PN Test 5

A patient on bed rest has been instructed on performing quadriceps setting exercises. What statement by the patient indicates the need for further instruction? a. "I should hold the muscle in contraction for at least a minute." b. "I should release the muscle and count to five before contracting again." c. "The exercises will benefit me most if I perform them three to four times a day." d. "These exercises are good to recondition my muscles in preparation for getting out of bed."

a Quadriceps setting exercises are a helpful tool to recondition the muscles after injury or surgery. The muscle contraction should be "held" for a count of five, not a full minute. The patient would be correct in stating that he should release the muscle and count to five before contracting again, that the most benefit will be obtained from performing them three to four times a day, and that they are good for reconditioning muscles in preparation for getting out of bed.

a nurse is assessing a client as part of an admission history. the client reports drinking an herbal tea every afternoon at work to relieve stress. the nurse should suspect the tea includes which of the following ingredients? a. chamomile b. ginseng c. ginger d. echinacea

a the nurse should suspect that the tea contains chamomile. ginger helps with nausea. ginseng improves physical endurance. echinacea boosts the immune system

the client with a cervical spine injury has crutchfield tongs applied in the ED. the nurse should perform which essential action when caring for this client? a. providing a standard bedframe b. removing the weights to reposition the client c. removing the weights if the client is uncomfortable d. comparing the amount of prescribed weights with the amount is use

b the client should not drive because the device impairs the range of vision

a nurse is reviewing the medical record for a client who has RA. the nurse should review which of the following lab results when monitoring this disease? select all that apply a. urinalysis b. erythrocyte sedimentation rate (ESR) c. BUN d. antinuclear antibody (ANA) titer e. WBC count

b, d, e ESR, ANA, and WBC diagnoses RA. urinalysis and BUN detect kidney function

a nurse is caring for a preschooler who is experiencing mild pain. which of the following types of medication should the nurse administer first? a. opioid analgesic b. antianxiety medication c. nonsteroidal antiinflammatory drug d. sedative

c according to evidence based practice the nurse should administer a nonopioid medication. opioids can only be given if moderate to severe pain. only give an antianxiety and sedative if nonopioid analgesic doesnt work.

a nurse responds to a roadside emergency and finds a middle aged man with pain and tenderness over the left leg. the nurse notes a closed bone deformity with inability to move the leg. while waiting for the paramedics what is the most important nursing action? a. immobilization of the leg b. realigning the bones c. applying warm packs d. elevating the extremity

a The most important action is to immobilize the leg so that bone fragments do not do more tissue damage and so movement doesn't cause increased pain. The nurse must not try to realign the bones. Warm packs are not applied to a fracture and the nurse wouldn't have them in this situation. Elevating the extremity would be helpful if possible after the leg is immobilized.

The nurse is caring for a patient who has experienced a stroke. The nurse has implemented range-of-motion exercises. The nurse recognizes that contractures may begin within what time period? a. 1 week b. 1 month c. 2 weeks d. 24 hours

a When skeletal muscles are not regularly stretched and contracted to their normal limits, they attempt to adapt themselves to this limited use by becoming shorter and less elastic. An "adaptive shortening," or contracture, begins to form within 3 to 7 days after immobilization of a body part, and the process usually is complete in 6 to 8 weeks.

A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete? a. Gait and balance b. Speech and hearing c. Mental alertness d. Ability to follow directions

a When the patient is walking, the nurse is assessing for gait and balance (mobility). Speech, hearing, mental alertness, and the ability to follow directions do not have a bearing on mobility.

a client is being discharged home after application of a plaster leg house. the nurse determines that the client understands proper care of the cast if the client makes which statement? a. i need to avoid getting the cast wet b. i will use my fingertips to lift and move the cast c. i need to cover the casted leg with warm blankets d. i can use a padded coat hanger end to scratch under the cast

a a plaster cast must remain dry to keep its strength. the cast should be handled using the palms of the hand not the fingertips until fully dry. air should circulate freely around the cast to help it dry, the cast gives off heat as it dries. the client should never scratch under a cast. a cool hair dryer can be used to help eliminate itching

the nurse is caring for a client with the fresh application of a plaster leg cast. the nurse should plan to prevent the development of compartment syndrome by which action? a. elevating the limb and applying ice to the affected leg b. elevating the limb and covering the limb with bath blankets c. keeping the leg horizontal and applying ice to the affected leg d. placing the leg in a slightly dependent position and applying ice

a compartment syndrome is prevented by controlling edema. this is achieved most optimally with elevation and application of ice. therefore the other options are incorrect

a nurse is caring for a client scheduled for abdominal surgery. the client reports of being worried. which of the following actions should the nurse take? a. offer information on a relaxation technique and ask the client if he is interested in trying it b. request a social worker see the client to discuss meditation c. attempt to use biofeedback techniques with the client d. tell the client many people feel the same way before surgery and to think of something else

a its appropriate for the nurse to to recommend a noninvasive technique to facilitate coping and allow the client to make an informed decision about care. meditation does not require special training, biofeedback requires special training, and the last choice is not therapeutic because it is stereotyping and dismisses the clients feelings.

a client has just undergone a CT scan with a contrast medium. which statement by the client demonstrates an understanding of postprocedure? a. i should drink extra fluids for the remainder of the day b. i should not take any medication for atleast 4 hours c. i should eat lightly for the remainder of the day d. i should rest quietly for the remainder of the day

a the client may resume all activities, but drink extra fluids to replace those lost with diuresis from the contrast

a nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. the nurse asks the client whether she has been vomiting or nausea. which of the following pain characteristics is the nurse attempting to determine? a. presence of associated manifestations b. location of the pain c. pain quality d. aggravating and relieving factors

a the nurse should attempt to identify manifestations about the pain. the nurse should ask about the other options, but it is asking for what manifestations the nurse is trying to ask

a nurse is planning care for a client who is on bed rest. which of the following interventions should the nurse include? a. encourage the client to perform antiembolic exercises every 2 hours b. instruct the client to cough and deep breathe every 4 hours c. restrict the clients fluid intake d. reposition the client every 4 hours

a the nurse should encourage the patient to perform antiembolic exercises every 1-2 hours to promote venous return. the nurse should instruct the client to cough and deep breathe every 1-2 hours, the nurse should increase the intake of fluid, and the nurse should repositon every 1-2 hours to prevent pressure ulcers

a nurse is caring for a client who ha several risk factors for hearing loss. which of the following medications that the client currently takes should alert the nurse to further risk for ototoxicity? select all that apply a. furosemide b. ibuprofen c. cimetidine d. simvastatin e. amiodarone

a, b furosemide can cause hearing loss as well as blurred vision, and ibuprofen can cause hearing loss as well as vision loss. cimetidine decreases gastric acid and has no effect on hearing, simvastatin helps lower cholesterol, and has no effect on hearing. amiodarone an antidysrhythmic medication is more likely to cause blurred vision instead of hearing loss

a 24 year old woman limps into the ED after twisting her ankle during a soccer game. on examination there is local swelling and difficulty maintaining balance. what immediate therapeutic measures should the nurse provide? select all that apply a. application of elastic bandage b. application of an ice pack c. elevation of the ankle d. ankle rest and limited weight bearing e. application of topical anesthetic

a, b, c Elevation, application of ice, and then wrapping with an elastic bandage are immediate measures used in the emergency department for a sprained ankle. Ankle rest and limited weight bearing should occur after leaving the E. R. A topical anesthetic is not used for an ankle sprain.

