NURS 120 WEEK 3 QUIZ
A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of a. a fluid-filled sac found at some joints. b. a synovial membrane that lines the joint. c. the connective tissue joining bones within a joint. d. the fibrocartilage that acts as a shock absorber in the knee
a. a fluid-filled sac found at some joints.
A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. assess the surgical site for hemorrhage. b. remove the prosthesis and wrap the site. c. place the patient in a side-lying position. d. keep the residual limb elevated on a pillow.
a. assess the surgical site for hemorrhage.
A patient complains of shoulder pain when the nurse moves the patient's arm behind the back. Which question should the nurse ask? a. "Are you able to feed yourself without difficulty?" b. "Do you have difficulty when you are putting on a shirt?" c. "Are you able to sleep through the night without waking?" d. "Do you ever have trouble lowering yourself to the toilet?"
b. "Do you have difficulty when you are putting on a shirt?
Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."
b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day."
A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective? a. "I will keep my back straight when I lift above than my waist." b. "I will begin doing exercises to strengthen and support my back." c. "I will tell my boss I need a job where I can stay seated at a desk." d. "I can sleep with my hips and knees extended to prevent back strain."
b. "I will begin doing exercises to strengthen and support my back."
A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed? a. "After I apply the medication, I can get dressed as usual." b. "If the medication burns when I apply it, I will wipe it off." c. "I need to minimize time in the sun while using the Elidel." d. "I will rub the medication in gently every morning and night."
b. "If the medication burns when I apply it, I will wipe it off."
The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. c. Check the O2 saturation. b. Assess patient orientation. d. Observe for facial asymmetry.
c. Check the O2 saturation.
The nurse should reposition the patient who has just had a laminectomy and diskectomy by a. instructing the patient to move the legs before turning the rest of the body. b. having the patient turn by grasping the side rails and pulling the shoulders over. c. placing a pillow between the patient's legs and turning the entire body as a unit. d. turning the patient's head and shoulders first, followed by the hips, legs, and feet.
c. placing a pillow between the patient's legs and turning the entire body as a unit.
The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."
d. "I can sleep in any position that is comfortable for me."
The nurse notes crackling sounds and a grating sensation with palpation of an older patient's elbow. How will this finding be documented? a. Torticollis c. Subluxation b. Crepitation d. Epicondylitis
b. Crepitation
Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? a. Ask the patient about any nausea. b. Obtain the patient's oral temperature. c. Review the patient's serum creatinine. d. Change the prescribed wet-to-dry dressing.
c. Review the patient's serum creatinine.
Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.
d. Capillary refill to the fingers is prolonged.
The nurse notes the presence of white lesions that resemble milk curds in the back of a patient's throat. Which question by the nurse is appropriate at this time? a. "Are you taking any medications?" b. "Do you have a productive cough?" c. "How often do you brush your teeth?" d. "Have you had an oral herpes infection?"
a. "Are you taking any medications?"
A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "Check and clean the pin insertion sites daily." b. "Remove the external fixator for your shower." c. "Remain on bed rest until bone healing is complete." d. "Take prophylactic antibiotics until the fixator is removed."
a. "Check and clean the pin insertion sites daily."
Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)? a. Administer patch testing to a patient with allergic dermatitis. b. Interview a new patient about chronic health problems and allergies. c. Apply a sterile dressing after the health care provider excises a mole. d. Explain potassium hydroxide testing to a patient with a skin infection. e. Teach a patient about site care after a punch biopsy of an upper arm lesion.
a. Administer patch testing to a patient with allergic dermatitis. c. Apply a sterile dressing after the health care provider excises a mole.
Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? a. Assess for hip pain. c. Check peripheral pulses. b. Assess for contractures. d. Monitor for hip dislocation
a. Assess for hip pain.
A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? a. Check the patient's prescribed weight-bearing status. b. Use a mechanical lift to transfer the patient to the chair. c. Delegate the transfer to nursing assistive personnel (NAP). d. Decrease the pain medication before getting the patient up.
a. Check the patient's prescribed weight-bearing status.
The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan? a. Clean the infected areas with soap and water. b. Apply alcohol-based cleansers on the lesions. c. Avoid use of antibiotic ointments on the lesions. d. Use petroleum jelly (Vaseline) to soften crusty areas.
a. Clean the infected areas with soap and water.
