Unit 6

Réussis tes devoirs et examens dès maintenant avec Quizwiz!

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 per day. Knowing that the metabolic rate increases 7% for each Fahrenheit degree above 100° in body temperature, how many total calories should the patient receive each day?

ANS: 2140 calories

The nurse is preparing an adolescent girl for an instrumentation procedure to treat scoliosis. Which of the following should the nurse include? a. Nasogastric intubation and urinary catheter may be required. b. Ambulation will not be allowed for up to 3 months. c. Surgery eliminates the need for casting and bracing. d. Discomfort can be controlled with nonpharmacologic methods.

ANS: A Harrington instrumentation is a surgical procedure. Nasogastric intubation and urinary catheterization may be required.

Which of the following types of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop b. Bryant c. Russell d. Buck extension

An advantage to using a fiberglass cast instead of a plaster cast is that a fiberglass cast: a. Is less expensive. c. Molds closely to body parts. b. Dries rapidly. d. Has a smooth exterior.

ANS: B A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive. Plaster casts mold closer to body parts. Synthetic casts have a rough exterior, which may scratch surfaces. p1540

Where is the urethra opening located in cases of hypospadias? A. On the ventral surface of the penis B. On the dorsal surface of the penis C. At the upper portion of the testicular vault D. Within a bladder extrophy

Answer: A Hypospadias is a urologic abnormality in which the urethral opening is located on the ventral surface of the penis anywhere from the corona to the perineum. Hormonal influences in utero, environmental factors, and genetic factors are possible causes.

Which instructions should you include in the discharge instructions for a patient with epididymitis? A. Refrain from sexual intercourse. B. Continue to participate in liberal exercise. C. Take frequent sitz baths. D. Eat a low-salt diet.

Answer: A Patients with epididymitis should be encouraged to refrain from sexual intercourse during the acute phase. Conservative treatment consists of bed rest with elevation of the scrotum, use of ice packs, and analgesics. Ambulation places the scrotum in a dependent position and increases pain. Salt does not affect epididymitis recovery.

What is the most common cause of erectile dysfunction? A. Aging B. Benign prostatic hyperplasia C. Vascular disease D. Psychological distress

Answer: C Common causes of ED include diabetes, vascular disease, side effects from medications, results of surgery (e.g., prostatectomy), trauma, chronic illness, decreased gonadal hormone secretion, stress, difficulty in a relationship, or depression. The most common cause of ED is vascular disease.

In reviewing bone remodeling, what should the nurse know about the involvement of bone cells? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are mature bone cells. D. Osteons create a dense bone structure.

B. Osteoblasts deposit new bone. Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure, but these are not involved with bone remodeling.

The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects what to be included in the care of the affected leg? A Progressive leg exercises to obtain 90-degree flexion B Early ambulation with full weight bearing on the left leg C Bed rest for 3 days with the left leg immobilized in extension D Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation

A Progressive leg exercises to obtain 90-degree flexion Although early ambulation is not done, the patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible. Because this is painful after surgery, the patient requires good pain management and often the use of a CPM machine. The patient's knee is unlikely to dislocate.

Which of the following findings during a female breast examination should the nurse report as suspicious for breast cancer? a) A poorly defined, firm lump that is nontender and nonmovable b) Multiple nodules of round, lumpy, tender tissue in both breasts c) A single soft, mobile, lobular nodule that is nontender d) A single soft lump that is well-defined and tender

A poorly defined, firm lump that is nontender and nonmovable A poorly defined, firm lump that is nontender, nonmovable, and fixed to the skin is characteristic of breast cancer. All other choices are usually associated with benign processes. All patients should have a diagnosis of cancer based upon physical assessment and tissue pathology.

The nurse recognizes that which patients are at highest risk for physiologic fatigue? (Select all that apply.) A. Parents of a newborn B. Adolescent with anorexia C. 25-year-old pregnant female D. Grandmother who takes 12 mile walks E. Businessman who consumes six cups coffee/day

A, B, C, E

he occupational health nurse is making rounds in a factory. Which employees need further education about energy conservation strategies? (Select all that apply.) A. Workers reaching up to high shelf often to obtain cleaning supplies B. Workers bending over to lift boxes onto conveyer belt C. Workers who have delegated out parts of their activities D. Workers standing for long periods E. Workers standing at desks at waist level

A, B, D

The nurse is caring for a 62-year-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? A. Avoid straining during defecation. B. Restrict fluids to prevent incontinence. C. Sexual functioning will not be affected. D. Prostate exams are not needed after surgery.

A. Avoid straining during defecation. Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided in the postoperative recovery period to prevent a postoperative hemorrhage. Instruct the patient to drink at least 2 L of fluid every day. Digital rectal examinations should be performed yearly. The prostate gland is not totally removed and may enlarge after a TURP. Sexual functioning may change after prostate surgery. Changes may include retrograde ejaculation, erectile dysfunction, and decreased orgasmic sensation.

The role of the complement system in opsonization affects which response of the inflammatory process? A. Cellular B. Vascular C. Healing D. Formation of exudate

A. Cellular

Cause = change in pH; change in local ionic concentration; nerve stimulation by chemicals; pressure from fluid exudate A. Pain B. Loss of function C. Swelling D. Redness E. Heat

A. Pain

Cause = hyperemia from vasodilation. A. Redness B. Heat C. Swelling D. Pain E. Loss of function

A. Redness

Replacement of lost cells and tissues with cells of the same type. A. Regeneration B. Brushing your teeth C. Repair D. Fibroblasts

A. Regeneration

The nurse is preparing an adolescent with scoliosis for a Luque-rod segmental spinal instrumentation procedure. Which consideration should the nurse include? a. Nasogastric intubation and urinary catheter may be required. b. Ambulation will not be allowed for up to 3 months. c. Surgery eliminates the need for casting and bracing. d. Discomfort can be controlled with nonpharmacologic methods.

ANS: A Luque-rod segmental spinal instrumentation is a surgical procedure. Nasogastric intubation and urinary catheterization may be required. Ambulation is allowed as soon as possible. Depending on the instrumentation used, most patients walk by the second or third postoperative day. Casting and bracing are required postoperatively. The child usually has considerable pain for the first few days after surgery. Intravenous opioids should be administered on a regular basis.p1535

The nurse will plan to teach a 67-yr-old patient who has been diagnosed with orchitis about a. pain management. b. emergency surgery. c. application of heat to the scrotum. d. aspiration of fluid from the scrotal sac.

ANS: A Orchitis is very painful, and effective pain management will be needed. Heat, aspiration, and surgery are not used to treat orchitis. DIF: Cognitive Level: Apply (application) REF: 1284 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Osteosarcoma is the most common bone cancer in children. Where are most of the primary tumor sites? a. Femur b. Humerus c. Pelvis d. Tibia

ANS: A Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half occur in the femur.

Osteosarcoma is the most common bone cancer in children. Where are most of the primary tumor sites? a. Femur b. Humerus c. Pelvis d. Tibia

ANS: A Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half occur in the femur. After the femur, most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges. p1561

While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? a. Prioritization and administration of nursing care throughout the day b. Completing all nursing care in the morning so the patient can rest the remainder of the day c. Completing all nursing care in the evening when the patient is more rested d. Limiting visitors, thus promoting the maximal amount of hours for sleep

ANS: A Pacing activities throughout the day conserves energy, and nursing care should be paced as well. Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue. Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

Four-year-old David is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain. c. Reposition the child and notify physician. d. Chart the observations and check the extremity again in 15 minutes.

ANS: A The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner.

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Encourage increased oral fluid intake. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order.

ANS: A The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful

Discharge planning for the child with juvenile arthritis includes the need for: a. Routine ophthalmologic examinations to assess for visual problems. b. A low-calorie diet to decrease or control weight in the less mobile child. c. Avoiding the use of aspirin to decrease gastric irritation. d. Immobilizing the painful joints, which are the result of the inflammatory process.

ANS: A The systemic effects of juvenile arthritis can result in visual problems, making routine eye examinations important. Children with juvenile arthritis do not have problems with increased weight and often are anorexic and in need of high-calorie diets. Children with arthritis are often treated with aspirin. Children with arthritis are able to immobilize their own joints. Range-of-motion exercises are important for maintaining joint flexibility and preventing restricted movement in the affected joints. p1564

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? SELECT ALL THAT APPLY. a. Cleansing the wound b. Managing pain c. Applying a dry sterile dressing d. Using cold water in the bath

ANS: A & B Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

The nurse would explain to a patient that effective treatments for atopic pruritus include which treatments? SELECT ALL THAT APPLY. a. Oral steroids b. Topical steroids c. Oral antihistamines d. Topical antihistamines e. Topical petroleum ointment

ANS: A & B Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical antihistamines are not usually given, because they are ineffective and may cause further irritation. Petroleum is also ineffective.

