Practice Questions: Week 4 Assessment

A patient reports shoulder pain when the nurse moves the patient's arm behind the back. Which question should the nurse ask?

b. "Do you have difficulty when you are putting on a shirt?"

For a patient who has had right hip arthroplasty, which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

a. Reposition the patient every 1 to 2 hours.

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective?

b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day."

A patient's temperature has been 101° F (38.3° C) for several days. The patient's normal caloric intake to meet nutritional needs is 2000 calories perday. If the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

2140 calories

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.

A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?

a. Elevate the ankle above heart level.

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions.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?

d. Ask the patient to describe the impact of psoriasis on quality of life.

Which integumentary assessment data from an older patient admitted with bacterial pneumonia should be of concern to the nurse?

b. Reports a history of allergic rashes

A 60-yr-old patient had open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, What should the nurse identify as the priority patient problem?

b. Risk for infection

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?

b. Separation of proximal wound edges

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?

b. Symmetric

When admitting a patient with stage 3 pressure injuries on both heels, which information obtained by the nurse will have the most impact on wound healing?

b. The patient takes oral hypoglycemic agents daily.

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?

b. The patient uses a tanning booth weekly.

A sprain can be defined as which one of the following?

A stretching or tearing of ligaments

Which lab values are most important to monitor for nutritional assessment in pts. with decub. ulcers?

Albumin and Protein

Term for medical removal of dead, damaged, or infected tissue to improve healing?

Debridement

Which assessment finding for a patient who is in traction requires immediate intervention?

Weights are sitting on the floor

The nurse notes 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?"

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse including in discharge teaching?

a. "Check and clean the pin insertion sites daily."

Which instructions should the nurse include in the teaching plan for a patient with impetigo?

a. Clean the crusted areas with soap and water.

Which finding from analysis of fluid from a patient's right knee arthrocentesis should be of concern to the nurse?

a. Cloudy fluid

Which action should the urgent care nurse take for a patient with a possible knee meniscus injury?

b. Apply an immobilizer to the affected leg.

The nurse should instruct a patient with a nondisplaced fractured left radius that the cast will need to remain in place for what amount of time?

b. At least six weeks

A patient who is to have no weight bearing on the left leg is learning to use crutches. Which observation by the nurse indicates the patient can safely ambulate independently?

b. The patient advances the left leg and both crutches together and then advances the right leg.

Which medication information should the nurse identify as a potential risk to a patient's musculoskeletal system?

b. The patient has asthma requiring frequent therapy with oral corticosteroids.

After receiving a change-of-shift report, which patient should the nurse assess first?

b. The patient receiving chemotherapy who has a temperature of 102° F.

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding should indicate to the nurse a potential complication of the fracture?

c. Abdomen is distended, and bowel sounds are absent.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take?

c. Assess the pedal pulses.

Which finding in a patient with a Colles' fracture of the left wrist should the nurse identify as most important to communicate immediately to the health care provider?

c. Capillary refill to the fingers is slow.

A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family?

c. Change the patient's position every 1 to 2 hours.

A patient with dark skin has been admitted to the hospital with acute decompensated heart failure. How would the nurse assess this patient for cyanosis?

c. Check the lips and oral mucous membranes.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action should the nurse take first? (Question #44)

c. Check the patient's O2 saturation using pulse oximetry.

Which information should the nurse include in the teaching plan for a patient diagnosed with basal cell carcinoma (BCC)?

c. Minimizing sun exposure reduces risk for future BCC.

A factory line worker has repetitive strain syndrome in the left elbow. What topic should the nurse plan to include in patient teaching?

d. Modifying arm movements

The nurse notes that a patient's open abdominal wound widens as it extends deeper into the abdomen. How would the nurse document this characteristic?

d. Undermining

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which prescribed action will the nurse implement first?

d. Wrap the ankle and apply an ice pack.

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.

Type of fracture when the bone breaks into pieces

comminuted

Which action should the nurse take 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.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. What should the nurse do when the patient arrives on the orthopedic unit after surgery?

a. Assess the surgical site for hemorrhage.

The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate?

B. Document the assessment.

Which one of these is NOT a S/S of a Fat embolism?

Bradycardia (S/S: sudden onset of SOB, Tachypnea, sudden onset of chest pain or headache)

Type of traction used in lower limbs & pt. wears constricting boot with weights to keep proper alignment.

Buck's

Which one is NOT a S/S of compartment syndrome?

Increased skin sensation (S/S: decreased pulses, Cyanosis, Unrelieved pain)

Which one these areas are not included in the "P's" for assessing compartment syndrome?