Which finding from analysis of fluid from a patient's right knee arthrocentesis will be of concern to the nurse? a. Cloudy fluid c. Pale yellow fluid b. Scant thin fluid d. Straw-colored fluid
a. Cloudy fluid
A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)? a. Cool, wet cloths or compresses can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. c. Add oil to your bath water to aid in moisturizing the affected skin. d. Rub yourself dry with a towel after bathing to prevent skin maceration. e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.
a. Cool, wet cloths or compresses can be used to reduce itching. b. Take cool or tepid baths several times daily to decrease itching. e. Use of an over-the-counter (OTC) antihistamine can reduce scratching.
Which nursing action is correct when performing the straight-leg raising test for an ambulatory patient with back pain? a. Lift the patient's leg to a 60-degree angle from the bed. b. Place the patient in the prone position on the exam table. c. Ask the patient to dangle both legs over the edge of the exam table. d. Instruct the patient to elevate the legs and tense the abdominal muscles.
a. Lift the patient's leg to a 60-degree angle from the bed.
Which actions will the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur (select all that apply)? a. Monitor serum calcium. b. Teach about the need for strict bed rest. c. Discontinue use of sustained-release opioids. d. Support the left leg when repositioning the patient. e. Support family and patient as they discuss the prognosis.
a. Monitor serum calcium. d. Support the left leg when repositioning the patient. e. Support family and patient as they discuss the prognosis.
A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.
a. Notify the health care provider.
The nurse working in the dermatology clinic assesses a young adult female patient who has. severe cystic acne. Which assessment finding is of concern related to the patient's prescribed isotretinoin ? a. The patient recently had an intrauterine device removed. b. The patient already has some acne scarring on her forehead. c. The patient has also used topical antibiotics to treat the acne. d. The patient has a strong family history of rheumatoid arthritis
a. The patient recently had an intrauterine device removed.
In which order will the nurse implement these interprofessional interventions prescribed for a patient admitted with acute osteomyelitis with a temperature of 101.2° F? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain blood cultures from two sites. b. Administer dose of gentamicin 60 mg IV. c. Send to radiology for computed tomography (CT) scan of right leg. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever
a. Obtain blood cultures from two sites. b. Administer dose of gentamicin 60 mg IV. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever c. Send to radiology for computed tomography (CT) scan of right leg.
A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take? a. Prepare the patient for a skin biopsy. b. Teach the use of corticosteroid cream. c. Explain how to apply tretinoin (Retin-A) to the face. d. Discuss the need for topical application of antibiotics.
a. Prepare the patient for a skin biopsy.
Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain intensity and tolerance.
a. Reposition the patient every 1 to 2 hours.
Which action will the nurse take when caring for a patient with osteomalacia? a. Teach about the use of vitamin D supplements. b. Educate about the need for weight-bearing exercise. c. Discuss the use of medications such as bisphosphonates. d. Emphasize the importance of sunscreen use when outside.
a. Teach about the use of vitamin D supplements.
A patient has a new order for magnetic resonance imaging (MRI) to evaluate possible left femur osteomyelitis after hip arthroplasty surgery. Which information indicates the nurse should consult with the health care provider before scheduling the MRI? a. The patient has a pacemaker. c. The patient wears a hearing aid. b. The patient is claustrophobic. d. The patient is allergic to shellfish.
a. The patient has a pacemaker
A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect? a. Thinning of the affected skin c. Dryness and scaling in the area b. Alopecia of the affected areas d. Reddish-brown skin discoloration
a. Thinning of the affected skin
Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection? a. Use a sunscreen with a high SPF when exposed to the sun. b. Sun exposure may decrease the effectiveness of the medication. c. Photosensitivity may result in an artificial-looking tan appearance. d. Wear sunglasses to avoid eye damage while taking this medication.
a. Use a sunscreen with a high SPF when exposed to the sun.
A patient with severe kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. The nurse will plan to a. explain the procedure. b. start an IV line for contrast medium injection. c. give an oral sedative 60 to 90 minutes before the procedure. d. screen the patient for allergies to shellfish or iodine products.
a. explain the procedure.