The patient presents to the clinic after falling from her bike and is diagnosed with a Grade II ankle sprain. The nurse should make which statements to the patient regarding the treatment of her sprained ankle? Select all that apply. a. "Rest your ankle as much as possible." b. "Prop your ankle on pillows while resting." c. "You should wrap your ankle with an elastic bandage." d. "Take stimulant laxatives with your narcotic pain medication." e. "Place an ice pack on your ankle for 30 minutes every 4 hours." f. "Begin walking on your injured ankle after 24 hours, and increase your ambulation as tolerated."

a, b, c The nurse should educate the patient about the acronym RICE: rest, ice, compression, and elevation. The patient will not likely be prescribed a narcotic pain medication for a grade II sprain. In addition, increased fluids and dietary fluids would be recommended first, then a stool softener, and, lastly, a laxative. The patient should use an ice pack for 10 to 20 minutes every 1 to 2 hours. The patient should not walk on the ankle until cleared by the physician.

the nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. which instructions should the nurse include on the list? select all that apply a. keep the casts and extremity elevated b. the cast needs to be kept dry and clean c. allow the wet cast 24-72 hours to dry d. expect tingling and numbness in the extremity e. use a hair dryer set on warm to hot setting to dry the cast f. use a soft padded object that will fit under the cast to scratch the skin under the cast

a, b, c a plaster cast takes about 24-72 hours to dry (synthetic casts take about 20 minutes to dry). the cast and extremity may be elevated to reduce edema. a wet cast is handled with the palms of the hand until the cast is dry. a cool setting on a hair dryer may be used. heat causes the cast to warm and can cause burns under the cast. the cast needs to be kept clean and dry. instruct the client to not use anything to scratch under the cast, because it could cause an infection instruct the client to report and pain swelling, discoloration, tingling, numbness or coolness, or diminished pulse.

a nurse is reviewing a providers prescription by telephone for morphine for a client who is reporting moderate to severe pain. which of the following nursing actions are appropriate? select all that apply a. repeat the details of the prescription to the provider b. have another nurse listen to the phone prescription c. obtain the providers signature on the prescription within 24 hours d. decline the verbal prescription within 24 hours e. tell the charge nurse that the provider has prescribed morphine by telephone

a, b, c the nurse should repeat the medication information, having another nurse listen to the phone is a safety precaution, and the provider must sign the prescription within 24 hours. unrelieved pain could become an emergency situation. there is no need to inform a charge nurse every time an order is given over the phone

a nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. which of the following information should the nurse include? select all that apply a. clients who smoke should consider cessation programs b. clients who have DM should maintain blood glucose within the expected reference range c. unplug electrical equipment when performing repairs d. clients who have vascular disease should maintain good foot care e. wait 2 hours after taking pain medication to drive

a, b, c, d smoking cessation, regulating blood glucose and maintaining good foot care can help prevent arteriosclerosis. unplugging equipment prevents electrocution. driving under the influence of medication could lead to an amputation

a nurse is reviewing information with a client who has osteoarthritis of the hip and knee. which of the following instructions should the nurse reinforce? select all that apply a. apply heat to joints to alleviate pain b. iced inflamed joints following activity c. install an elevated toilet seat d. take tub baths e. complete high energy activities in the morning

a, b, c, e applying heat helps to relieve temporary pain, applying ice to inflamed joints decreases edema, elevated toilet seat can help to reduce strain on the affected joints, and encouraging high activity in the morning helps promote independence. taking a tub bath increases strain on affected joints

The nurse is providing education to a middle-aged female about her changing health needs. The nurse should be sure to include information on which age-related changes? Select all that apply. a. Loss of bone mass b. Decrease in height c. Increased circulation d. Decreased muscle mass e. Increased mineral exchange

a, b, d Osteoporosis is especially prevalent in women and is partially responsible for the decrease in height of both genders. Loss of muscle mass and strength is also a function of aging. Mineral exchange and circulation decrease with age.

a nurse is instructing a client who has an injury to the left lower extremity, about the use of a cane. which of the following instructions should the nurse include? select all that apply a. hold the cane to the right side b. keep two points of support on the floor c. place the cane 15 inches in front of the feet before advancing d. after advancing the cane, move the weaker food forward e. advance the stronger leg so that it aligns evenly with the cane

a, b, d the client should hold the cane on the uninjured side of the body, the client should keep two sides of support, and the client should advance the weaker leg first and then the stronger leg.

a nurse is discussing occurrences that will require completion of an incident report with a newly licensed nurse. which of the following should the nurse include in the teaching? select all that apply a. medication error b. needlesticks c. conflict with provider and nursing staff d. omission of prescription e. missed specimen collection of a prescribed laboratory test

a, b, d the nurse should complete an incident report regarding a medication error, a needlestick, and omission of a prescription. the nurse should report a conflict with staff to a nurse manager, and a missed specimen should be reported.

the nurse should watch for potential complications in a young adult patient with a fractured femur with internal fixation and a long leg cast, such as: a. infection or osteomyelitis b. compartment syndrome c. pneumonia or stroke d. pulmonary fat embolus e. electrolyte imbalance f. nonunion oof the bone

a, b, d, f A fat embolus is a threat when a long bone such as the femur is fractured; infection and possible osteomyelitis, compartment syndrome, and non-union of the bone are other potential complications for which to watch. Pneumonia or stroke is not likely in a young adult. Electrolyte imbalance is a possibility for any patient undergoing injury and surgery but would be more likely in an older adult.

a nurse in an outpatient clinic is collecting data from a client who has RA. the client reports increased joint swelling and tenderness. which of the following findings should the nurse expect? select all that apply a. recent influenza b. decreased ROM c. hypersalivation d. increased BP e. pain at rest

a, b, e some conditions like recent influenza can exacerbate RA, clients with RA usually experience decreased ROM, and often have pain. people with RA report xerostomia not hypersalivation and increased BP is not indicative of RA

A child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone? a. Physiological bonding and growth b. Speech and hearing development c. Intellectual and psychomotor function d. Childhood play interaction

a, c, d Patients who experience immobility often have psychological issues such as helplessness, anger, and anxiety. Hunger, increased communication, and improved self-worth are usually the opposite of what is experienced.

a nurse is admitting a patient with a possible skull fracture. which clinical findings would likely confirm the diagnosis. select all that apply a. battle sign b. partial blindness c. ecchymosis around the eyes d. rhinorrhea e. swallowing difficulty

a, c, d Signs of skull fracture are usually: Battle sign, ecchymosis around the eyes, and rhinorrhea are signs of skull fracture. Partial blindness is not a sign of skull fracture.

a nurse is teaching a group of nursing students on complimentary and alternative therapies that can incorporate into their practice without the need for specialized licensing or certification. which of the following should the nurse encourage the students to use? select all that apply a. guided imagery b. massage therapy c. meditation d. music therapy e. therapeutic touch

a, c, d nurses may use guided imagery, meditation, and music therapy with clients when they understand the general principles of these therapies. massage therapy and therapeutic touch practitioners require training and certification

