount, type, and odor of drainage

B. wash hands thoroughly Explanation: The first thing the nurse must do is wash hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of the dressing change procedure that come after hand washing.

The nurse is reinforcing education for a client regarding back safety. Which response by the client indicates the education was effective? A. "I'll start carrying objects at arm's length from my body." B. "I'll sleep on my back at night." C. "I'll carry objects close to my body." D. "I'll lift items by bending over at my waist."

C. "I'll carry objects close to my body." Explanation: Keeping objects close to the body's center of gravity by carrying them close to the body lessens strain on the back. Carrying objects away from the body, sleeping on the back, and bending over at the waist to lift objects all increase back strain.

The nurse is reinforcing education for a client diagnosed with gout. What statement made by the client demonstrates an understanding by the client? A. "I'll increase my fluids so that the inflammation will be reduced." B. "Increasing fluid intake will increase the calcium my body absorbs." C. "Increasing fluid intake will cause my body to excrete more uric acid." D. "Increasing fluids will help provide a cushion for my bones."

C. "Increasing fluid intake will cause my body to excrete more uric acid." Explanation: Fluids promote the excretion of uric acid. Fluids don't decrease inflammation, increase calcium absorption, or provide a cushion for bones.

A client who was casted for a recent fracture of the right ulna reports severe pain, numbness, and tingling of the right arm. What would be the nurse's most appropriate response? A. Administer acetaminophen as prescribed. B. Lower the arm below the level of the heart. C. Immediately report the client's symptoms. D. Apply a heating pad to the area.

C. Immediately report the client's symptoms. Explanation: Severe pain, numbness, and tingling are symptoms of impaired circulation due to compartment syndrome, which is a medical emergency. Don't give analgesics until the client has been assessed and treated. Lowering the arm below the level of the heart and applying heat will decrease venous outflow and impair the circulation even more.

An x-ray shows a spiral fracture of a 4-year-old child's arm. What information is a priority for the nurse to be on the alert for? A. A neurological condition causing unsteadiness B. Inadequate supervision of the child on play equipment C. Other physical signs, statements, and behaviors indicating possible abuse. D. Inadequate nutrition leading to softening of the bones.

C. Other physical signs, statements, and behaviors indicating possible abuse.

When assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is: A. planning for the client's rehabilitation and discharge. B. providing emotional support to the client and family. C. maintaining the client's fluid, electrolyte, and acid-base balance. D. preserving full range of motion in all affected joints.

C. maintaining the client's fluid, electrolyte, and acid-base balance. Explanation: The most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life- threatening complications, such as shock, disseminated intravascular coagulation (DIC), respiratory failure, cardiac failure, and acute tubular necrosis. The other options are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance.

The health care provider has ordered sulfasalazine for a child with juvenile rheumatoid arthritis. The nurse questions the order when reading that the client has an allergy to what medication? A. alprazolam B. naproxen C. sulfamethoxazole-trimethoprim D. penicillin

C. sulfamethoxazole-trimethoprim Explanation: Sulfamethoxazole-trimethoprim is a sulfa drug as is sulfasalazine. If a person has a reaction to one sulfa drug, it is highly probable they would have a reaction to another. Alprazolam, naproxen, and penicillin will not make the nurse question the health care provider's order.

The nurse is discussing preventive interventions to avoid musculoskeletal injuries. Which should the nurse encourage the client to take with calcium to help metabolize the calcium? A. vitamin B6 B. magnesium C. vitamin D D. potassium

C. vitamin D

A child has just returned to the room with a cast on the leg after open reduction of a fractured femur. What is the most appropriate action for a nurse to take when a 6 cm by 10 cm area of blood is noted on the cast? A. Tape gauze pads over the bloody area.

D. Call the health care provider. Explanation: The health care provider should be notified with the findings. Gauze pads may be placed over the bloody drainage after the child has been assessed and the health care provider notified. Telling the client that this is normal is giving false assurance. Lowering the leg is not appropriate intervention for bleeding.

Which of the following assessment data from a client with a joint immobilization device should they immediately report to the provider? A. Sensation distal to the device B. Fingers pink and warm distal to the device. C. Discomfort at the injury site D. Capillary refill time > 3 seconds distal to the device

D. Capillary refill time > 3 seconds distal to the device

A client has a potential soft-tissue injury and may need an MRI, what question should the nurse be sure to ask? A. Have you had an x-ray recently? B. Are you allergic to iodine or shellfish? C. Is there any possibility you may be pregnant? D. Do you have any plates, rods or other metallic implants?

D. Do you have any plates, rods or other metallic implants?

A client questions their diagnosis of rheumatoid arthritis, stating they're too young and haven't "mistreated" their joints. What is the best answer for the nurse to give? A. A mis-diagnosis has probably happened, I will go call your provider. B. It's probably working at a keyboard that has caused it. C. Your diet must be very high in purine. D. Rheumatoid arthritis is an autoimmune disease, it can affect anyone, even children.

D. Rheumatoid arthritis is an autoimmune disease, it can affect anyone, even children.

A client is admitted to an acute care facility with osteomyelitis. Which organism usually causes this infection? A. Escherichia coli B. Klebsiella C. Pseudomonas D. Staphylococcus aureus

D. Staphylococcus aureus Explanation: S. aureus is the most common cause of osteomyelitis. Less often, E. coli, Klebsiella, or Pseudomonas is the causative organism. Proteus and Salmonella are relatively rare causes. In a few cases, osteomyelitis results from a viral or fungal infection.

A client with a fractured femur is in Russell's traction and asks the nurse to help with back care. Which nursing action is most appropriate? A. telling the client that back care cannot be performed while he's in traction B. removing the weight to give the client more slack to move C. supporting the weight to give the client more slack to move D. telling the client to use the trapeze to lift his back off the bed

D. telling the client to use the trapeze to lift his back off the bed Explanation: The traction must not be disturbed to maintain correct alignment. Therefore, the client should use the trapeze to lift his back off of the bed. The client can have back care as long as the trapeze is used and the alignment is not disturbed. The weight shouldn't be moved without a health care provider's order; it should hang freely without touching anything.

A child with muscular dystrophy has lost complete control of his lower extremities. There is some strength bilaterally in the upper extremities, but poor trunk control. Which mechanism would be the most important to have on the wheelchair? A. anti-tip device B. extended brakes C. headrest support D. wheelchair belt

D. wheelchair belt Explanation: Since the child has poor trunk control, a belt will prevent falling out of the wheelchair. Anti-tip devices, headrest supports, and extended brakes are all important options, but are not the most important mechanisms in this situation.