The occupational health nurse will teach the patient whose job involves many hours of typing to a. obtain a keyboard pad to support the wrist. b. do stretching exercises before starting work. c. wrap the wrists with compression bandages every morning. d. avoid using nonsteroidal anti-inflammatory drugs (NSAIDs) for pain
a. obtain a keyboard pad to support the wrist.
A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You will not be able to serve a tennis ball again." b. "You will begin work with a physical therapist tomorrow." c. "Keep the shoulder immobilizer on for the first 4 days to minimize pain." d. "The surgeon will use the drop-arm test to determine the success of surgery."
b. "You will begin work with a physical therapist tomorrow."
The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient's instructions? a. "5-FU will shrink the lesion to prepare for surgical excision." b. "Your cheek area will be eroded and it will take several weeks to heal." c. "You may develop nausea and anorexia, but good nutrition is important during treatment." d. "You will need to avoid crowds because of the risk for infection caused by chemotherapy."
b. "Your cheek area will be eroded and it will take several weeks to heal."
There is one opening in the schedule at the dermatology clinic, and four patients are seeking appointments today. Which patient will the nurse schedule for the available opening? a. 50-yr-old with skin redness after having a chemical peel 3 days ago b. 38-year old with a 7-mm nevus on the face that has recently become darker c. 62-yr-old with multiple small, soft, pedunculated papules in both axillary areas d. 42-yr-old with complaints of itching after using topical fluorouracil on the nose
b. 38-year old with a 7-mm nevus on the face that has recently become darker
A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. The patient complains of pelvic pain with palpation. d. Ecchymoses are visible across the abdomen and hips.
b. Abdomen is distended and bowel sounds are absent.
After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.
b. Administer prescribed PRN O2 at 4 L/min.
The day after a having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take? a. Explain the reasons for the pain. b. Administer prescribed analgesics. c. Reposition the patient to assure good alignment. d. Inform the patient that this pain will diminish over time.
b. Administer prescribed analgesics.
Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take? a. Observe output from the surgical drain. b. Administer prescribed pain medication. c. Instruct the patient about benefits of early ambulation. d. Change the dressing and document the wound appearance.
b. Administer prescribed pain medication.
Which action will the urgent care nurse take for a patient with a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Apply an immobilizer to the affected leg. c. Avoid palpation or movement of the knee. d. Administer intravenous opioids for pain management
b. Apply an immobilizer to the affected leg.
Which action will the nurse take first when a patient is seen in the outpatient clinic with neck pain? a. Provide information about therapeutic neck exercises. b. Ask about numbness or tingling of the hands and arms. c. Suggest the patient alternate the use of heat and cold to the neck. d. Teach about the use of nonsteroidal anti-inflammatory drugs (NSAIDs).
b. Ask about numbness or tingling of the hands and arms.
Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient
b. Ask the patient about abdominal discomfort.
When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next? a. Suggest an appointment with a dermatologist. b. Assess the patient for evidence of liver disease. c. Teach the patient about skin changes with aging. d. Discuss the use of sunscreen to prevent skin cancers.
b. Assess the patient for evidence of liver disease.
A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Logroll the patient every 2 hours. b. Assist the patient with ambulation. c. Discuss the need for genetic testing with the patient. d. Teach the patient about the muscle biopsy procedure.
b. Assist the patient with ambulation.
When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Remove and reapply traction periodically. b. Ensure the weight for the traction is hanging freely. c. Monitor the skin under the traction boot for redness. d. Check for intact sensation and movement in the affected leg.
b. Ensure the weight for the traction is hanging freely.
A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information will be included in the discharge teaching? a. How to apply warm packs to the leg to reduce pain b. How to monitor and care for a long-term IV catheter c. The need for daily aerobic exercise to help maintain muscle strength d. The reason for taking oral antibiotics for 7 to 10 days after discharge
b. How to monitor and care for a long-term IV catheter
A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention will the nurse include in the initial plan of care? a. Quadriceps-setting exercises b. Immobilization of the left leg c. Positioning the left leg in flexion d. Assisted weight-bearing ambulation
b. Immobilization of the left leg
A 35-yr-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain? a. History of sun exposure by the patient b. Method of contraception used by the patient c. Length of time the patient has used fluorouracil d. Appearance of the treated areas on the patient's face
b. Method of contraception used by the patient
Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic? a. Grade leg muscle strength for a patient with back pain. b. Obtain blood sample for uric acid from a patient with gout. c. Perform straight-leg-raise testing for a patient with sciatica. d. Check for knee joint crepitation before arthroscopic surgery.
b. Obtain blood sample for uric acid from a patient with gout.