The nurse is caring for an infant with developmental dysplasia of the hip. Which clinical manifestations should the nurse expect to observe (Select all that apply)? a. Positive Ortolani sign b. Unequal gluteal folds c. Negative Babinski's sign d. Trendelenburg's sign e. Telescoping of the affected limb f. Lordosis

ANS: A, B A positive Ortolani sign and unequal gluteal folds are clinical manifestations of developmental dysplasia of the hip seen from birth to 2 to 3 months. Negative Babinski's sign, Trendelenburg's sign, telescoping of the affected limb, and lordosis are not clinical manifestations of developmental dysplasia of the hip. p1549

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? SELECT ALL THAT APPLY. a. Applying over-the-counter lotions to skin that is not broken b. Assisting the client with frequent turning to prevent pressure ulcers c. Covering the client who complains of being cold with more blankets d. Placing a sterile gauze pad over broken skin to contain drainage e. Assessing a patient complaining of an itching rash

ANS: A, B, C, D All the above options can be delegated to an unlicensed assistive personnel employee except assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

The nurse is providing care for a client who has a permanent biliary drainage tube (T-tube) inserted to provide palliative care. Which action would the nurse take postoperatively? a. Maintain intermittent low suction to limit trauma. b. Cleanse the area around the insertion site to prevent skin breakdown. c. Attach the tube to a negative-pressure drainage system to promote drainage. d. Reposition the client frequently to increase the flow of bile through the tube.

ANS: B Bile is irritating to the skin; cleansing the area around the T-tube to prevent skin breakdown is a priority. Suction is contraindicated; drainage is via gravity. The T-tube is attached to a bag for straight drainage via gravity, not suction that uses negative pressure. Repositioning the client is vital to prevent venous and pulmonary stasis, not for facilitating the drainage of bile.

Which skin color alteration may be observed in a client diagnosed with methemoglobinemia? a. Red b. Blue c. White d. Yellow-orange

ANS: B Blue discoloration of the skin may indicate an increase in deoxygenated blood, which is associated with methemoglobinemia. Red (erythema) may be associated with generalized inflammation. White (pallor) may indicate a decreased level of hemoglobin or it may signify a risk of anemia and shock. A yellow-orange skin discoloration may indicate jaundice and is associated with liver disorders.

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a. Decreasing pain b. Decreasing pruritus c. Preventing infection d. Promoting drying of lesions

ANS: B Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for additional teaching? a. "I wear a hat and sit under the umbrella when not in the water." b. "I don't bother with sunscreen on overcast days." c. "I use a sunscreen with the highest SPF number." d. "I wear a UV shirt and limit exposure to the sun by covering up."

ANS: B The sun's rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

A patient is seen at the urgent care center after falling on the right arm and shoulder. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The right arm appears shorter than the left. c. There is decreased range of motion of the shoulder. d. The patient is complaining of arm and shoulder pain.

ANS: B A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

A patient who has a cast in place after fracturing the radius asks when the cast can be removed. The nurse will instruct the patient that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

ANS: B Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.

The nurse performing a focused examination to determine possible causes of infertility will assess for a. hydrocele. c. epididymitis. b. varicocele. d. paraphimosis.

ANS: B Persistent varicoceles are commonly associated with infertility. Hydrocele, epididymitis, and paraphimosis are not risk factors for infertility. DIF: Cognitive Level: Understand (comprehension) REF: 1285 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse is preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patient's weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient out of bed to nursing assistive personnel (NAP).

ANS: B The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism? a. Candida albicans b. Group A -hemolytic streptococci c. Staphylococcus aureus d. E. Coli

ANS: C Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

A 53-yr-old patient is scheduled for an annual physical examination. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS).

ANS: C An annual digital rectal exam (DRE) and PSA are usually recommended starting at age 50 years for men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA results are abnormal. DIF: Cognitive Level: Apply (application) REF: 1273 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which information will the nurse teach a patient who has chronic prostatitis? a. Ibuprofen (Motrin) should provide good pain control. b. Prescribed antibiotics should be taken for 7 to 10 days. c. Intercourse or masturbation will help relieve symptoms. d. Cold packs used every 4 hours will decrease inflammation.

ANS: C Ejaculation helps drain the prostate and relieve pain. Warm baths are recommended to reduce pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed but usually do not offer adequate pain relief. Antibiotics for chronic prostatitis are taken for 4 to 12 weeks. DIF: Cognitive Level: Apply (application) REF: 1283 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When does idiopathic scoliosis become most noticeable? a. Newborn period b. When child starts to walk c. During preadolescent growth spurt d. Adolescence

ANS: C Idiopathic scoliosis is most noticeable during the preadolescent growth spurt and is seldom apparent before age 10 years. p1557

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that: a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

ANS: C Serial casting, the preferred treatment, is begun shortly after birth before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention. p1551

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure

ANS: C The patient's complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing. Because associated peripheral vasoconstriction and sympathetic nervous system stimulation will occur, skin flushing and hypotension are not expected. Muscle cramps are not expected with chills and shivering or with a rising temperature

The plan of care for a patient immediately after a perineal radical prostatectomy will include decreasing the risk for infection related to a. urinary incontinence. c. fecal wound contamination. b. prolonged urinary stasis. d. suprapubic catheter placement.

ANS: C The perineal approach increases the risk for infection because the incision is located close to the anus, and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery. DIF: Cognitive Level: Apply (application) REF: 1278 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (Select all that apply)? a. Palpable distal pulse b. Capillary refill to extremity of <3 seconds c. Severe pain not relieved by analgesics d. Tingling of extremity e. Inability to move extremity

ANS: C, D, E Indications of compartment syndrome are severe pain not relieved by analgesics, tingling of extremity, and inability to move extremity. A palpable distal pulse and capillary refill to the extremity of <3 seconds are expected findings. Ch48 Musculoskeletal/Articular Dysfunction p1540

A patient asks the nurse what the purpose of the Wood's light is. Which response by the nurse is accurate? a. "We will put an anesthetic on your skin to prevent pain." b. "The lamp can help detect skin cancers." c. "Some patients feel a pressure-like sensation." d. "It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions."

ANS: D The Wood's light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching? a. Bathing and drying the skin vigorously to stimulate circulation b. Keeping the head of the bed elevated 30 degrees c. Limiting intake of fluid and offer frequent snacks d. Turning the patient at least every 2 hours

ANS: D The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

Which ethnic group has the highest incidence of prostate cancer? A. African Americans B. Asians C. Whites D. Hispanics

Answer: A The incidence of prostate cancer worldwide is higher among African Americans than in any other ethnic group. The reasons for the higher rate are unknown.

When providing teaching regarding potential complications after perineal resection of the prostate, what should you include? A. Deep vein thrombosis B. Pulmonary embolism C. Colonic constipation D. Urinary incontinence

Answer: D The two major complications after a radical prostatectomy are erectile dysfunction and urinary incontinence.

Which are treatment-related causes of fatigue? (Select all that apply.) A. Blood transfusion B. Chemotherapy C. Radiation therapy D. Surgery E. Side effects of medications

B, C, D, E

Cause = swelling and pain. A. Pain B. Loss of function C. Swelling D. Redness E. Heat

B. Loss of function

A sequential reaction to cell injury. A. Complement system B. Inflammatory response C. Neutrophils D. Infection

B.Inflammatory response

A patient presents to the clinic complaining of nausea, vomiting, and fatigue. Lab results reveal elevated BUN and creatinine levels. Which acute condition is this patient at most risk for developing? A. Influenza B. Mononucleosis C. Acute renal failure D. Pneumonia

An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse's best response? A. "Walk at least 5 miles every day for exercise." B. "Wear proper fitting shoes to prevent tripping." C. "Talk with your physician about a calcium supplement." D. "Stand up slowly so you don't feel faint."

What percentage of hip fractures is the result of falls? A. 50% B. 80% C. 90% D. 100%

The nurse is caring for a patient with osteoarthritis who is about to undergo total left knee arthroplasty. The nurse assesses the patient carefully to be sure that there is no evidence of what in the preoperative period? A Pain B Left knee stiffness C Left knee infection D Left knee instability

C Left knee infection It is critical that the patient be free of infection before a total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring extensive surgery. For this reason, the nurse monitors the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability may be present with osteoarthritis.

In which order will the nurse take these actions when caring for a patient in the emergency department with a right leg fracture after a motor vehicle crash? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

C, D, B, E, A, F The initial actions should be to ensure adequate airway, breathing, and circulation. This should be followed by checking the neurovascular condition of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-ray examination. The tetanus prophylaxis is the least urgent of the actions.

A male patient with a diagnosis of Parkinson's disease (PD) has been admitted recently to a long-term care facility. Which action should the health care team take in order to promote adequate nutrition for this patient? A. Provide multivitamins with each meal. B. Provide a diet that is low in complex carbohydrates and high in protein. C. Provide small, frequent meals throughout the day that are easy to chew and swallow. D. Provide the patient with a minced or pureed diet that is high in potassium and low in sodium.

C. Nutritional support is a priority in the care of individuals with PD. Such patients may benefit from meals that are smaller and more frequent than normal and that are easy to chew and swallow. Multivitamins are not necessary at each meal, and vitamin intake, along with protein intake, must be monitored to prevent contraindications with medications. It is likely premature to introduce a minced or pureed diet, and a low carbohydrate diet is not indicated.