The nurse is participating in a patient care conference to plan the care for a patient with osteoporosis. Which issues should be discussed for inclusion in this patient's care plan? Select all that apply. a. Pain b. Difficulty breathing c. Potential for excessive fluid d. Difficulty providing own hygiene e. Difficulty moving about the house and/or work setting(s)

a, d, e Pain, difficulty providing own hygiene, and moving about the house are common issues that should be discussed when planning the patient's care. There is no indication the patient has difficulty breathing or managing fluid intake.

a nurse is collecting data from a client who has osteoarthritis of the knees and fingers. which of the following manifestations should the nurse expect to find? select all that apply a. heberden's nodes b. swelling of all joints c. small body frame d. enlarged joints size e. limp when walking

a, d, e heberdens nodules are enlarged nodules on the distal interphalangeal joints in the hands and feet of a client who has osteoarthritis, a client can manifest large joints and a limp from osteoarthritis. swelling and small body frame are signs of RA

a nurse is assisting an older adult at home who has rheumatoid arthritis in the hands and wrists. the nurse would intervene to teach the patient about joint protection if the patient: a. turned the door knob counterclockwise b. used the palms of the hands to push up and off the bed c. carried groceries into the house using both hands d. pushed the door open with their arms

b A patient with rheumatoid arthritis in the hands and wrists should not use the palms of the hands to push up off the bed as this puts undue pressure on the wrists. Turning the doorknob either direction should be done slowly and gently to prevent pain in the fingers and wrists. Groceries should be carried using both arms and hands and by holding the package close to the chest. Pushing the door open with an arm rather than the wrist and hand is appropriate.

During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development? a. Vitamins and minerals b. Protein and calcium c. Fats and carbohydrates d. Zinc and potassium

b Adequate stores of protein and calcium allow the developing musculoskeletal system to grow properly. Without the proper vitamins, minerals, and protein, the bones would not develop as they should.

a young patient returns from the OR after a BKA and is alert and quiet. the stump is elevated with the dressing dry and intact. what is the priority problem for this patient? a. altered body image b. potential for bleeding c. altered mobility d. insufficient knowledge

b After an amputation, a risk for bleeding is a priority safety concern. Disturbed body image will occur but is not the priority at this time. Impaired mobility has occurred but is not the priority nursing diagnosis at this time. Deficient knowledge is a probability regarding stump care, adjusting to a prosthesis, and using crutches or a wheelchair as well as maintaining balance while up but is not the priority at this time.

a nurse is assuming recovery room care of a 54 year old patient who has carpal tunnel repair. on receiving the patient, what is the priority nursing assessment? a. sensation in the fingertips b. color, warmth, and capillary refill c. condition of the dressing d. ROM

b Checking circulation in the hand by checking color, warmth and capillary refill is the priority nursing assessment after carpal tunnel surgery. Sensation in the fingertips will be important after any local anesthetic has worn off. The condition of the dressing is checked but is not the greatest priority. Range of motion of the wrist is not checked at this time so soon after surgery.

a nurse has just received shift report on four assigned orthopedic patients. which patient should the nurse check on first? a. a young trauma patient with a BKA who is having phantom pain b. an older adult woman with a with a total hip replacement who needs assistance with the bedpan c. a women with an external fixation who has a fever and foul odor at the pin sites d. a man with a full leg cast who reports persistent pain despite elevation and pain medication

b Obtaining assistance for the hip replacement patient needing help with the bedpan should be handled first so that the patient does not have an accident with feces or urine in the bed that might contaminate her wound and dressing; a nursing assistant could be sent to attend to the patient. The patient with phantom pain needs assistance but does not take priority. The woman with an external fixation device who has a fever and foul odor at the pin site is experiencing an infection and the surgeon needs to be notified so that treatment can be started. This would be the nurse's second action. The man with the full leg cast experiencing pain needs to be reassessed and pain relief sought.

a nurse is evaluating teaching to a client who has a new prescription for sequential compression devices. which of the following statements should indicate to the nurse that the client understands the teaching? a. this device will keep me from getting sores on my skin b. this thing will keep the blood pumping through my leg c. with this thing on my leg muscles wont get weak d. this device is going to keep my joints in good shape

b SCDs promote venous return in the deep veins of the legs and thus help prevent thrombus prevention. the nurse assesses the skin under the SCDs every 8 hours, continuous passive motions machines keep the muscles and joints active

a young man is admitted to the ED after an injury to the left leg sustained playing football. he is complaining of pain around the knee and upper tibia. which data from the nurses assessment would indicate a fracture of the tibia rather than a connective tissue injury of the knee? a. pain and soft tissue swelling around the knee and an abrasion on the knee b. pain, ecchymosis below the knee, and crepitation with any movement of the knee c. pain, swelling, and loss of function in the foot d. limping when walking, facial grimace, and some swelling of the lower knee and lower leg

b Signs of fracture include pain, swelling, ecchymosis into the tissues surrounding the fracture and crepitation upon movement of the affected bone. An abrasion of the knee, pain, and soft-tissue swelling most likely indicate a connective tissue injury. Loss of function of the foot would not occur with a fracture of the upper tibia. The patient would be unable to walk with a fracture of the upper tibia due to extreme pain when trying to walk.

The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement? a. "Proper care of the skin is important because the immobilized patient does not want to smell bad." b. "Proper care of the skin is important because the immobilized patient is at high risk for breakdown." c. "Proper care of the skin is important because the immobilized patient will have many visitors." d. "Proper care of the skin is important because the immobilized patient will be incontinent."

b Skin care is important for an immobilized patient because the patient is prone to skin breakdown from pressure and body fluids. Body odor (smell) is embarrassing to the patient, but it does not pose a risk to the skin. Not every immobilized patient is incontinent. Having visitors does not pose a risk to the skin.

The nurse is assessing injuries on a patient admitted to the unit who had fallen at home several hours ago. When looking at the patient's history, the nurse notices that he has smoked at least four packs of cigarettes per day for the past 60 years. What impact does smoking have on the musculoskeletal health of a patient? a. Smoking increases the risk of more falls in the elderly. b. Smoking increases the risk of developing osteoporosis. c. Smoking decreases the risk of developing osteoporosis. d. Smoking decreases the risk of a hip fracture as you age.

b Smoking has a significant impact on the musculoskeletal health of a patient because it increases the risk of developing osteoporosis, increases the risk of a hip fracture with aging, increases the risk of developing exercise-related injuries, has a detrimental effect on fracture and wound healing, has a detrimental effect on athletic performance, and is associated with low back pain and rheumatoid arthritis.