A teenaged male patient who is on a wrestling team is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis? a. Ring - like rashes with red, scaly borders over the entire scalp b. Papular, wheal-like lesions with white deposits on the hair shaft c. Patchy areas of alopecia with small vesicles and excoriated areas d. Red, hive - like papules and plaques with sharply circumscribed borders
b. Papular, wheal-like lesions with white deposits on the hair shaft
Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.
b. Patient has been incontinent of urine and stool.
A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first? a. Patient who reports foot pain after hammertoe surgery b. Patient who has not voided 10 hours after a laminectomy c. Patient with low back pain and a positive straight-leg-raise test d. Patient with osteomyelitis who has a temperature of 100.5° F (38.1° C)
b. Patient who has not voided 10 hours after a laminectomy
The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding? a. Elevate the patient's leg. b. Press firmly on the lesion. c. Check the temperature of the skin around the lesion. d. Palpate the dorsalis pedis and posterior tibial pulses.
b. Press firmly on the lesion.
Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of concern to the nurse? a. Brown macules on extremities b. Reports a history of allergic rashes c. Skin wrinkled with tenting on both hands d. Longitudinal nail ridges and sparse scalp hair
b. Reports a history of allergic rashes
Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm synthetic cast? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."
c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours."
During assessment of the patient's skin, the nurse observes a similar pattern of discrete, small, raised lesions on the left and right upper back areas. Which term should the nurse use to document the distribution of these lesions? a. Confluent c. Zosteriform b. Symmetric d. Generalized
b. Symmetric
A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.
b. The patient advances the left leg and both crutches together and then advances the right leg.
A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull on shoes and socks. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.
b. The patient leans over to pull on shoes and socks.
A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching? a. The patient has multiple dysplastic nevi. b. The patient uses a tanning booth weekly. c. The patient is fair-skinned and has blue eyes. d. The patient's mother died of a malignant melanoma.
b. The patient uses a tanning booth weekly.
Which information in a 67-yr-old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? a. The patient sprained her ankle at age 13. b. The patient's mother became shorter with aging. c. The patient takes ibuprofen for occasional headaches. d. The patient's father died of complications of miliary tuberculosis.
b. The patient's mother became shorter with aging.
A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect? a. Hypertrophied scars on both ankles b. Thickening of the skin around the ankles c. Yellowish-brown skin around both ankles d. Complete absence of melanin in both ankles
b. Thickening of the skin around the ankles
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin? a. Use a sunscreen with an SPF of at least 10 for adequate protection. b. Try to stay out of the direct sun between the hours of 10 AM and 2 PM. c. Water resistant sunscreens will provide good protection when swimming. d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
b. Try to stay out of the direct sun between the hours of 10 AM and 2 PM.
A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implement first? a. Send the patient for ankle x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3)
b. Wrap the ankle and apply an ice pack.
An assessment finding for a 55-yr-old patient that alerts the nurse to the presence of osteoporosis is a. bowed legs. c. the report of frequent falls. b. a loss of height. d. an aversion to dairy products.
b. a loss of height.
When administering alendronate (Fosamax) to a patient with osteoporosis, the nurse will a. ask about any leg cramps or hot flashes. b. assist the patient to sit up at the bedside. c. be sure that the patient has recently eaten. d. administer the ordered calcium carbonate.
b. assist the patient to sit up at the bedside.
A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.
b. avoid handling the cast using fingertips.
After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to a. report the patient's complaint to the surgeon. b. check the chart for preoperative assessment data. c. check the vital signs for indications of hemorrhage. d. turn the patient to the left to relieve pressure on the right leg
b. check the chart for preoperative assessment data.
The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.
b. for at least 3 weeks.
The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.
b. how and when to cut the immobilizing wires.