A 54-year-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM before a bone scan. The nurse should plan to send the patient for the bone scan at what time? A. 9:30 PM B. 10:00 AM C. 11:00 AM D. 1:00 PM

C. 11:00 AM A technician usually administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. 10:00 AM would be too early; 1:00 PM and 9:30 PM would be too late.

Consists of WBCs, microorganisms (dead and alive), liquefied dead cells, and other debris. (example = furuncle, abscess, cellulitis) A. Catarrhal B. Hemorrhagic C. Purulent D. Serous E. Fibrinous

C. Purulent

Fever that accompanies inflammation is most likely caused by A. Increased production and activity of neutrophils B. Massive vasodilation during the vascular response C. Release of IL-1, IL-6, and TNF from monocytes D. Activation of the complement system

C. Release of IL-1, IL-6, and TNF from monocytes

Based on the significant effects of chronic idiopathic fatigue, what is the nurse's priority assessment? A. Cholesterol level and lipid profile B. Creatinine and BUN levels C. Memory loss testing D. Mental health evaluation

Mobility for the patient changes throughout the lifespan. What is the term that best describes this process? A. Aging and illness B. Illness and disease C. Health and wellness D. Growth and development

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? A. "Patients must have a trapeze over the bed to move properly." B. "Patients should move themselves in bed to prevent immobility." C. "Patients should always have a two-person assist to move in bed." D. "Patients must be moved correctly in bed to prevent shearing."

The nurse palpates swollen nodes in a patient's neck who presented to the clinic with complaints of fatigue lasting at least 2 weeks. What is the nurse's best action? A. Advise patient this finding is normal. B. Review patient's thyroid lab work. C. Perform deep tendon reflexes. D. Notify the healthcare provider.

Found in tissues where cells produce mucus. Mucus production is accelerated by inflammatory response. (examples = runny nose associated with upper respiratory tract infection) A. Serous B. Purulent C. Fibrinous D. Catarrhal E. Hemorrhagic

D. Catarrhal

Which task can the nurse delegate to an unlicensed assistive personnel (UAP) in the care of a patient who has recently undergone prostatectomy? A. Assessing the patient's incision B. Irrigating the patient's Foley catheter C. Assessing the patient's pain and selecting analgesia D. Performing cleansing of the meatus and perineal region

D. Performing cleansing of the meatus and perineal region Performing perineal care is an appropriate task for delegation. Selecting analgesia, irrigating the patient's catheter, and assessing his incision are not appropriate skills or tasks for unlicensed personnel.

The nurse observes a 74-yr-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? Provide the patient with diversional activities. Document the activity in the patient's health record. Take the patient's blood pressure sitting and standing. Ask if the patient is feeling either anxious or depressed.

Document the activity in the patient's health record. Patients with Parkinson's disease are instructed to rock from side to side to stimulate balance mechanisms and decrease akinesia.

Occurs with increasing vascular permeability and fibrinogen leakage into interstitial spaces. Excessive amounts of fibrin coating tissue surfaces may cause them to adhere. (examples = adhesions) A. Purulent B. Serous C. Catarrhal D. Hemorrhagic E. Fibrinous

E. Fibrinous

Cause = increased metabolism at inflammatory site. A. Swelling B. Loss of function C. Pain D. Redness E. Heat

E. Heat

Cause = fluid shift to interstitial spaces; fluid exudate accumulation. A. Pain B. Loss of function C. Heat D. Redness E. Swelling

E. Swelling

The nurse is planning care for a patient with hypercalcemia secondary to bone metastasis. Which of the following interventions will be included in the plan of care? (Select all that apply.) a) Increasing oral fluids b) Monitoring for Chvostek's sign c) Hyperactive reflex assessment d) Placement of an oral airway at the bedside e) Observation for muscle weakness f) Implementing seizure precautions

Increasing oral fluids Observation for muscle weakness Serious complications of hypercalcemia include severe muscle weakness, dehydration, loss of deep tendon reflexes, paralytic ileus, and electrocardiographic changes. Early manifestations of hypercalcemia include fatigue, loss of appetite, nausea, vomiting, constipation, and polyuria (increased urine output).

A concerned community group is planning a program focused on problems of cellular regulation as a result of exposure to environmental carcinogens other than smoking. Based on its goal of reaching as many at-risk persons as possible, which population should be targeted? a) Low-income workers b) Women older than age 80 c) Families with infants or young children d) Persons of color

Low-income workers Low-income workers are the population at greatest risk for exposure to environmental carcinogens other than smoking and therefore should be targeted for a program related to this risk. Environmental carcinogens other than smoking include sun exposure and pollutants such as radon and asbestos in the air, water, soil, or food. Exposure to these pollutants is thought to account for only 6% of cancer deaths, but a large number of people are affected and most of these cases occur disproportionately among lower-income workers and communities.

Which of the following are examples of primary prevention of changes in cellular regulation resulting in malignant neoplasia? (Select all that apply.) a) Having a colonoscopy b) Engaging in regular exercise c) Prophylactic mastectomy d) Eating a balanced diet e) Performing self-breast examination f) Not smoking

Not smoking Engaging in regular exercise Prophylactic mastectomy Eating a balanced diet The cornerstones of primary prevention of cancer risk (i.e., change in cellular regulation resulting in malignant neoplasia) are participating in regular physical activity, eating a balanced diet, and avoiding smoking and excessive sun exposure. Another primary prevention strategy is prophylactic surgery such as mastectomy of oophorectomy as advised by a person's health care provider. Self-breast examination and other screening tests such as colonoscopy are examples of secondary prevention.

Which principles apply to the normal process of cellular regulation? Select any that apply. a) Meiosis is the form of replication by which damaged tissue is replaced. b) Once the cell cycle is entered, the cell is committed to it. c) Surveillance mechanisms monitor for errors in replication. d) Not all genes are active in every cell. e) All healthy cells proliferate at the same rate.

Once the cell cycle is entered, the cell is committed to it. Surveillance mechanisms monitor for errors in replication. Not all genes are active in every cell. The cell cycle refers to the series of events associated with normal cell reproduction. The cell must leave the resting state (G0) to enter the cell cycle with its phases of G1, G2, and M. Entering the cell cycle is an irreversible act and commits the cell to eventual mitosis. Normal cell replication requires accurate signaling within and between cells. Signaling occurs throughout the cell cycle and surveillance mechanisms monitor for errors and either repair or destroy the cell to prevent replication of errors. All normal cells, with the exception of ova and sperm, contain a full complement of human genes but not all the genes are active in every cell. Mitosis, not meiosis, is the form of replication by which damaged tissue is replaced. Cellular proliferation rate varies according to the tissue involved.

What priority intervention will the nurse employ to prevent injury to the patient with bone cancer? a) Using a lift sheet when repositioning the patient b) Providing small, frequent meals rich in calcium and phosphorus c) Positioning the patient so the heels do not touch the mattress d) Applying pressure for a full 5 minutes after intramuscular injections

Using a lift sheet when repositioning the patient The resultant bone destruction from bone cancer can cause pathologic fractures by grasping or pulling on a patient by the extremities or trunk of the body during re-positioning. Use of a lift sheet evenly distributes the patient's weight, lessening the chance of fractures occurring. While safety risks exist, the priority for bone cancer is reducing risk of fractures.

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? a. Atelectasis b. Bronchospasm c. Hypoventilation d. Pulmonary embolism

a. Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

A female patient complains of a "scab that just won't heal" under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse's best action? a. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. b. End the appointment and tell the patient to use skin protection during sun exposure. c. Suggest further testing with a cancer specialist and provide the appropriate literature. d. Tell her to put a bandage on the scab and set a follow-up appointment in 1 week.

a. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns.

a. Prioritization and administration of nursing care throughout the day

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? a. Supine b. Lateral c. Semi-Fowler's d. High-Fowler's

b. Lateral Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

A nurse is reviewing assessment findings for a female patient admitted to the oncology unit. Which finding should alert the nurse to contact the physician? a. Blood pressure 130/88 b. Noticeable difference in circumference of lower legs c. Presence of goiter previously identified on prior admission d. Negative guaiac test

b. Noticeable difference in circumference of lower legs

When a *74-yr*-old patient is seen in the health clinic with new development of a *stooped posture, shuffling gait, and pill rolling-type tremor*, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

b. antiparkinsonian drugs. The clinical diagnosis of *Parkinson's* is made when *tremor, rigidity, and akinesia, and postural instability* are present.

A 65-year-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. evaluating the home for environmental safety. c. promoting physical exercise and a well-balanced diet. d. designing an exercise program to strengthen and stretch specific muscles.

c Rationale: Promotion of physical exercise and a well-balanced diet are major concerns of nursing care for patients with Parkinson's disease.

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action will the nurse take first? a. Elevate the leg on 2 pillows. b. Apply a compression bandage. c. Assess leg pulses and sensation. d. Place ice packs on the lower leg.

c. Assess leg pulses and sensation. The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

Which discharge instruction will the emergency department nurse include for a patient with a sprained ankle? a. Keep the ankle loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the ankle above the heart. d. Gently move the ankle through the range of motion.

c. Use pillows to elevate the ankle above the heart. Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.