a nurse is assisting with a group discussion about fractures. which of the following actions information should the nurse include? a. children need a longer time to heal from a fracture than an adult b. epiphyseal plate injuries can result in altered bone growth c. a greenstick fracture is a complete break in the bone d. bones are unable to bend so they break

b detection of plate injury is crucial to prevent altered bone growth. children heal faster than adults. a greenstick fracture is a partial break in the bone. childrens bones are pliable and can bend 45 degrees before they break

a nurse is reviewing information about capsaicin cream with a client who reports continuous knee pain from osteoarthritis. which of the following information should the nurse reinforce? a. continuous pain relief is provided b. inspect for skin irritation and cuts prior to application c. cover the area with tight bandages after application d. apply the medication every 2 hours during the day

b if there are cuts in the skin the hot peppers in the cream will cause burning in the areas of skin breakdown. capsaicin cream is a temporary pain relief, covering the skin with a bandage after application could lead to skin irritation, and you can only apply capsaicin cream up to 4 times a day

the nurse is evaluating the clients use of a cane for left sided weakness. the nurse should intervene and correct the client if the nurse observed that the client performed which action? a. holds the cane on the right side b. moves the cane when the right leg is moved c. leans on the cane when the right leg swings through d. keeps the cane 6 inches out to the side of the right foot

b the cane is help on the stronger side to minimize stress on the affected extremity and provide a wide base of support. the cane is help 6 inches lateral to the fifth great toe. the cane is moved forward with the affected leg. the client leans on the cane for added support while the stronger side swings through

the nurse is planning to reinforce instructions to the client about how to stand on crutches. in the instructions the nurse should plan to tell the client to place the crutches in which position? a. 3 inches infront of the foot and side of the clients toes b. 8 inches infront of the foot and side of the clients toes c. 15 inches to the front and side of the clients toes d. 20 inches to the front and side of the clients toes

b the classic tripod position is taught to the client before giving instructions on gait. the crutches are placed anywhere from 6-10 inches in front and to the side of the client depending on the clients body size. this provides a wide base of support to the client and improves balance

the nurse has provided discharge instructions to a client with an application of a halo device. the nurse determines that the client needs further teaching if which statement is made? a. i will use a straw for drinking b. i will drive only during the day time c. i will use caution because the device alters balance d. i will wash the skin daily under the lambs wool liner of the vest

b the client should not drive because the device impairs the range of vision

a client is complaining of skin irritation from the edges of a cast applied the previous day. the nurse should plan for which intervention? a. massaging the skin at the rim of the cast b. petaling the cast edges with adhesive tape c. using a rough file to smooth the cast edges d. applying lotion to the skin at the rim of the cast

b the edges of the cast can be petaled with adhesive tape to minimize skin irritation. if a client has a cast applied and returns home, the client can be taught to do the same. massaging and applying lotion will not alleviate the skin irritation from the cast edges. filing the edges could cause pieces to fall off and irritate the skin

a nurse is planning to use healing intention with a client who is recovering from a lengthy illness. which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? a. tell the client the goal of the therapy is to promote healing b. ask whether the client is comfortable with using prayer c. encourage the client to participate actively for best results d. instruct the client to relax during the therapy

b the first step to take in the action process is to assess what the client wants or feels. the other options are correct but they are not the very first step you take

a nurse is reviewing documentation with a group of newly licensed nurses. which of the following guidelines should be followed when documenting in a clients record? select all that apply a. cover errors with correction fluid, and write in correct information b. put the dates and time on all entries c. document objective data, leaving out opinions d. use as many abbreviations as possible e. wait until the end of the shift to document

b, c the day and time confirm the recording of the correct sequence of events and documentation should be factual, descriptive, and objective without judgement or criticism. correction fluid implies the nurse was trying to hide something, too many abbreviations will make it too difficult to understand, and documentation should be current, waiting til the end of the day could result in data omission

a 40 year old man with a t4 spinal injury suddenly complains of severe headache, increased pulse rate, sweating, and flushing above the level of spinal cord lesion and goose bumps below the level of injury. which immediate nursing actions should be included? select all that apply a. place in flat bed b. identify the cause of the spasm c. decreased blood pressure d. provide measures to facilitate bowel movement e. clamp indwelling catheter

b, c, d Identify and gently relieve the cause of the autonomic dysreflexia reaction, decrease the blood pressure by elevating the head of the bed 45 degrees or sit the patient up, and institute measures to evacuate the bowel, will not resolve the problem and may exacerbate it.

a nurse is caring for a child who is in skeletal traction. which of the following actions should the nurse take? select all that apply a. remove the weights to reposition the child b. check the childs position frequently c. observe pin sites every 4 hours d. ensure the weights are hanging freely e. ensure the ropes knot is in contact with the pulley

b, c, d checking position ensures alignment, observing pin sites often will help to monitor for infection, and ensure the weights are hanging freely to allow for prescribed traction. only the provider should remove the weights except for in emergency situations. the knot rope should not touch the pulley as this will alter the weight of the traction

a nurse is collecting data from an infant. the nurse should identify that which of the following findings indicates that the infant is experiencing pain? select all that apply a. pursed lips b. loud cry c. lowered eyebrows d. rigid body e. pushes away stimulus

b, c, d infants experiencing pain may have a loud cry, low and drawn together eyebrows, and rigid body. they also have an open mouth, not pursed lips.

a nurse is discussing the HIPPA privacy rule with nurses during new nurse orientation. which of the following information should the nurse include? select all that apply a. a single electronic records password is provided for the nurses on the same unit b. family members should provide a code prior to receiving client health information c. communication if client information can occur at the nurses station d. a client can request a copy of her medical record

b, c, d, e many hospitals have a security code to ask about the patients health status, communication about patient status should only happen in a private setting, clients have the right to read and obtain a copy of their medical record, and the client can only photocopy a patients record to give to another facility. each staff should have their own password to protect the patients information

a nurse is caring for a child who sustained a fracture. which of the following actions should the nurse take? select all that apply a. place a heat pack on the site of injury b. elevate the affected limb c. check the neurovascular status frequently d. encourage ROM of the affected limb e. stabilize the injury

b, c, e elevating the limb with decrease risk for swelling, checking neurovascular status helps determine blood flow to the extremity, and stabilizing will help prevent further injury. an ice pack is placed to help prevent swelling and the nurse should encourage ROM on the unaffected limb

The patient presents to the clinic with a compound fracture of the right leg. The nurse anticipates the administration of which classes of medications? Select all that apply. a. Aspirin b. Tetanus booster c. Hepatitis B vaccine d. Intravenous (IV) morphine e. IV antibiotics

b, d, e The nurse should anticipate administering a tetanus immunization or booster, IV narcotic pain medications, and IV prophylactic antibiotics to prevent infection and control pain in the patient who has suffered an open fracture. The patient has an open wound, so aspirin is not appropriate due to the risk of bleeding. The hepatitis B vaccine is not necessary for this patient.

a nurse is caring for a client who recently had a CVA and has aphasia. which of the following interventions should the nurse use to promote communication with this client? select all that apply a. increase the volume in your voice b. make sure only one person speaks at a time c. avoid discouraging the client by saying that you do not understand him d. allow plenty of time for the client to respond e. use brief sentences with simple words

b, d, e trying to understand more than one voice at a time is confusing, allowing time for the client to respond helps enhance communication, and brief sentences are easier to understand. the nurse should speak in a normal tone, no yelling. and feigning understanding shows a lack of respect for the clients needs and blocks further communication

a nurse is caring for a client who is postoperative. which of the following interventions should the nurse take to reduce the risk of thrombus development? select all that apply a. instruct the client to perform the valsalva maneuver b. apply elastic stockings c. review lab values for total protein level d. place pillows under the client's knees and lower extremities e. assist the client to shift positions often

b, e elastic stockings promote venous return and prevent thrombus formulation and frequent position changes prevents venous stasis. valsalva maneuver does not affect peripheral circulation, the total protein level is important for healing and preventing skin breakdown, and placing pillows under the extremity could impair circulation.