The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which statement by a patient indicates additional patient teaching is needed? a. "I will need to participate in physical therapy after surgery." b. "I wish I did not need to have chemotherapy after this surgery." c. "I did not have this bone cancer until my leg broke a week ago." d. "I can use the patient-controlled analgesia (PCA) to manage postoperative pain."
c. "I did not have this bone cancer until my leg broke a week ago."
A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."
c. "I will be able to use my fingers with more flexibility to grasp things."
After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."
c. "Tell me what you know about your options for treatment."
After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first? a. Elevate the leg on 2 pillows. c. Assess leg pulses and sensation. b. Apply a compression bandage. d. Place ice packs on the lower leg.
c. Assess leg pulses and sensation.
In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle crash? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.
c. Assess lung sounds. d. Take blood pressure. b. Check pedal pulses. e. Apply splint to the leg. a. Obtain x-rays. f. Administer tetanus prophylaxis.
A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.
c. Assess the left axilla and change absorbent dressings as needed.
Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Expect most falls to happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Get instruction in range-of-motion exercises from a physical therapist.
c. Buy shoes that provide good support and are comfortable to wear.
When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Avoid nonsteroidal anti-inflammatory drugs (NSAIDs). c. Call the health care provider for numbness of the hand. d. Keep the hand immobile to prevent soft tissue swelling.
c. Call the health care provider for numbness of the hand.
A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse assess this patient for cyanosis? a. Assess the skin color of the earlobes. b. Apply pressure to the palms of the hands. c. Check the lips and oral mucous membranes. d. Examine capillary refill time of the nail beds.
c. Check the lips and oral mucous membranes.
When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurse's most important action? a. Instruct the patient about the importance of nutrition for skin health. b. Make a referral to a podiatrist so that the nails can be safely trimmed. c. Consult with the health care provider about the need for further diagnostic testing. d. Teach the patient about using moisturizing creams and lotions to decrease dry skin
c. Consult with the health care provider about the need for further diagnostic testing.
The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure? a. Sterile gloves c. Cotton-tipped applicators b. Patch test instruments d. Syringe and intradermal needle
c. Cotton-tipped applicators
Which information will the nurse include when teaching a patient with acute low back pain (select all that apply)? a. Sleep in a prone position with the legs extended. b. Keep the knees straight when leaning forward to pick something up. c. Expect symptoms of acute low back pain to improve in a few weeks. d. Avoid activities that require twisting of the back or prolonged sitting. e. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.
c. Expect symptoms of acute low back pain to improve in a few weeks. d. Avoid activities that require twisting of the back or prolonged sitting. e. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.
A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy? a. Shave biopsy c. Incisional biopsy b. Punch biopsy d. Excisional biopsy
c. Incisional biopsy
Which nursing action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Check ability to plantar and dorsiflex the foot. b. Determine the patient's readiness to ambulate. c. Log roll the patient from side to side every 2 hours. d. Ask about pain management with the patient-controlled analgesia (PCA).
c. Log roll the patient from side to side every 2 hours.
Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)? a. Treatment plans include watchful waiting. b. Screening for metastasis will be important. c. Minimizing sun exposure reduces risk for future BCC. d. Low dose systemic chemotherapy is used to treat BCC
c. Minimizing sun exposure reduces risk for future BCC.
Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider? a. Dry, scaly patches on the face b. Numerous varicosities on both legs c. Petechiae on the chest and abdomen d. Small dilated blood vessels on the face
c. Petechiae on the chest and abdomen
A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot
c. Slow capillary refill of the left foot
When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patient's body. Which action should the nurse take first? a. Ensure the patient wears shoes with nonslip soles. b. Discourage using throw rugs throughout the house. c. Talk with the patient alone and ask about the bruising. d. Notify the health care provider so that radiographs can be ordered.
c. Talk with the patient alone and ask about the bruising.
The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed? a. The patient takes a tepid bath before applying the cream. b. The patient spreads the cream using a downward motion. c. The patient applies a thick layer of the cream to the affected skin. d. The patient covers the area with a dressing after applying the cream
c. The patient applies a thick layer of the cream to the affected skin.