A factory line worker has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. b. elbow injections. c. wearing a left wrist splint. d. modifying arm movements.

d. modifying arm movements. Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

When assessing for Tinel's sign in a patient with possible right carpal tunnel syndrome, the nurse will ask the patient about a. weakness in the right little finger. b. burning in the right elbow and forearm. c. tremor when gripping with the right hand. d. tingling in the right thumb and index finger.

d. tingling in the right thumb and index finger. Testing for Tinel's sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome.

When performing discharge teaching for a patient after a vasectomy, the nurse instructs the patient that he a. should continue to use other methods of birth control for 6 weeks. b. should not have sexual intercourse until his 6-week follow-up visit. c. may have temporary erectile dysfunction (ED) because of swelling. d. will notice a decrease in the appearance and volume of his ejaculate.

ANS: A Because it takes about 6 weeks to evacuate sperm that are distal to the vasectomy site, the patient should use contraception for 6 weeks. ED that occurs after vasectomy is psychologic in origin and not related to postoperative swelling. The patient does not need to abstain from intercourse. The appearance and volume of the ejaculate are not changed because sperm are a minor component of the ejaculate. DIF: Cognitive Level: Understand (comprehension) REF: 1286 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which example is associated with third spacing in a burn injury? a. Blister formation b. Edema formation c. Fluid mobilization d. Fluid accumulation

ANS: A Blister formation is an example of third spacing in burn injuries. Edema formation and fluid mobilization generally happen in every burn injury. Fluid accumulation is formed in second spacing in a burn injury.

Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis b. Ankylosis c. Lordosis d. Kyphosis

ANS: D Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine. Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint. Lordosis is an accentuation of the cervical or lumbar curvature beyond physiologic limits. p1556

A patient with breast cancer asks the nurse why 6 weeks of daily radiation treatments is necessary. What is the nurse's best response? a) "Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time." b) "The cost of larger doses of radiation for a shorter period of time is justified by the results." c) "Your cancer is widespread and requires more than the usual amount of radiation treatment." d) "It is less likely your hair will fall out or you will become anemic if radiation is given in smaller doses over a longer period of time."

"Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time." Because of the varying responses of all the cancer cells within a given tumor, smaller doses of radiation given on a daily basis for a set period of time provides multiple opportunities for the destruction of cancer cells while minimizing damage to normal tissues.

The nurse is reviewing a patient for risk factors of chronic fatigue syndrome. Which factors should the nurse identify as placing the patient at risk for chronic fatigue syndrome? (Select all that apply.) A. Feeling tired upon awakening B. Chronic migraines C. Tenderness under the jaw D. 5 episodes tonsillitis/past year E. Swollen, painful knees

A, C, D, E

A patient with chronic kidney disease is most likely to complain of which symptom? A. Fatigue B. Thirst C. Constipation D. Excess bleeding

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

A, B, D Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.

Musculoskeletal assessment is an important component of care for patients on what type of long-term therapy? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers

A. Corticosteroids Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.

What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia? a. Risk for injury related to poor blood clotting b. Fatigue related to decreased cellular oxygenation c. Disturbed body image related to skin color changes d. Imbalanced nutrition, less than body requirements related to anorexia

ANS B

The following male patients recently arrived in the emergency department. Which one should the nurse assess first? a. A 19-yr-old patient who is complaining of severe scrotal pain b. A 60-yr-old patient with a nontender ulceration of the glans penis c. A 64-yr-old patient who has dysuria after brachytherapy for prostate cancer d. A 22-yr-old patient who has purulent urethral drainage and severe back pain

ANS: A The patient's age and symptoms suggest possible testicular torsion, which will require rapid treatment to prevent testicular necrosis. The other patients also require assessment by the nurse, but their history and symptoms indicate nonemergent problems (acute prostatitis, cancer of the penis, and radiation-associated urinary tract irritation). DIF: Cognitive Level: Analyze (analysis) REF: 1285 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

Which term would the nurse use to document a 1 cm elevated solid lesion noted on a client's skin? a. Papule b. Nodule c. Vesicle d. Pustule

ANS: B A nodule is an elevated solid lesion greater than 0.5 cm in diameter. A papule is an elevated solid lesion less than 0.5 cm in diameter. A vesicle is a circumscribed, superficial collection of serous fluid. A pustule is an elevated, superficial lesion filled with purulent fluid.

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in a dependent position. b. handle the cast with the palms of the hands. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

ANS: B Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

The nurse taking a focused health history for a patient with possible testicular cancer will ask the patient about a history of a. testicular torsion. b. testicular trauma. c. undescended testicles. d. sexually transmitted infection (STI).

ANS: C Cryptorchidism is a risk factor for testicular cancer if it is not corrected before puberty. STI, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer. DIF: Cognitive Level: Understand (comprehension) REF: 1284 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to perform which actions? SELECT ALL THAT APPLY. a. Bathe and dry the skin vigorously to stimulate circulation. b. Keep the head of the bed elevated 30 degrees. c. Offer nutritional supplements and frequent snacks. d. Turn the patient at least every 2 hours. e. Maintain a cooler environment when bathing.

ANS: C & D The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline. Older adults are more prone to hypothermia if bathed in a cooler environment.

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

ANS: D Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent need to notify the surgeon

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. The nurse immediately assesses the patient for A. an aura or focal seizure. B. nystagmus or confusion. C. abdominal pain or cramping. D. irregular pulse or palpitations.

B. Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity.

The nurse observes a 74-year-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? A. Provide the patient with diversional activities. B. Document the activity in the patient's health record. C. Take the patient's blood pressure sitting and standing. D. Ask if the patient is feeling either anxious or depressed.

B. Patients with Parkinson's disease are instructed to rock from side to side to stimulate balance mechanisms and decrease akinesia.

A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

B. Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing.

B. The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

The nurse formulates a nursing diagnosis of impaired physical mobility related to decreased muscle strength for a 78-year-old patient following left total knee replacement. What would be an appropriate nursing intervention for this patient? A Promote vitamin C and calcium intake in the diet. B Provide passive range of motion to all of the joints q4hr. C Encourage isometric quadriceps-setting exercises at least qid. D Keep the left leg in extension and abduction to prevent contractures.

C Encourage isometric quadriceps-setting exercises at least qid. Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery along with a continuous passive motion (CPM) machine. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to do active range of motion to all joints. Keeping the leg in one position (extension and abduction) potentially will result in contractures.

The nurse teaches a 30-year-old man with a family history of prostate cancer about dietary factors associated with prostate cancer. The nurse determines that teaching is successful if the patient selects which menu? A. Grilled steak, French fries, and vanilla shake B. Hamburger with cheese, pudding, and coffee C. Baked chicken, peas, apple slices, and skim milk D. Grilled cheese sandwich, onion rings, and hot tea

C. Baked chicken, peas, apple slices, and skim milk A diet high in red meat and high-fat dairy products along with a low intake of vegetables and fruits may increase the risk of prostate cancer.

The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement? A. "The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus." B. "The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed." C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." D. "The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management."

C. "The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing." After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience paralytic ileus and interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery patients often wear a soft or hard cervical collar to immobilize the neck.

The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus? A. 22-year-old female with gonorrhea who is an IV drug user B. 48-year-old male with muscular dystrophy and acute bronchitis C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago

C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

Which medication information will the nurse identify as a concern for a patient's musculoskeletal status? a. The patient takes a daily multivitamin and calcium supplement. b. The patient takes hormone therapy (HT) to prevent "hot flashes." c. The patient has severe asthma and requires frequent therapy with oral corticosteroids. d. The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).

C. Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.

The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring? A Paresthesia B Pitting edema C Poor venous return D Compartment syndrome

D Compartment syndrome The nurse should suspect compartment syndrome with one or more of the following six Ps: paresthesia, pallor, pulselessness, pain distal to the injury and unrelieved with opioids, pressure increases in the compartment, and paralysis. Although paresthesia and poor venous return are evident, these are just some of the manifestations of compartment syndrome.

This morning a 21-year-old male patient had a long leg cast applied and wants to get up and try out his crutches before dinner. The nurse will not allow this. What is the best rationale that the nurse should give the patient for this decision? A The cast is not dry yet, and it may be damaged while using crutches. B The nurse does not have anyone available to accompany the patient. C Rest, ice, compression, and elevation are in process to decrease pain. D Excess edema and other problems are prevented when the leg is elevated for 24 hours

D Excess edema and other problems are prevented when the leg is elevated for 24 hours For the first 24 hours after a lower extremity cast is applied, the leg will be elevated on pillows above the heart level to avoid excessive edema and compartment syndrome. The cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement

D. Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

D. The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.

Interfere with tissue granulation, induce immunosuppressive effects, prevent liberation of lysosomes. A. NSAIDs B. Salicylates C. Brushing your teeth D. Corticosteroids

D. Corticosteroids

The nurse is reinforcing health teaching about osteoporosis with a 72-year-old patient admitted to the hospital. In reviewing this disorder, what should the nurse explain to the patient? A. With a family history of osteoporosis, there is no way to prevent or slow bone resorption. B. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. C. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

D. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise. The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements and/or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.