The patient presents to the clinic with symptoms indicative of osteoporosis. The nurse anticipates which study will be performed in order to confirm the diagnosis? a. Chest x-ray b. Nuclear scan c. Bone density d. Computed tomography (CT) scan

c Bone density evaluation is the most relevant diagnostic for osteoporosis. A CT scan and chest x-ray can provide information about damage associated with osteoporosis. A nuclear scan would not be helpful for the patient with osteoporosis.

a patient with a plaster cast of the right arm complains of itching underneath the cast. what should the nurse do to alleviate the symptom? a. encourage deep breaths and scratch the other arm b. insert a cotton tip applicator under the cast c. forcefully inject 50 mL air underneath the cast d. administer pain medications

c Forcefully injecting 50 mL of air underneath the case helps relieve itching. For some people scratching the other arm will help relieve itching and this could be suggested if the air injection isn't helpful. Nothing should ever be inserted under the cast to help relieve itching. Pain medication does not usually relieve itching.

The nurse is educating the patient with osteoporosis on the best diet choices to improve bone density. The patient would demonstrate an understanding of the teaching by selecting which food choice that has the highest calcium content? a. 1 cup spinach b. 1 cup chopped kale c. 1 cup low-fat yogurt d. 1 ounce sliced carrots

c Low-fat yogurt is the best source for well-absorbed calcium. Spinach, kale, and some other green leafy vegetables do contain calcium, but it is not as readily absorbed. Carrots are not a source of calcium.

a nurse is caring for a client who is receiving morphine via PCA pump after abdominal surgery. which of the following statements indicated that the client knows how to use the device? a. ill wait to use the device until absolutely necessary b. ill be careful about pushing the button too much so i dont get an overdose c. i should tell the nurse if the pain doesnt stop while i am using this device d. i will ask my adult child to press the dose button when i am sleeping

c PCA allows the client to self administer pain meds when needed. the nurse should remind the patient to use the pump when pain starts to better control pain, PCA pumps have a timer that controls how much is being released at intervals they cannot get more medicine at other intervals, and the nurse should instruct the patient that nobody else needs to push the button except the client

a 30 year old man is admitted to the ED after a motor vehicle accident. after examination, the patient is diagnosed with a T6 spinal cord injury. he has flaccid paralysis, slowed heart rate, low BP, and no bowel sounds. the patient must be developing: a. autonomic dysreflexia b. muscle spasms c. spinal shock d. diabetes insipidus

c Spinal shock is characterized by flaccid paralysis and loss of reflex activity and of sensation below the level of the injury. Autonomic dysreflexia is characterized by excessively high blood pressure. Muscle spasms cause pain in muscular areas. Diabetes insipidus is characterized by excessive thirst and excretion of large amounts of severely dilute urine.

a difference in the postoperative care of a client with a knee replacement compared with a patient after a hip replacement is that the patient with a hip replacement: a. has less chance of developing a DVT b. remains on bed rest for several days c. is allowed to stand at the side of the bed first day post op d. has a CPM machine to exercise the joint

c The patient with a hip replacement is gotten up to stand at the side of the bed on the 1st postoperative day. Both patients have a risk of developing a deep venous thrombosis. The patient with a hip replacement is not on bed rest. Only the patient with a knee replacement has a continuous passive motion machine to exercise the joint.

after sustaining a rotator cuff tear, a patients arm is placed in a sling. the patient is instructed to rest and take ibuprofen for pain. which patient statement indicates the need for further teaching? a. i will have less stomach upset if i take the medicine with food b. i will not be able to play tennis for a while c. i need to rest in my bed for the next 2 days d. the sling must be worn most of the time

c The patient with a rotator cuff tear does not need bed rest. Taking ibuprofen with food is advisable to prevent stomach irritation. The patient will not be able to play tennis for a while. The sling should be worn most of the time.

The nurse is assisting the patient to use the 4-point gait with crutches. Which behavior by the patient demonstrates understanding? a. The patient initially advances the left foot. b. The patient initially advances the right foot. c. The patient initially advances the left crutch. d. The patient initially advances the right crutch.

c When performing the 4-point crutch gait, the patient should begin by advancing the left crutch followed by advancing the right foot.

the nurse is preparing information for change of shift report. which of the following information should the nurse include in the report? a. intake and output for the shift b. BP from the pervious day c. bone scan scheduled for today d. medication routine from the MAR

c a bone scan is important because the nurse might have to modify the clients care to accommodate leaving the unit. unless there is a significant change in i&o, BP, and medication routine the oncoming nurse can read that stuff in the chart

which is a recommended guideline for safe computerizing? a. passwords to the computer system should only be changed if lost b. computer terminals may be left unattended during client care activities c. accidental deletions from the computerized file need to be reported to the nursing manager or supervisor d. copies of printouts from computerized files should be kept on a clip board at the nurses station for other nurses to access

c after any inadvertent deletions of permanent computerized records, the nurse should type up an explanation into the computer file with the time, date, and his or her initials. the nurse should also contact the supervisor with a written explanation of the situation. options 1, 2, and 4 represent unsafe charting actions

the nurse is caring for the client who has suffered a spinal cord injury. the nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication for which s/s is noted? a. sudden tachycardia b. pallor of the face and neck c. severe, throbbing headache d. severe, sudden hypotension

c anybody with a spinal cord injury above the T7 level is at risk for autonomic dysreflexia, s/s are severe, sudden, throbbing headache, flushing of the face and neck, bradycardia and severe hypotension

a nurse is caring for a client who had am amphetamine overdose and has sensory overload. which of the following interventions should the nurse implement? a. immediately complete a thorough assessment b. put the client in a room with a client who has hearing loss c. provide a private room and limit stimulation d. speak at a higher volume to the client and encourage ambulation

c minimizing stimuli helps clients who have sensory overload. brief assessments are better to not overwhelm the client, rooming with someone with hearing loss and speaking louder increases stimuli.

a client has sustained a closed fracture and just had a cast applied to the affected arm. the client is complaining of intense pain. the nurse has evaluated the limb, applied an ice pack, and administered an analgesic, which was ineffective in relieving the pain. the nurse interprets that this pain may be caused by which condition? a. infection under the cast b. the anxiety of the client c. impaired tissue perfusion d. the newness of the fracture

c most pain associated with fractures can be minimized with rest, elevation, application of a cold compress, and administration of analgesics. pain that is not relieved with these measures needs to be reported to theRN and HCP because is may be the result of impaired tissue perfusion, tissue breakdown, or necrosis. because this is a new closed fracture and cast, infection would not have time to set in

the nurse is checking the casted extremity of a client. the nurse should check for which sign indicative of infection? a. dependent edema b. diminished distal pulse c. presence of a hot spot on the cast d. coolness and pallor of the extremity

c s/s of infection under a casted area include odor or purulent drainage from the cast or the presence of hot spots, which are areas of the cast that are warmer than others. the HCP should be notified if any of these occur. signs of impaired circulation in the distal limb are coolness and pallor, diminished arterial pulse, and edema

a nurse is caring for a client who has been sitting in a chair for 1 hour. which of the following complications is the greatest risk for the patient? a. decreased subcutaneous fat b. muscle atrophy c. pressure ulcer d. fecal impaction

c the greatest risk for this client is injury from skin breakdown due to unrelieved pressure over a bony prominence for prolonged time sitting in a chair.