Which medication information will the nurse identify as a potential risk to a patient's musculoskeletal system? a. The patient takes a daily multivitamin and calcium supplement. b. The patient takes hormone replacement therapy (HRT) to prevent "hot flashes." c. The patient has severe asthma requiring frequent therapy with oral corticosteroids. d. The patient has headaches treated with nonsteroidal anti-inflammatory drugs (NSAIDs).
c. The patient has severe asthma requiring frequent therapy with oral corticosteroids.
Which information obtained during the nurse's assessment of a patient's nutritional-metabolic pattern may indicates increased risk for musculoskeletal problems? a. The patient takes a multivitamin daily. b. The patient dislikes fruits and vegetables. c. The patient is 5 ft, 2 in tall and weighs 180 lb. d. The patient prefers whole milk to nonfat milk.
c. The patient is 5 ft, 2 in tall and weighs 180 lb.
The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching? a. The patient applies corticosteroid cream to pruritic areas. b. The patient adds oilated oatmeal to the bath water every day. c. The patient uses bacitracin-neomycin-polymyxin on minor abrasions. d. The patient takes diphenhydramine at night if persistent itching occurs.
c. The patient uses bacitracin-neomycin-polymyxin on minor abrasions.
A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.
c. The right arm appears shorter than the left.
When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation
c. Use a cervical collar to stabilize the spine.
Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.
c. Use pillows to elevate the ankle above the heart.
Which information will the nurse include when teaching an older patient about skin care? a. Dry the skin thoroughly before applying lotions. b. Bathe and wash hair daily with soap and shampoo. c. Use warm water and a moisturizing soap when bathing. d. Use antibacterial soaps when bathing to avoid infection.
c. Use warm water and a moisturizing soap when bathing.
What is the best method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus? a. Change the dressing using sterile gloves. b. Apply antibiotic ointment over the wound. c. Wash hands and properly dispose of soiled dressings. d. Soak the dressing in sterile normal saline before removal.
c. Wash hands and properly dispose of soiled dressings.
A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. c. assess the pedal pulses. b. splint the lower leg. d. verify tetanus immunization.
c. assess the pedal pulses.
A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. have the patient lift the buttocks slightly by using a trapeze over the bed. d. turn the patient partially to each side with the assistance of another nurse
c. have the patient lift the buttocks slightly by using a trapeze over the bed.
A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. The nurse identifies a need for additional teaching related to health maintenance when the nurse finds that the patient a. is frustrated with the length of treatment required. b. takes and records the oral temperature twice a day. c. is unable to plantar flex the foot on the affected side. d. uses crutches to avoid weight bearing on the affected leg.
c. is unable to plantar flex the foot on the affected side.
An appropriate nursing intervention for a patient who has acute low back pain and muscle spasms is to teach the patient to a. keep both feet flat on the floor when prolonged standing is required. b. twist gently from side to side to maintain range of motion in the spine. c. keep the head elevated slightly and flex the knees when resting in bed. d. avoid the use of cold packs because they will exacerbate the muscle spasms
c. keep the head elevated slightly and flex the knees when resting in bed.
A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. a knee immobilizer. c. monitored anesthesia care. b. gentle knee flexion. d. physical activity restrictions.
c. monitored anesthesia care.
After completing the health history, the nurse assessing the musculoskeletal system will begin by a. having the patient move the extremities against resistance. b. feeling for the presence of crepitus during joint movement. c. observing the patient's body build and muscle configuration. d. checking active and passive range of motion for the extremities.
c. observing the patient's body build and muscle configuration.
The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should document the patient's muscle strength as level a. 0. c. 2. b. 1. d. 3
d. 3
The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2 . What is the nurse's appropriate action? a. Discuss the use of drying agents to minimize infection risk. b. Instruct the patient about the use of mild soap to clean skinfolds. c. Teach the patient about treating fungal infections in the skinfolds. d. Ask the patient about a personal or family history of type 2 diabetes.
d. Ask the patient about a personal or family history of type 2 diabetes.
A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first? a. Discuss the possibility of participating in an online support group. b. Encourage the patient to volunteer to work on community projects. c. Suggest that the patient use cosmetics to cover the psoriatic lesions. d. Ask the patient to describe the impact of psoriasis on quality of life.
d. Ask the patient to describe the impact of psoriasis on quality of life.