Results from rupture or necrosis of blood vessel walls; it consists of RBCs that escape into tissue. (example = hematoma). A. Purulent B. Catarrhal C. Serous D. Hemorrhagic E. Fibrinous

D. Hemorrhagic

Upon entering the room, the nurse finds the patient, who has just had a mastectomy, crying. When the nurse asks about her crying, the patient states, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? a) "I know this is hard, but chances of survival are greatly improved now." b) "Would you like to talk to someone who also has had a mastectomy?" c) "It is okay to cry; mourning the loss of your breast is important for getting past this." d) "How have you coped with difficult situations in the past?"

"It is okay to cry; mourning the loss of your breast is important for getting past this." Cancer surgery can involve the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy response in adapting or adjusting to a new image. Discussion of survival, talking with someone else who has undergone a mastectomy, or asking about prior coping behaviors does not address the patient's feelings about loss of the breast.

27. A patient with a tremor is being evaluated for Parkinson's disease. The nurse explains to the patient that Parkinson's disease can be confirmed by a. CT and MRI scans. b. relief of symptoms with administration of dopaminergic agents. c. the presence of tremors that increase during voluntary movement. d. cerebral angiogram that reveals the presence of cerebral atherosclerosis.

27. b. Although clinical manifestations are characteristic in PD, no laboratory or diagnostic tests are specific for the condition. A diagnosis is made when at least two of the three signs of the classic triad are present and it is confirmed with a positive response to antiparkinsonian medication. Research regarding the role of genetic testing and MRI to diagnose PD is ongoing. Essential tremors increase during voluntary movement whereas the tremors of PD are more prominent at rest.

28. Which observation of the patient made by the nurse is most indicative of Parkinson's disease? a. Large, embellished handwriting b. Weakness of one leg resulting in a limping walk c. Difficulty rising from a chair and beginning to walk d. Onset of muscle spasms occurring with voluntary movement

28. c. The bradykinesia of PD prevents automatic movements and activities such as beginning to walk, rising from a chair, or even swallowing saliva cannot be executed unless they are consciously willed. Handwriting is affected by the tremor and results in the writing trailing off at the end of words. Specific limb weakness and muscle spasms are not characteristic of PD.

29. A patient with Parkinson's disease is started on levodopa. What should the nurse explain about this drug? a. It stimulates dopamine receptors in the basal ganglia. b. It promotes the release of dopamine from brain neurons. c. It is a precursor of dopamine that is converted to dopamine in the brain. d. It prevents the excessive breakdown of dopamine in the peripheral tissues.

29. c. Peripheral dopamine does not cross the blood-brain barrier but its precursor, levodopa, is able to enter the brain, where it is converted to dopamine, increasing the supply that is deficient in PD. Other drugs used to treat PD include bromocriptine, which stimulates dopamine receptors in the basal ganglia, and amantadine, which blocks the reuptake of dopamine into presynaptic neurons. Carbidopa is an agent that is usually administered with levodopa to prevent the levodopa from being metabolized in peripheral tissues before it can reach the brain.

The lack of weight bearing leads to what effects on the skeletal system? A. Demineralization, calcium loss B. Thickened bones C. Increased range of motion D. Increased calcium deposition in the bones

The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement? A. "Patients with impaired bed mobility have an increased risk for pressure ulcers." B. "Patients with impaired bed mobility like to have extra visitors." C. "Patients with impaired bed mobility need to have a mechanical soft diet." D. "Patients with impaired bed mobility are prone to constipation."

A 54-year-old patient with acute osteomyelitis asks the nurse how this problem will be treated. Which response by the nurse is most appropriate? A. "IV antibiotics are usually required for several weeks." B. "Oral antibiotics are often required for several months." C. "Surgery is almost always necessary to remove the dead tissue that is likely to be present." D. "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy."

A. "IV antibiotics are usually required for several weeks." The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. This is because bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all of the microorganisms. Surgery may be used for chronic osteomyelitis, which may include debridement of the devitalized and infected tissue and irrigation of the affected bone with antibiotics

After a vasectomy, what teaching should be included in the discharge teaching? A. "You will want to use an alternative form of contraception for 6 weeks." B. "You may lose some secondary sexual characteristics after this surgery." C. "You may have erectile dysfunction for several months after this surgery." D. "You will be uncomfortable, but you may safely have sexual intercourse today."

A. "You will want to use an alternative form of contraception for 6 weeks." As vasectomies are usually done for sterilization purposes, to safely have sexual intercourse, the patient will need to use an alternative form of contraception until semen examination reveals no sperm, usually at least 10 ejaculations or 6 weeks to evacuate sperm distal to the surgical site. Hormones are not affected, so there is no loss of secondary sexual characteristics or erectile function. Most men experience too much pain to have sexual intercourse on the day of their surgery, so this is not an appropriate comment by the nurse.

The nurse is teaching clinic patients about risk factors for testicular cancer. Which individual is at highest risk for developing testicular cancer? A. A 30-year-old white male with a history of cryptorchidism B. A 48-year-old African American male with erectile dysfunction C. A 19-year-old Asian male who had surgery for testicular torsion D. A 28-year-old Hispanic male with infertility caused by a varicocele

A. A 30-year-old white male with a history of cryptorchidism The incidence of testicular cancer is four times higher in white males than in African American males. Testicular tumors are also more common in males who have had undescended testes (cryptorchidism) or a family history of testicular cancer or anomalies. Other predisposing factors include orchitis, human immunodeficiency virus infection, maternal exposure to DES, and testicular cancer in the contralateral testis.

A 72-year-old patient with kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. The nurse will plan to a. explain the procedure. b. start an IV line for contrast medium injection. c. give an oral sedative 60 to 90 minutes before the procedure. d. screen the patient for allergies to shellfish or iodine products.

A. DXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Because the procedure is painless, no antianxiety medications are required.

First leukocytes to arrive at the site of inflammation. A. Neutrophils B. Monocytes C. Leukocytes D. Basophils

A. Neutrophils

The nurse is performing a musculoskeletal assessment of an 81-year-old female patient whose mobility has been progressively decreasing in recent months. How should the nurse best assess the patient's range of motion (ROM) in the affected leg? A. Observe the patient's unassisted ROM in the affected leg. B. Perform passive ROM, asking the patient to report any pain. C. Ask the patient to lift progressive weights with the affected leg. D. Move both of the patient's legs from a supine position to full flexion.

A. Observe the patient's unassisted ROM in the affected leg. Passive ROM should be performed with extreme caution and may be best avoided when assessing older patients. Observing the patient's active ROM is more accurate and safe than asking the patient to lift weights with her legs.

A patient has a new order for magnetic resonance imaging (MRI) to evaluate for left femur osteomyelitis after a hip replacement surgery. Which information indicates that the nurse should consult with the health care provider before scheduling the MRI? a. The patient has a pacemaker. b. The patient is claustrophobic. c. The patient wears a hearing aid. d. The patient is allergic to shellfish.

A. Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.

Which nursing intervention is most appropriate when turning a patient following spinal surgery? A. Placing a pillow between the patient's legs and turning the body as a unit B. Having the patient turn to the side by grasping the side rails to help turn over C. Elevating the head of bed 30 degrees and having the patient extend the legs while turning D. Turning the patient's head and shoulders and then the hips, keeping the patient's body centered in the bed

A. Placing a pillow between the patient's legs and turning the body as a unit Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort following spinal surgery. Having the patient turn by grasping the side rail to help, elevating the head of the bed, and turning with extended legs or turning the patient's head and shoulders and then the hips will not maintain proper spine alignment and may cause damage.

Healing as a result of lost cells being replaced by connective tissue A. Repair B. Regeneration C. Brushing your teeth D. Primary intention

A. Repair

A 71-year-old patient with a diagnosis of benign prostatic hyperplasia (BPH) has been scheduled for a contact laser technique. What is the primary goal of this intervention? A. Resumption of normal urinary drainage B. Maintenance of normal sexual functioning C. Prevention of acute or chronic renal failure D. Prevention of fluid and electrolyte imbalances

A. Resumption of normal urinary drainage The most significant signs and symptoms of BPH relate to the disruption of normal urinary drainage and consequent urine retention, incontinence, and pain. A laser technique vaporizes prostate tissue and cauterizes blood vessels and is used as an effective alternative to a TURP to resolve these problems. Fluid imbalances, sexual functioning, and kidney disease may result from uncontrolled BPH, but the central focus remains urinary drainage.

A 33-year-old patient noticed a painless lump in his scrotum on self-examination of his testicles and a feeling of heaviness. The nurse should first teach him about what diagnostic test? A. Ultrasound B. Cremasteric reflex C. Doppler ultrasound D. Transillumination with a flashlight

A. Ultrasound When the scrotum has a painless lump, scrotal swelling, and a feeling of heaviness, testicular cancer is suspected, and an ultrasound of the testes is indicated. Blood tests will also be done. The cremasteric reflex and Doppler ultrasound are done to diagnose testicular torsion. Transillumination with a flashlight is done to diagnose a hydrocele.