Parietal (Paresthesia, Pain, Pulse)

Which stage of a decubitus ulcer is described as the skin is broken to the epidermis or dermis?

Stage 2

In which stage of decubitus ulcer is described as injury extending into subcut. fat layer?

Stage 3

A patient with left knee pain is diagnosed with bursitis. What area should the nurse explain is the site of inflammation in bursitis?

a. A fluid-filled sac found at some joints.

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. Add oil to your bath water to moisturize the affected skin. b. Cool, wet clothes or compresses can be used to reduce itching. c. Use an over-the-counter (OTC) antihistamine to reduce itching. d. Take cool or tepid baths several times daily to decrease itching. e. Rub yourself dry with a towel after bathing to prevent skin maceration. ANS: B, C, D

A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? (Put a comma and a space between each answer choice [A, B, C, D]).

a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol). ANS:A, D, B, C

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 ANS: D, E

A patient who arrives at the emergency department with severe left knee pain is diagnosed with a patellar dislocation. What should be the nurse's initial focus for patient teaching?

b. Monitored anesthesia care

Which patient statement indicates understanding of the nurse's teaching about a new short-arm synthetic cast?

c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours."

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which patient statement to the nurse indicates that additional teaching is needed?

d. "I can sleep in any position that is comfortable for me."

The nurse finds that a patient can flex the arms when no resistance is applied but is unable to flex against light resistance. How should the nurse document the patient's muscle strength level?

d. 3

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?

d. The patient uses bacitracin-neomycin-polymyxin on minor abrasions.

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/VN)?

d. The patient who needs a hydrocolloid dressing change for a stage 3 sacral pressure injury.

A patient has possible right carpal tunnel syndrome. What symptom should the nurse expect with a positive Tinel's sign?

d. Tingling in the right thumb and index finger

Type of fracture in which the bone is bent but not broken all the way?

greenstick

Fracture that is described as a small crack or severe bruise within a bone.

hairline or stress

Which one is NOT a purpose of traction?

increase healing time (reduce pain and spasms, immobilize the joint or part of the body, reduce fracture or dislocation)

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?

b. Press firmly on the lesion.

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/VN)? (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. ANS: A, C

A patient with severe kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. Which action should the nurse plan to take?

a. Explain the procedure to the patient.

Which action should the nurse include 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.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy?

a. Low serum albumin level

A patient who has diabetes and acute abdominal pain is admitted for an exploratory laparotomy. When planning postoperative interventions to promote wound healing, what is the nurse's highest priority?

a. Maintaining the patient's blood glucose within a normal range

A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines 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.

A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/μL and a band count of 11%. What prescribed action should the nurse take first?

a. Obtain cultures of the wound.

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.

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?

b. "If the medication burns when I apply it, I will wipe it off."

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. Which information will the nurse include in postoperative teaching?

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. Which statement should the nurse include in the patient's instructions?

b. "Your cheek area will be eroded and take several weeks to heal."

The nurse will perform which action for a wet-to-dry dressing change on a patient's stage 3 sacral pressure injury?

b. Administer a prescribed PRN oral analgesic 30 minutes before the change.

The day after a having a right below-the-knee amputation, a patient reports pain in the missing right foot. Which action is most important for the nurse to take?

b. Administer prescribed analgesics.

When performing a skin assessment, the nurse notes angiomas on the chest of an older patient. Which action should the nurse take next?

b. Assess the patient for evidence of liver disease.

The nurse notes crackling sounds and a grating sensation with palpation of an older patient's elbow. How should this finding be documented?

b. Crepitation

Which information should the nurse include in discharge teaching for a patient who has had a repair of a fractured mandible?

b. How and when to cut the immobilizing wires

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?

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?

c. "Tell me what you know about your options for treatment."

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?

c. 38-year old with a 7-mm nevus on the face that has recently become darker

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?

c. Papular, wheal-like lesions with white deposits on the hair shaft

Which abnormality on the skin of an older patient is the priority for the nurse to discuss with the health care provider?

c. Petechiae on the chest and abdomen

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?

c. Rising body temperature

A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider?

c. Slow capillary refill of the left foot

A patient from a long-term care facility is admitted to the hospital with a sacral pressure injury. The base of the wound involves subcutaneous tissue. How should the nurse classify this pressure injury?

c. Stage 3

The home health nurse notices irregular patterns of bruising at different stages of healing on an older patient's body. Which action should the nurse take first?

c. Talk with the patient alone and ask about the bruising.

Which information obtained during the nurse's assessment may indicate a patient's increased risk for musculoskeletal problems?

c. The patient is 5 ft, 2 in tall and weighs 180 lb.