The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Applying antibiotic cream to the groin b. Obtaining cultures from ruptured lesions c. Evaluating the patient's personal hygiene d. Cleaning the skin with antimicrobial soap
d. Cleaning the skin with antimicrobial soap
The nurse is developing a health promotion plan for an older adult who worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)? a. Vitiligo b. Alopecia c. Intertrigo d. Erythema e. Actinic keratosis
d. Erythema e. Actinic keratosis
A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure? a. Shield any unaffected areas with lead-lined drapes. b. Apply petroleum jelly to the areas around the lesions. c. Cleanse the skin carefully with antiseptic soap prior to PUVA. d. Have the patient use protective eyewear while receiving PUVA.
d. Have the patient use protective eyewear while receiving PUVA.
Which finding for a 77-yr-old patient seen in the outpatient clinic requires further nursing assessment and intervention? a. Symmetric joint swelling of fingers b. Decreased right knee range of motion c. Report of left hip aching when jogging d. History of recent loss of balance and fall
d. History of recent loss of balance and fall
Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? a. Pancakes with syrup and bacon b. Whole wheat toast and fresh fruit c. Egg-white omelet and a half grapefruit d. Oatmeal with skim milk and fruit yogurt
d. Oatmeal with skim milk and fruit yogurt
After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is complaining of facial pain b. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity d. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf
d. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf
Which action will the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty? a. Avoid extension of the right knee beyond 120 degrees. b. Use a compression bandage to keep the right knee flexed. c. Teach about the need to avoid weight bearing for 4 weeks. d. Start progressive knee exercises to obtain 90-degree flexion.
d. Start progressive knee exercises to obtain 90-degree flexion.
A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure? a. Curettage c. Punch biopsy b. Cryosurgery d. Surgical excision
d. Surgical excision
An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care? a. Schedule daily appointments for dressing changes. b. Describe the use of topical fluorouracil on the incision. c. Teach how to use sterile technique to clean the suture line. d. Teach the use of cold packs to reduce bruising and swelling
d. Teach the use of cold packs to reduce bruising and swelling
Which assessment finding for a patient who has had surgical reduction of an open fracture of the right radius requires notification of the health care provider? a. Serous wound drainage c. Right arm pain with movement b. Right arm muscle spasms d. Temperature 101.4° F (38.6° C)
d. Temperature 101.4° F (38.6° C)
The nurse assesses a patient who has just arrived in the post-anesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately? a. The patient complains of incisional pain. b. The patient's heart rate is 110 beats/min. c. The patient is unable to detect when the eyelids are touched. d. The skin around the incision is pale and cold when palpated.
d. The skin around the incision is pale and cold when palpated.
A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman, the nurse explains that a. with a family history of osteoporosis, there is no way to prevent or slow bone resorption. b. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. c. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. d. calcium loss from bones can be slowed by increasing calcium intake and weightbearing exercise.
d. calcium loss from bones can be slowed by increasing calcium intake and weightbearing exercise
The nurse who notes that a 59-yr-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about a. discography studies. b. myelographic testing. c. magnetic resonance imaging (MRI). d. dual-energy x-ray absorptiometry (DXA)
d. dual-energy x-ray absorptiometry (DXA)
A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. c. wearing a left wrist splint. b. elbow injections. d. modifying arm movements.
d. modifying arm movements.
The nurse will determine more teaching is needed if a patient with discomfort from a bunion says, "I will a. give away my high-heeled shoes." b. take ibuprofen (Motrin) if I need it." c. use the bunion pad to cushion the area." d. only wear sandals, no closed-toe shoes."
d. only wear sandals, no closed-toe shoes."
The nurse evaluating effectiveness of prescribed calcitonin and ibandronate (Boniva) for a patient with Paget's disease will consider the patient's a. oral intake. c. grip strength. b. daily weight. d. pain intensity
d. pain intensity
The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.
d. risk for infection related to disruption of skin integrity.
When assessing for Tinel's sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. burning in the right elbow and forearm. c. tremor when gripping with the right hand. d. tingling in the right thumb and index finger
d. tingling in the right thumb and index finger