A patient is not certain whether she and her family should participate in a genetic screening plan. She asks the nurse why the X-linked recessive disorder that has been noted in some of her family members is expressed in males more frequently than in females. What is the nurse's best response? a. "The disease tends to show up in males because they do not have a second X chromosome to balance the expression of the gene." b. "One X chromosome of a pair is always inactive in females. This inactivity effectively negates the effects of the gene." c. "Females are known to have more effective DNA repair mechanisms than males, thus negating the damage caused by the recessive gene." d. "Expression of genes from the male's Y chromosome does not occur in females, so they are essentially immune to the effects of the gene."

ANS A

While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age

ANS D

Which of the following terms is used to describe a type of fracture that does not produce a break in the skin? a. Simple b. Compound c. Complicated d. Comminuted

ANS: A If a fracture does not produce a break in the skin, it is called a simple, or closed, fracture.

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature

ANS: A, C, B, D The first nursing action should be to increase the IV infusion rate. Because the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient's temperature should be assessed to determine the effects of vasodilation caused by rewarming.

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Notify the patient's health care provider

ANS: A, C, B, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider

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 first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last

In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ 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 The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.

While collecting a health history on a patient admitted for colon cancer, which of the following questions would be a priority to ask this patient? a. "Have you noticed any blood in your stool?" b. "Have you been experiencing nausea?" c. "Do you have back pain?" d. "Have you noticed any swelling in your abdomen?"

ANS: A Early colon cancer is often asymptomatic, with occult or frank blood in the stool being an assessment finding in a patient diagnosed with colon cancer. If pain is present, it is usually lower abdominal cramping. Constipation and diarrhea are more frequent findings than nausea or ascites.

A client has bright-red erythematosus macules and papules on the skin. The nurse would expect to teach the client about which condition? a. Medication eruption b. Atopic dermatitis c. Contact dermatitis d. Nonspecific eczematous dermatitis

ANS: A Medication eruptions are characterized by bright-red erythematosus macules and papules on the skin, which occur because of an adverse reaction to a medication. Atopic dermatitis is characterized by scaling and excoriation, which occurs due to food allergies, chemicals, or stress. Contact dermatitis manifests as localized eczematous eruption when the skin comes into direct contact with irritants or allergens. Nonspecific eczematous dermatitis results in evolution of lesions from vesicles to weeping papules and plaques.

A nurse is conducting community education classes on skin cancer. One participant says to the nurse: "I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?" How should the nurse respond? a. "That is not correct. Melanoma is more commonly found on the torso or the lower legs of women." b. "That is correct, because the face and arms are exposed more often to the sun." c. "That is not correct. Melanoma occurs on the top of the head in men but is rare in women." d. "That is incorrect. Melanoma is most commonly seen in dark-skinned individuals."

ANS: A Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet. Dark-skinned individuals are less likely to get melanoma.

A 22-yr-old patient tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. Which question should the nurse ask to assess for possible etiologic factors in this age group? a. "Do you use recreational drugs or drink alcohol?" b. "Do you experience an unusual amount of stress?" c. "Do you have cardiovascular or peripheral vascular disease?" d. "Do you have a history of an erection that lasted for 6 hours or more?"

ANS: A A common etiologic factor for erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are not common etiologic factors in younger men. DIF: Cognitive Level: Apply (application) REF: 1287 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

ANS: A A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.

ANS: A A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature

A 70-yr-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) is being discharged from the hospital today. Which patient statement indicates a need for the nurse to provide additional instruction? a. "I should call the doctor if I have incontinence at home." b. "I will avoid driving until I get approval from my doctor." c. "I should schedule yearly appointments for prostate examinations." d. "I will increase fiber and fluids in my diet to prevent constipation."

ANS: A Because incontinence is common for several weeks after a TURP, the patient does not need to call the health care provider if this occurs. The other patient statements indicate that the patient has a good understanding of post-TURP instructions. DIF: Cognitive Level: Apply (application) REF: 1274 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

What effect does immobilization have on the cardiovascular system? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes

ANS: A Because of decreased muscle contraction, the physiologic effects of immobilization include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found, with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes, with an inability to adapt readily to the upright position and pooling of blood in the extremities in the upright position. Ch48 Musculoskeletal/Articular Dysfunction p1533

A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, "My symptoms are much worse this week." Which response by the nurse is appropriate? a. "Have you taken any over-the-counter (OTC) medications recently?" b. "I will talk to the doctor about a prostate specific antigen (PSA) test." c. "Have you talked to the doctor about surgery such as transurethral resection of the prostate (TURP)?" d. "The prostate gland changes in size from day to day, and this may be making your symptoms worse."

ANS: A Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer. DIF: Cognitive Level: Apply (application) REF: 1273 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which of the following can result from the bone demineralization associated with immobility? a. Osteoporosis b. Urinary retention c. Pooling of blood d. Susceptibility to infection

ANS: A Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi.

An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. The nurse's approach should include which of the following? a. Answer questions with straightforward honesty. b. Avoid discussing the seriousness of the condition. c. Explain that although the amputation is difficult, it will cure the cancer. d. Assist adolescent in accepting the amputation as better than a long course of chemotherapy.

ANS: A Honesty is essential to gain the child's cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so he or she has time to reflect on the diagnosis and subsequent treatment. This allows questions to be answered.

The nurse will inform a patient with cancer of the prostate that side effects of leuprolide (Lupron) may include a. flushing. c. infection. b. dizziness. d. incontinence.

ANS: A Hot flashes may occur with decreased testosterone production. Dizziness may occur with the a-blockers used for benign prostatic hyperplasia. Urinary incontinence may occur after prostate surgery, but it is not an expected side effect of medication. Risk for infection is increased in patients receiving chemotherapy. DIF: Cognitive Level: Understand (comprehension) REF: 1280 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? a. "You will need to assess and clean the pin insertion sites daily." b. "The external fixator can be removed during the bath or shower." c. "You will need to remain on bed rest until bone healing is complete." d. "Prophylactic antibiotics are used until the external fixator is removed."

ANS: A Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this material? a. Soak in a bathtub. c. Apply powder to absorb material. b. Vigorously scrub the leg. d. Carefully pick material off of the leg.

ANS: A Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child. p1542

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Assess the ankle's range of motion (ROM). d. Assess whether the patient can bear weight on the affected ankle.

ANS: A Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues

A young girl has just injured her ankle at school. In addition to calling the child's parents, the most appropriate, immediate action by the school nurse is which of the following? a. Apply ice. b. Observe for edema and discoloration. c. Encourage child to assume a position of comfort. d. Obtain parental permission for administration of acetaminophen or aspirin.

ANS: A Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied.

A young girl has just injured her ankle at school. In addition to calling the child's parents, the most appropriate immediate action by the school nurse is to: a. Apply ice. b. Observe for edema and discoloration. c. Encourage child to assume a comfortable position. d. Obtain parental permission for administration of acetaminophen or aspirin.

ANS: A Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied. Observing for edema and discoloration, encouraging the child to assume a comfortable position, and obtaining parental permission or administration of acetaminophen or aspirin are not immediate priorities. p1537

Four-year-old David is placed in Buck's extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse. What should the nurse do first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain. c. Reposition the child and notify the physician. d. Chart the observations and check the extremity again in 15 minutes.

ANS: A The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. Pain medication should be given after the practitioner is notified. This is an emergency condition; immediate reporting is indicated. The findings should be documented with ongoing assessment. p1554

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patient's temperature is 100.3° F (37.9° C). c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.

ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities

A patient with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the hand. Which patient statement to the nurse indicates realistic expectation for the surgery? a. "I will be able to use my fingers to grasp objects better." b. "I will not have to do as many hand exercises after the surgery." c. "This procedure will prevent further deformity in my hands and fingers." d. "My fingers will appear more normal in size and shape after this surgery."

ANS: A The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. b. Start antibiotic therapy. c. Redress the wound with wet-to-dry dressings. d. Continue to monitor the wound for purulent drainage.

ANS: A The increase in WBC count with the increased bands (shift to the left) indicates that the patient probably has a bacterial infection, and the nurse should obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well

When doing discharge teaching for a patient who has had a repair of a fractured mandible, the nurse will include information about a. when and how to cut the immobilizing wires. b. self-administration of nasogastric tube feedings. c. the use of sterile technique for dressing changes. d. the importance of including high-fiber foods in the diet.

ANS: A The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.

Which of the following is most descriptive of the therapeutic management of osteosarcoma? a. Treatment usually consists of surgery and chemotherapy. b. Amputation of affected extremity is rarely necessary. c. Intensive irradiation is the primary treatment. d. Bone marrow transplantation offers the best chance of long-term survival.

ANS: A The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy.

What is most descriptive of the therapeutic management of osteosarcoma? a. Treatment usually consists of surgery and chemotherapy. b. Amputation of the affected extremity is rarely necessary. c. Intensive irradiation is the primary treatment. d. Bone marrow transplantation offers the best chance of long-term survival.