The nurse should plan to use a wet-to-dry dressing for which patient?

d. A patient who has a wound with purulent drainage and dry brown areas.

A patient with rheumatoid arthritis has been taking oral corticosteroids for 2 years. Which nursing action is most likely to detect early signs of infection in this patient?

d. Ask about feelings of fatigue or malaise.

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?

d. Ask the patient about a personal or family history of type 2 diabetes.

The nurse is caring for a patient diagnosed with furunculosis. Which action could the nurse delegate to unlicensed assistive personnel (UAP)?

d. Cleaning the skin with antimicrobial soap

The nurse notes that a 59-yr-old female patient has lost 1 inch in height over the past 2 years. What diagnostic test should the nurse plan to discuss with the patient?

d. Dual-energy x-ray absorptiometry (DXA)

Which finding for a 77-yr-old patient seen in the outpatient clinic is the highest priority for further nursing assessment and intervention?

d. History of recent loss of balance and fall

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?

d. Teach the use of cold packs to reduce bruising and swelling.

What should the occupational health nurse advise a patient whose job involves many hours of typing?

a. Obtain a keyboard pad to support the wrist.

In which order should the nurse complete actions when caring for a patient in the emergency department who has a right leg fracture? (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. ANS:C, D, B, E, A, F

A new nurse performs a dressing change on a patient's stage 2 left heel pressure injury. Which action by the new nurse indicates a need for further teaching about pressure injury care?

a. The new nurse cleans the injury with half-strength peroxide.

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.

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.

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

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?

b. Administer prescribed PRN O2 at 4 L/min.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take?

b. Administer prescribed pain medication.

The nurse is caring for a patient who is using Buck's traction after a hip fracture. Which action can the nurse delegate to experienced unlicensed assistive personnel (UAP)?

b. Ensure the weight for the traction is hanging freely.

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?

b. Method of contraception used by the patient

Which task can the nurse assign to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic?

b. Obtain blood sample for uric acid from a patient with gout.

Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the health care provider?

b. Patient has been incontinent of urine and stool.

After change-of-shift report, which patient should the nurse assess first?

b. Patient with repaired right femoral shaft fracture who reports tightness in the calf.

A patient who reports chronic itching of the ankles continuously scratches the area. Which assessment finding should the nurse expect?

b. Thickening of the skin around the ankles

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action should the nurse take first?

c. Assess leg pulses and sensation.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first?

c. Assess patient orientation.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a sling. Which intervention should the nurse include in the plan of care?

c. Assess the left axilla and change absorbent dressings as needed.

What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures?

c. Buy shoes that provide good support and are comfortable to wear.

Which information should the nurse include in discharge instructions for a patient with comminuted left forearm fractures and a long-arm cast?

c. Call the health care provider for numbness of the hand.

A young adult patient receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). The patient denies any discomfort. Which action by the nurse is appropriate?

c. Check the patient's temperature again in 4 hours.

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?

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?

c. Cotton-tipped applicators

A patient's 4 3-cm leg wound has a 0.4-cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?

c. Hydrocolloid dressing

After the home health nurse teaches a patient's family member about how to care for a sacral pressure injury, which finding indicates that additional teaching is needed?

c. The family member dries the wound using a hair dryer on a low setting.

The nurse teaches 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?

c. The patient applies a thick layer of the cream to the affected skin.

Which information in a 67-yr-old woman's health history should alert the nurse to the need for a focused assessment of the musculoskeletal system?

c. The patient's mother became shorter with aging.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding should the nurse identify as most important to communicate to the health care provider?

c. The right arm appears shorter than the left.

The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?

c. The skin around the incision is pale and cold.

When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first?

c. Use a cervical collar to stabilize the spine.

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?

d. Have the patient use protective eyewear while receiving PUVA.

Which action should the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty?

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?

d. Surgical excision

The nurse is caring for a patient who has a pelvic fracture and an external fixation device. How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum?

c. Have the patient lift the back and buttocks using a trapeze.

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?

c. Incisional biopsy

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

c. Leaning over to pull on shoes and socks

After completing the health history, how should the nurse begin to assess the musculoskeletal system?

c. Observe the patient's body build and muscle configuration.

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?

c. Try to stay out of the direct sun between the hours of 10 AM and 2 PM.

Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle?

c. Use pillows to elevate the ankle above the heart.

Which information will the nurse include when teaching an older patient about skin care?

c. Use warm water and a moisturizing soap when bathing.

What is the most effective method to prevent the spread of infection to others when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?

c. Wash hands and properly dispose of soiled dressings.