a nurse is collecting data from a client who is reporting pain and despite taking analgesia. which of the following actions should the nurse take to determine the intensity of the clients pain? a. ask the client what precipitates the pain b. question the client about the location of the pain c. offer the client a pain scale to measure the pain d. use open ended questions to identify the patients pain sensations

c the nurse should use the pain scale to help identify the patients pain level. what precipitates, location, and open ended questions about pain sensations do not tell the intensity of the pain

a nurse is reinforcing teaching with a client who has RA and a new prescription for methotrexate. which of the following client statements indicates understanding? a. a will be sure to return to the clinic every year to have my blood drawn while im taking methotrexate b. i will take this medication on an empty stomach c. i will let the doctor know if i develop sores in my mouth while taking this medication d. i should stop taking oral contraceptives while taking methotrexate

c ulcerations are the first sign of toxicity. the blood levels are monitored frequently, methotrexate should be taken with food to reduce GI distress, and oral contraceptives have no effect on methotrexate

the nurse witnesses a client sustain a fall and suspects the client's leg may be fractured. which action is the priority? a. take a set of vital signs b. call the radiology department c. immobilize the leg before moving the client d. reassure the client that everything will be fine

c when a fracture is suspected it is imperative that the area is splinted before the client is moved. emergency help should be called if the client is not hospitalized. a HCP is called for the hospitalized client. the nurse should remain with the client and provide realistic reassurance. the nurse does not prescribe radiology tests

a nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. which of the following effects should the nurse anticipate? select all that apply a. urinary incontinence b. diarrhea c. bradypnea d. orthostatic hypotension e. nausea

c, d, e opioid analgesia can cause respiratory depression, orthostatic hypotension, and nausea and vomiting. urinary retention and constipation are adverse effects of opioid analgesia

a nurse is caring for a client who has a prescription for cyclosporine for RA. which of the following medications increases the risk of toxicity when take concurrently with cyclosporine? a. phenytoin b. rifampin c. carbamazepine d. erythromycin

d erythromycin increases cyclosporine levels, so taking the two together causes toxicity. the other medications decrease cyclosporine levels

a client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. the nurses response based on the understanding that Buck's extension traction has which primary function? a. allows bony healing to begin before surgery b. provides a rigid immobilization to the fracture site c. lengthens the fractured leg to prevent severing of blood vessels d. provides comfort by reducing muscle spasms and provides fracture immobilization

d Buck's extension traction is a type of skin traction often applied after a his fracture, before the fracture is reduced in surgery. it reduces muscle spasms and helps immobilize the fracture. it does not lengthen the leg for the purpose of preventing blood vessel severance. it also does not allow for bony healing to begin

Which nursing action is most appropriate for monitoring a patient with a casted lower extremity for infection? a. Assess vital signs every hour while the patient is awake. b. Remove the cast weekly to check the wound for signs of infection. c. Remove the cast bi-weekly to check the wound for signs of infection. d. Assess temperature trends and sniff around the cast for signs of foul odor.

d The most appropriate nursing action for monitoring a patient with a casted lower extremity for signs of infection is to assess for signs of infection every shift: assess wound for redness, swelling, and tenderness; administer prophylactic antibiotics as ordered; assess temperature trends and trend of white blood count values for signs of infection; assess patient for subjective signs of malaise; and sniff around the cast for signs of foul odor indicating infection. The cast should never be removed bi-weekly or weekly unless the physician orders it to be removed. Assessing vital signs is important but is not required on an hourly basis.

For the patient who needs the support of a crutch while walking, the type of crutch selected will depend on which assessment? a. The gait the patient will use b. What is most comfortable for the patient c. The availability of insurance reimbursement d. The extent of the patient's disability or paralysis

d The type of crutch to be used will depend on the extent of disability or paralysis and the patient's ability to bear weight and maintain balance. If the crutches are too short or too long, the patient will have problems with moving and shifting his or her weight. Reimbursement, the type of gait, and what is most comfortable for the patient are important considerations, but less so than the extent of the patient's disability.

The LPN/LVN is caring for a patient who has had a total hip replacement. Which intervention should be implemented for this patient to help prevent dislocation? a. Adjust the patient's chair so that the hips are flexed in a normal position. b. Ensure the surgical bone cement remains firmly bonded with the prosthesis. c. Assist the patient to bear weight on the operative side within the first 24 hours. d. Secure the abduction wedge between the legs until the surgeon requests removal.

d Use of an abduction wedge in the postoperative period is needed to prevent abduction. The pillow is applied immediately after surgery in the recovery area. It is to remain in place until removal is requested by the surgeon. Weight bearing is not necessarily indicated in the first 24-hour postoperative period. Normal sitting postures are to be avoided; they could potentially result in dislocation.

the nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. the client has a leg fracture, and a plaster cast has been applied. in positioning the casted leg, the nurse should perform which intervention? a. keep the leg in a level position b. elevate the leg for 3 hours and put flat for 1 hour c. keep the leg level for 3 hours and elevate it for 1 hour d. elevate the legs continuously for 24-48 hours

d a casted extremity is elevated continuously fro the first 24-48 hours to minimize swelling and to promote venous drainage. therefore the other options are correct

a nurse is contributing to the plan of care for a child following a surgical procedure. which of the following interventions should the nurse recommend? a. administer NSAIDS for pain greater than 7 on a 0-10 scale b. administer intranasal analgesics prn c. administer IM analgesics for pain d. administer analgesics on a schedule

d administering on a schedule helps to achieve optimal pain management. NSAIDS are used for mild to moderate pain. intranasal analgesics are used for someone over 18 years old. IM pain medications are not recommended for children

a nurse is reinforcing teaching with a client who is to have a bone scan. which of the following statements should the nurse include? a. you will receive an injection of a radioactive isotope when the scanning procedure begins b. you will be in a tube like structure during the procedure c. you will need to take radioactive precautions with your urine for the next 24 hours after the procedure d. you will have to urinate before the procedure

d an empty bladder helps visualization on the pelvic bones. the radioactive isotope is injected through IV prior to the procedure, it is not a tube like structure like an MRI, and radioactive precautions are not necessary for this procedure

the client with a cervical spine injury has crutchfield tongs applied in the ED. the nurse should perform which essential action when caring for this client? a. providing a standard bedframe b. removing the weights to reposition the client c. removing the weights if the client is uncomfortable d. comparing the amount of prescribed weights with the amount is use

d crutchfield tongs are applied after drilling holes in the clients skull under local anesthesia, weights are added to the tongs to align the cervical spine

a nurse is caring for a client who has a new diagnosis of fibromyalgia. which of the following medications should the nurse anticipate being prescribed for this client? a. colchicine b. hydroxychloroquine c. auranofin d. duloxetine

d duloxetine is a serotonin-norepinepherine reuptake inhibitor used to treat fibromyalgia. colchicine is to treat gout, auranofin treats RA, and hydroxychloroquine treats RA

a nurse is preparing to perform a peripheral vision test on a child. which of the following actions should the nurse take? a. place the child 10 feet away from a snellen chart b. show a set of cards to a child at a time c. cover the childs eyes while performing the test on the other eye d. have the child focus on an object while performing the test

when performing a peripheral vision test on a child use an object like a pencil and bring it into the childs peripheral vision. a child goes 10 feet away from a snellen chart. only give one card at a time when doing the color test. the nurse only covers a childs eye when doing a cover test