ANS: A The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy. Amputation is frequently required. Intensive irradiation and bone marrow transplantation are usually not part of the therapeutic management. p1561

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take? a. Cover the patient with a warm blanket and put on socks. b. Notify the anesthesia care provider about the temperature. c. Avoid the use of opioid analgesics until the patient is warmer. d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.

ANS: A The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period, there is no need to notify the anesthesia care provider, unless the patient continues to be hypothermic after active rewarming

Before assisting a patient with ambulation on the day after a total hip replacement, which action is most important for the nurse to take? a. Administer the ordered oral opioid pain medication. b. Instruct the patient about the benefits of ambulation. c. Ensure that the incisional drain has been discontinued. d. Change the hip dressing and document the wound appearance.

ANS: A The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

Several patients call the urology clinic requesting appointments with the health care provider as soon as possible. Which patient will the nurse schedule to be seen first? a. A 22-yr-old patient who has noticed a firm, nontender lump on his scrotum b. A 35-yr-old patient who is concerned that his scrotum "feels like a bag of worms" c. A 40-yr-old patient who has pelvic pain while being treated for chronic prostatitis d. A 70-yr-old patient who is reporting frequent urinary dribbling after a prostatectomy

ANS: A The patient's age and symptoms suggest possible testicular cancer. Some forms of testicular cancer can be very aggressive, so the patient should be evaluated by the health care provider as soon as possible. Varicoceles do require treatment but not emergently. Ongoing pelvic pain is common with chronic prostatitis. Urinary dribbling is a common problem after prostatectomy. DIF: Cognitive Level: Analyze (analysis) REF: 1285 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

ANS: A The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100°F (37.8°C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

ANS: A The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and/or possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient cough and deep breathe. Oral medications typically take more than 15 minutes for effective pain relief

A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing knee pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours.

ANS: A The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs (NSAIDs) improves pain control in postoperative patients. Patient teaching and reassurance are appropriate, but should be done after the patient's pain is relieved. If the patient continues to have pain after the morphine is administered, the health care provider should be notified

ANS: A, B, D Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations. DIF: Cognitive Level: Apply (application) REF: 1436-1437 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which functions are related to the subcutaneous layer of skin? SELECT ALL THAT APPLY. a. It provides insulation. b. It acts as an energy reservoir. c. It prevents systemic dehydration. d. It provides cells for wound healing. e. It acts as a mechanical shock absorber.

ANS: A, B, E The subcutaneous layer provides insulation and acts as an energy reservoir and mechanical shock absorber. The epidermal layer prevents systemic dehydration. The dermal layer provides cells for wound healing.

While examining a client, the nurse finds a 0.6 cm circumscribed elevation of the skin filled with serous fluid on the cheek. Which would the nurse suspect the finding to be? a. Papule b. Vesicle c. Nodule d. Pustule

ANS: B A circumscribed elevation of the skin filled with serous fluid and a lesion size of less than 1 cm describes a vesicle. A papule is palpable, circumscribed, has a solid elevation, and a size smaller than 1 cm. A nodule is an elevated solid mass, deeper and firmer than a papule, and 1 to 2 cm in diameter. A pustule is a circumscribed elevation of the skin similar to a vesicle but filled with pus and varies in size.

The health care provider prescribes finasteride (Proscar) for a patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that a. he should change position from lying to standing slowly to avoid dizziness. b. his interest in sexual activity may decrease while he is taking the medication. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

ANS: B A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Although orthostatic hypotension may occur if the patient is also taking a medication for erectile dysfunction, it should not occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not cause hypertension. DIF: Cognitive Level: Apply (application) REF: 1271 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately.

ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration

A patient with prostate cancer is taking estrogen daily to control tumor growth. He reports that his left calf is swollen and painful. Which of the following would be the nurse's best action? a. Instruct the client to keep the leg elevated. b. Measure the calf circumference and compare the measurement with the right calf circumference measurement. c. Apply ice to the calf after a 10-minute massage of the area. d. Document assessment findings as an expected response with estrogen therapy.

ANS: B An adverse reaction to hormonal manipulation therapy is the development of thrombus formation. Massaging a calf that is swollen and painful is never correct, because this action might break a clot, causing formation of an embolus, which could then travel to the lungs.

A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? a. Teach the patient to fully exhale into the incentive spirometer. b. Administer ordered analgesic medications before these activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.

ANS: B An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities. When using an incentive spirometer, the patient should be taught to inhale deeply, rather than exhale into the spirometer to promote lung expansion and prevent atelectasis

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day? a. Schedule the activity to begin after the patient has taken a nap. b. Administer prescribed analgesic medications before the activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.

ANS: B An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, concern about complications, and with rest and sleep, patients will have difficulty if there is a great deal of pain involved with these activities.

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 11.2 g/dL d. White blood cells 11,900/µL

ANS: B Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response

A 58-yr-old patient with erectile dysfunction (ED) tells the nurse he is interested in using sildenafil (Viagra). Which action should the nurse take first? a. Assure the patient that ED is common with aging. b. Ask the patient about any prescription drugs he is taking. c. Tell the patient that Viagra does not always work for ED. d. Discuss the common adverse effects of erectogenic drugs.

ANS: B Because some medications can cause ED and patients using nitrates should not take sildenafil, the nurse should first assess for prescription drug use. The nurse may want to teach the patient about realistic expectations and adverse effects of sildenafil therapy, but this should not be the first action. Although ED does increase with aging, it may be secondary to medication use or cardiovascular disease. DIF: Cognitive Level: Analysis (analyze) REF: 1288 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.

ANS: B Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should look for a cause such as bladder distention. Although hypoxemia is the most common cause, the patient's oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Orientation of the patient to bed controls is needed, but is not likely to be effective until the effects of anesthesia have resolved more completely

Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell out of a tree. When discussing this injury with her parents, the nurse should consider which of the following? a. Healing is usually delayed in this type of fracture. b. Bone growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. This type of fracture is inconsistent with a fall.

ANS: B Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected.

Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell off of a tree. When discussing this injury with her parents, the nurse should consider which statement? a. Healing is usually delayed in this type of fracture. b. Growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. This type of fracture is inconsistent with a fall.

ANS: B Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected. Healing of epiphyseal injuries is usually prompt. The epiphysis is the weakest point of the long bones. This is a frequent site of damage during trauma. p1554

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the ordered opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

ANS: B Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action

The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complications should the nurse monitor? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased production of stress hormones

ANS: B Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake, leads to hypercalcemia, and causes a negative nitrogen balance secondary to muscle atrophy. A decreased production of stress hormones occurs with decreased physical and emotional coping capacity. Ch48 Musculoskeletal/Articular Dysfunction p1531

A cancer patient's susceptibility to the syndrome of inappropriate antidiuretic hormone (SIADH) can be suspected with which of the following laboratory results? a. Serum potassium of 5.2 mmol/L b. Serum sodium of 120 mmol/L c. Hematocrit of 40% d. Blood urea nitrogen (BUN) of 10 mg/dL

ANS: B In SIADH, there is increased secretion of antidiuretic hormone (ADH) from the posterior pituitary gland, leading to increased water reabsorption from the distal convoluted tubule and collecting duct. As a result, weight increases and serum sodium and hematocrit levels are diluted, and, hence, a low serum sodium level is seen. ADH has no direct effect on serum potassium, because potassium is primarily an intracellular electrolyte and changes in the serum concentration of potassium rarely occur in SIADH. The blood urea nitrogen is normal.

A patient has hip replacement surgery using the posterior approach. Which patient action requires rapid intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull shoes and socks on. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing the teeth.

ANS: B Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

The nurse will plan to teach the patient who is incontinent of urine following a radical retropubic prostatectomy to a. restrict oral fluid intake. b. do pelvic muscle exercises. c. perform intermittent self-catheterization. d. use belladonna and opium suppositories.

ANS: B Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent self-catheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L. DIF: Cognitive Level: Apply (application) REF: 1278 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse in a health clinic receives requests for appointments from several patients. Which patient should be seen by the health care provider first? a. A 48-yr-old patient who has perineal pain and a temperature of 100.4° F b. A 58-yr-old patient who has a painful erection that has lasted more than 6 hours c. A 38-yr-old patient who reports that he had difficulty maintaining an erection twice last week d. A 68-yr-old patient who has pink urine after a transurethral resection of the prostate (TURP) 3 days ago

ANS: B Priapism can cause complications such as necrosis or hydronephrosis, and this patient should be treated immediately. The other patients do not require immediate action to prevent serious complications. DIF: Cognitive Level: Analyze (analysis) REF: 1283 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. Yearly mammography for women aged 40 years and older b. Using skin protection during sun exposure while at the beach c. Colonoscopy at age 50 and every 10 years as follow-up d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over

ANS: B Primary prevention of cancer involves avoidance to known causes of cancer, such as sun exposure. Secondary screening involves physical and diagnostic examination.