The nurse is preparing to care for a patient who requires skeletal traction. The nurse knows which statement is true regarding skeletal traction? a. It has a high risk of infection. b. It is used for only fractures of the lower extremity bones. c. It uses a series of removable pins, ropes, and weights to realign bones. d. It requires nurses to frequently assess and modify the amount of weight applied.

a Because of the pins or wires inserted into the affected bone, risk of infection is high and pin care must be meticulously performed. Skeletal traction does not allow the nurse to modify the amount of weight applied. Skeletal traction is used for the management of musculoskeletal conditions not limited to fractures.

a nurse is caring for a child who has a fracture. which of the following are manifestations of a fracture? select all that apply a. crepitus b. edema c. pain d. fever e. ecchymosis

a, b, c, e a fracture will leave bone fragments that will exhibit a grating sound like crepitus, swelling, pain, and bleeding under the skin are manifestations of a fracture. fever after a fracture is unexpected, it could mean there is an infection

a nurse is caring for a client following a below the elbow amputation. which of the following actions should the nurse take? select all that apply a. encourage dependent positioning of the residual limb b. inspect for presence and amount of drainage on the dressing c. implement shrinkage intervention of the residual limb d. wrap the residual limb in a circular manner using gauze e. observe for body image changes

a, b, c, e the limb should be placed in a dependent position to improve circulation, the nurse should note drainage on the dressing, the nurse should shrink the limb so that it fits into a prosthetic, and the nurse should monitor the clients feelings.

a nurse is collecting data from an older adult who has arteriosclerosis and is scheduled for a right lower extremity amputation. which of the following are expected findings in the effected extremity? select all that apply a. skin cool to touch mid calf to toes b. lower leg appearing dusky c. palpable pounding pedal pulse d. lack of hair on lower leg e.. blackened areas on several toes

a, b, d, e coolness, dusky, decreased hair growth, and blackened areas on the toes like gangrene could lead to devascularization.

a nurse is collecting data from a client who has a new diagnosis of multiple sclerosis. which of the following findings should the nurse expect? select all that apply a. areas of paresthesia b. involuntary eye movements c. alopecia d. increased salivation e. ataxia

a, b, e loss of skin sensation, nystagmus, and ataxia are all findings in a person with MS. hair loss and dysphagia are not manifestations of MS

a nurse is reviewing complimentary and alternative therapies with a group of nursing students. the nurse should classify which of the following interventions as a mind body therapy? select all that apply a. art therapy b. acupressure c. yoga d. therapeutic touch e. biofeedback

a, c, e art therapy allows the client to express emotions about their health, yoga helps mind-body therapy, and biofeedback increases mental awareness. acupressure focuses on the body structures and systems and therapeutic touch is an energy therapy because it involves using the hands to balance energy fields

a nurse is caring for a client who reports difficulty hearing. which of the following assessment findings indicate a sensorineural hearing loss in the left ear? select all that apply a. weber test showing lateralization to the right ear b. light reflex at 10 oclock in the left ear c. indications of obstruction in the left ear canal d. rinne test showing less time for air and bone conduction e. rinne test showing air conduction less than bone conduction in the left ear

a, d weber test demonstrates lateralization to the unaffected ear, and with sensorineural hearing loss in the left ear, length of time is decreased for both air and bone conduction. a light reflex at 10 oclock indicates air or fluid are in the tympanic membrane, obstruction in the ear canal indicates conductive hearing loss, and air conduction is greater than the bone conduction in the left ear.

The appearance of a petechial rash and respiratory distress 2 to 3 days after a fracture should be reported promptly because they may be symptomatic of which life-threatening complication? a. Infection b. Fat embolism c. Nerve damage d. Vitamin deficiency

b Fat embolism is a rare but serious complication of a bone fracture that has an abundance of marrow fat. The fat globules released when fat-bearing bone marrow is fractured must be large enough or sufficient in number to occlude a blood vessel, either partially or completely. Rupture of small venules in the area permits entrance of fat globules into the circulation. Signs and symptoms of fat embolism include a change in mental status followed by respiratory distress, tachypnea, crackles and wheezes that are heard when auscultating the lungs, rapid pulse, fever, and petechiae.

a nurse is caring for a client who has MS. which of the following findings should the nurse expect? a. fluctuations in BP b. loss of cognitive function c. ineffective cough d. drooping eyelids

b loss of cognitive function is a manifestation of MS. the other options are manifestations to amyotrophic lateral sclerosis

a nurse is assisting with preparing a plan of care to prevent a client from developing flexion contractures following a BKA 24 hours ago. which of the following actions should the nurse include in the plan of care? a. limit any types of exercise to the residual limb for the first 48 hours b. position the client prone several times a day c. wrap the stump in a figure 8 pattern d. encourage sitting in a chair during the day

b the nurse should position the client prone 20-30 minutes a day to prevent flexion.

the nurse is caring for a client who has had skeletal traction applied to the left leg. the client os complaining of severe left leg pain. which action should the nurse take first? a. provide pin care b. call the HCP c. check the client alignment in bed d. medicate the client with an analgesic

c a client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. the nurse calls the HCP if the realignment doesnt help. once traction is established severe pain indicates a problem. medicating the client should be done last after trying to find the cause. providing pin care is unrelated to the problem prescribed

The patient in the outpatient surgery center has just returned from surgery to decompress the medial nerve as treatment for carpal tunnel syndrome. Which assessment finding immediately after surgery would alert the nurse to a possible complication? a. Nail beds that are pink b. Numbness of the fingertips c. 5-second nail bed capillary refill d. Fingertips that are warm to the touch

c The nurse should assess the perfusion of the hand. A capillary refill time of more than 3 seconds may indicate a problem and should be reported to the surgeon immediately. Right after surgery, the patient is not expected to have sensation in the fingers. Pink, warm skin is a normal finding.

The nurse is caring for a patient who has had a knee replacement. Within 2 to 3 days, the LPN/LVN can likely anticipate which change in the plan of care? a. Walker training b. Enemas until clear c. Quadriceps setting exercises d. Cessation of pain medication

c Within 2 to 5 days, quadriceps-strengthening exercises, and straight-leg raising are started. Quadriceps setting exercises are accomplished by lying supine, straightening the legs, and pushing the back of the knees into the bed. Exercises are taught by the physical therapist, and the nurse often assists the patient in performing them. The arthroplasty patient then progresses to ambulation with a walker or crutches. There is no need to administer enemas to the patient. Pain medication may be needed for several days after the surgery.

The patient presents to the emergency department after a soccer game. The patient reports that she made a sharp turn and heard and felt a large pop from her knee. The patient reports, "Now, when I'm walking, it feels like my knee just gives out, and I almost fall. Plus, it's twice the size of my other knee, and I can't straighten it all the way." The nurse recognizes that these symptoms correspond with which injury? a. Torn meniscus b. Dislocated patella c. Torn quadriceps muscle d. Torn anterior cruciate ligament injury

d The turning motion followed by a loud pop with the patient's complaint of severe swelling, joint instability, and decreased extension indicates a torn anterior cruciate ligament. A meniscal tear has less swelling and joint instability, although some exists. If the patient had dislocated her patella, the patella would be in a different spot than normal, and this would be part of the patient's chief complaint. The patient's complaint centers on the knee, not the quadriceps.

a nurse is caring for a client who had an AKA. the client reports a sharp stabbing type of phantom pain. which of the following actions should the nurse take? a. remove the initial pressure dressing b. encourage the use of cold therapy c. question whether the pain is real d. administer an antiepileptic medication

d antiepileptic medication can help relieve pain. the other actions do not reduce phantom pain

a nurse is reinforcing teaching with a client who has MS and a new prescription for baclofen. which of the following statements should the nurse include in the teaching? a. this medication will help with your tremor b. this medication will help with your bladder function c. this medication may cause your skin to bruise easily d. this medication may cause your skin to appear yellow in color

d antispasmodics can cause the skin to turn yellow or jaundice. betablockers treat tremors. anticholingergic medications treats bladder dysfunction. steroids lead to easy bruising

the nurse is one of several people who witness a vehicle hit a pedestrian at a fairly slow speed on a small street. the individual is dazed and tries to get up, and the leg appears to be fractured. the nurse should plan to perform which action? a. try to manually reduce the fracture b. assist the person to get up and walk to the sidewalk c. leave the person for a few minutes to call an ambulance d. stay with the person and encourage the person to remain still

d with a suspected fracture the client is not moved unless it is dangerous in that spot. the nurse should remain with the client and have someone else call an ambulance. a fracture is not reduced at a scene. before moving the client, the site of fracture is immobilized to prevent further injury

a nurse is reinforcing teaching with a client who has a new diagnosis of RA. which of the following instructions should the nurse give? a. you can experience morning stiffness when you get out of bed b. you can experience abdominal pain c. you can experience weight gain d. you can experience low blood sugar

a the nurse should tell the client that they will experience RA with stiffness in the morning. people with RA experience pleuritic pain but abdominal pain, can experience weight loss not gain, and they do not experience low blood sugar

a nurse is caring for a child who is in a plaster shoulder spica cast. which of the following actions should the nurse take? a. use a heat lamp to facilitate drying b. avoid turning the child until the cast is dry c. position the cast below heart level during while it dries d. apple moleskin to the edges of the cast

d the nurse should apply moleskin to the edges of the cast to prevent cast from rubbing the childs skin. use a cool fan to dry. turn the child two hours to facilitate air drying. elevate the extremity above the heart to prevent swelling in the extremity

a nurse is caring for a toddler who has dysplasia of the hip and a hip spica cast is in place. the childs mother asks the nurse why pavlik harness is not being used. which of the following responses should the nurse make? a. the pavlik harness is used for children with scoliosis, not hip dysplasia b. the pavlik harness is used for school age children c. the pavlik harness cannot be used for your childs condition because her condition is too severe d. the pavlik harness is used for infants less than 6 months of age

d the pavlik harness is only for children under 6 months with hip dysplasia

a nurse is screening a toddler for hearing loss. which of the following findings are indications of hearing impairment? select all that apply a. uses monotone speech b. yells to express emotions c. wants to repeat conversations d. appears shy e. is overly attentive to the surroundings

a, b, c, d monotone speech, yelling, need for repeated conversations, and shyness are manifestations of hearing impairment. being nonattentive to surroundings is a manifestation of hearing impairment, not overly attentive

the nurse is evaluating the pin sites of a client in skeletal traction. the nurse would be least concerned with which finding? a. inflammation b. serous drainage c. pain at pin site d. purulent drainage

b a small amount of serous drainage is expected at pin insertion site. signs of infection like inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported

a nurse is caring for a client who has a new prescription for adalimumab for rheumatoid arthritis. based on the route of administration of the medication which of the following should the nurse plan to monitor? a. the vein for thrombophlebitis during IV administration b. the subq site for redness following injection c. the oral mucosa for ulceration after oral administration d. the skin irritation after removing a transdermal patch

b adalimumab is given subcutaneously so redness of the site needs to be monitored

instructions for a patient with a slipped disk with acute pain and sciatica should include: a. using ice packs on the area of back pain for 5-10 minutes each hour while awake for the first 48 hours b. resting in bed for 2-3 days and walking every hour even if walking causes more pain c. obtaining a massage each day to loosen the muscle spasms in the back d. not lifting anything heavier than 10 pounds for several weeks

a Ice packs are applied for 5 to 10 minutes at a time each hour for the first 48 hours to reduce muscle spasm in the back. Resting in bed is discouraged. Massage will be painful. The acute pain should to last several weeks.

the nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. the nurse determines that the client needs further teaching if the nurse observes the client doing which activity? a. pulling up on the trapeze b. flexing and extending the feet c. doing quadriceps-setting and gluteal-setting exercises d. performing active ROM to the right ankle and knee

d exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. the client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle setting exercises. the client may also flex and extend his or her feet. performing active ROM on the affected leg can be harmful

a nurse is discussing the care of a group of clients with a newly licensed nurse. which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. a client who has a broken femur and reports hip pain b. a client who has incisional pain 72 hour following pacemaker insertion c. a client who has food poisoning and reports abdominal cramping d. a client who has episodic back pain following a fall two years ago

d pain lasting longer than 6 months is considered chronic. the other options are all pain from an acute problem

the client has clear fluid leaking from the nose after a basilar skull fracture. the nurse determines that this is cerebral spinal fluid (CSF).if the fluid meets which criteria? a. is grossly bloody in appearance and has a ph of 6 b. clumps together on the dressing and has a ph of 7 c. is clear in appearance and tests negative for glucose d. separates onto concenteric rings and tests positive for glucose

d the CSF will separate from blood to yellow concentric rings on dressing material

a client is having a lumbar puncture performed. the nurse should place the client in which position for the procedure? a. supine, in semi-fowlers b. prone, in slight trendelenburg c. prone, with a pillow under the abdomen d. side lying, with legs pulled up and chin to the chest

d this position opens up the spaces between the vertebrae.

a nurse is reviewing instructions with a client who has hearing loss and has just started wearing hearing aids. which of the following statements should the nurse identify as an indication that the client understands the instructions? a. i use a damp cloth to clean the outside part of the hearing aid b. i clean the ear molds of my hearing aid with alcohol c. i keep the volume of my hearing aids turned up so i can hear better d. i take the batteries out of my hearing aids when i take them off at night

d to conserve battery life batteries should be removed when not in use. hearing aids should be completely dry at all times, the ear molds should be cleaned with mild soap and water, and to avoid feedback the client should keep it on the lowest setting