Which interaction is part of the discharge plan for a school-age child with osteomyelitis who is receiving home antibiotic therapy? a. Instructions for a low-calorie diet b. Arrangements for tutoring and schoolwork c. Instructions for a high-fat, low-protein diet d. Instructions for the parent to return the child to team sports immediately

ANS: B Promoting optimal growth and development in the school-age child is important. It is important to continue schoolwork and arrange for tutoring if indicated. The child with osteomyelitis should be on a high-calorie, high-protein diet. The child with osteomyelitis may need time for the bone to heal before returning to full activities.p1560

When planning care for a patient who has had hip replacement surgery, which nursing action can the nurse delegate to experienced nursing assistive personnel (NAP)? a. Teach quadriceps-setting exercises. b. Reposition the patient every 1 to 2 hours. c. Assess for skin irritation on the patient's back. d. Determine the patient's pain level and tolerance.

ANS: B Repositioning of patients is within the scope of practice of NAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

ANS: B Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait. DIF: Cognitive Level: Apply (application) REF: 1437 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When the nurse is caring for a patient who is on bed rest after having a complex pelvic fracture, which assessment finding is most important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdominal distention is present and bowel tones are absent. c. There are ecchymoses on the abdomen and hips. d. The patient complains of pelvic pain with palpation.

ANS: B The abdominal distention and absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

When does idiopathic scoliosis become most noticeable? a. Newborn period b. When child starts to walk c. During preadolescent growth spurt d. Adolescence

ANS: C Idiopathic scoliosis is most noticeable during the preadolescent growth spurt.

The nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the laboratory results of these patients. Which patient's PSA result is not expected to be elevated? a. A 38-yr-old patient who is being treated for acute prostatitis b. A 48-yr-old patient whose father died of metastatic prostate cancer c. A 52-yr-old patient who goes on long bicycle rides every weekend d. A 75-yr-old patient who uses saw palmetto to treat benign prostatic hyperplasia (BPH)

ANS: B The family history of prostate cancer and elevation of PSA indicate that further evaluation of the patient for prostate cancer is needed. Elevations in PSA for the other patients are not unusual. DIF: Cognitive Level: Apply (application) REF: 1281 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

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 most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention. The nurse should document the wound appearance and continue to monitor the wound. Notification of the health care provider, assessment every 2 hours, and obtaining wound cultures are not indicated because the healing is progressing normally.

A 27-yr-old patient who has testicular cancer is being admitted for a unilateral orchiectomy. The patient does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is appropriate for the nurse to take? a. Teach the patient and the wife that impotence is unlikely after unilateral orchiectomy. b. Ask the patient if he has any questions or concerns about the diagnosis and treatment. c. Inform the patient's wife that concerns about sexual function are common with this diagnosis. d. Document the patient's lack of communication on the health record and continue preoperative care.

ANS: B The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, the nurse should not offer teaching about complications after orchiectomy. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation. DIF: Cognitive Level: Apply (application) REF: 1280 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which action by the nurse is most appropriate? a. Refer the patient for home health care services. b. Discuss the specific concerns regarding self-care. c. Give the patient written instructions regarding care. d. Assess the patient's support system for care at home.

ANS: B The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care

A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first? a. Infuse normal saline at 50 mL/hr. b. Insert a urinary retention catheter. c. Draw blood for a complete blood count. d. Schedule pelvic magnetic resonance imaging

ANS: B The patient data indicate that the patient may have acute kidney injury caused by the BPH. The initial therapy will be to insert a catheter. The other actions are also appropriate, but they can be implemented after the acute urinary retention is resolved. DIF: Cognitive Level: Analyze (analysis) REF: 1269 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing

ANS: B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient

The nurse will plan to teach the patient scheduled for photovaporization of the prostate (PVP) a. that urine will appear bloody for several days. b. how to care for an indwelling urinary catheter. c. that symptom improvement takes 2 to 3 weeks. d. about complications associated with urethral stenting.

ANS: B The patient will have an indwelling catheter for 24 to 48 hours and will need teaching about catheter care. There is minimal bleeding with this procedure. Symptom improvement is almost immediate after PVP. Stent placement is not included in the procedure. DIF: Cognitive Level: Apply (application) REF: 1272 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

ANS: B The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate

A patient who has been hospitalized for 3 days with a hip fracture has sudden onset shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer the prescribed PRN oxygen at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.

A patient tells the nurse that he decided to seek treatment for erectile dysfunction (ED) because his wife "is losing patience with the situation." The nurse's follow-up questions should focus on the man's identified concern with a. low self-esteem. c. increased anxiety. b. role performance. d. infrequent intercourse.

ANS: B The patient's statement indicates that the relationship with his wife is his primary concern. Although anxiety, low self-esteem, and ineffective sexuality patterns may also be concerns, the patient information suggests that addressing the role performance problem will lead to the best outcome for this patient. DIF: Cognitive Level: Apply (application) REF: 1288 TOP: Nursing Process: Intervention MSC: NCLEX: Psychosocial Integrity

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.

ANS: B The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse, assessing and documenting the wound appearance, and clarifying physician orders with another nurse require registered-nurse (RN) level education and scope of practice

Which information will the nurse plan to include when teaching a young adult who has a family history of testicular cancer about testicular self-examination? a. Testicular self-examination should be done at least weekly. b. Testicular self-examination should be done in a warm room. c. The only structure normally felt in the scrotal sac is the testis. d. Call the health care provider if one testis is larger than the other.

ANS: B The testes will hang lower in the scrotum when the temperature is warm (e.g., during a shower), and it will be easier to palpate. The epididymis is also normally palpable in the scrotum. One testis is normally larger. Men at high risk should perform testicular self-examination monthly. DIF: Cognitive Level: Understand (comprehension) REF: 1286 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

The nurse uses the palms of the hands when handling a wet cast for which of the following reasons? a. To assess dryness of the cast b. To facilitate easy turning c. To keep the patient's limb balanced d. To avoid indenting the cast

ANS: D Wet casts should be handled by the palms of the hands, not the fingers, to avoid creating pressure points.

An appropriate nursing intervention when caring for a child in traction would be which of the following? a. Remove adhesive traction straps daily to prevent skin breakdown. b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles. c. Provide active range-of-motion exercises to affected extremity three times a day. d. Keep child in one position to maintain good alignment.

ANS: B Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles.

An appropriate nursing intervention when caring for a child in traction is to: a. Remove adhesive traction straps daily to prevent skin breakdown. b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles. c. Provide active range-of-motion exercises to affected extremity 3 times a day. d. Keep child in one position to maintain good alignment.

ANS: B Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released/replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained. p1545

When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Teach the patient how to perform Kegel exercises. b. Report any complaints of pain or spasms to the nurse. c. Monitor for increases in bleeding or presence of clots. d. Increase the flow rate of the irrigation if clots are noted.

ANS: B UAP education and role includes reporting patient concerns to supervising nurses. Patient teaching, assessments for complications, and actions such as bladder irrigation require more education and should be done by licensed nursing staff. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? SELECT ALL THAT APPLY. a. Axilla b. Fingers c. Ear lobes d. Forehead e. Upper thorax

ANS: B & C Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.

Which physical skin finding indicates opioid abuse? a. Diaphoresis b. Red, dry skin c. Needle marks d. Spider angiomas

ANS: C Needle marks of the skin indicate opioid abuse. Diaphoresis indicates sedative hypnotic abuse. Red, dry skin indicates phencyclidine abuse. Spider angiomas indicate alcohol abuse.

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a. Obtaining a complete blood count (CBC) b. Protection from excessive heat c. Protection from excessive ultraviolet (UV) exposure d. Instructing the patient to take their multivitamin prior to treatment

ANS: C Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? a. "Limit the time you spend in the sun." b. "Monitor for signs of infection." c. "Monitor spots for color change." d. "Use skin creams to prevent drying."

ANS: C The ABCDE method (check for asymmetry, border irregularity, color variation, diameter and evolving) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.

ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a. Apply the cream generously to affected areas. b. Apply a thin coat to affected areas, especially the face. c. Apply a thin coat to affected areas; avoid the face and groin. d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

ANS: C The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status.

ANS: C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains

After a patient with a left femur fracture has a hip spica cast applied, which nursing intervention will be included in the plan of care? a. Avoid placing the patient in the prone position. b. Use the cast support bar to reposition the patient. c. Ask the patient about any abdominal discomfort or nausea. d. Discuss the reasons for remaining on bed rest for several weeks.

ANS: C Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

Which statement is accurate concerning a child's musculoskeletal system and how it may be different from an adult's? a. Growth occurs in children as a result of an increase in the number of muscle fibers. b. Infants are at greater risk for fractures because their epiphyseal plates are not fused. c. Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. d. Children's bones have less blood flow.

ANS: C Because soft tissues are resilient in children, dislocations and sprains are less common than in adults. A child's growth occurs because of an increase in size rather than an increase in the number of the muscle fibers. Fractures in children younger than 1 year are unusual because a large amount of force is necessary to fracture their bones. A child's bones have greater blood flow than an adult's bones. p1536

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.

ANS: C Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer

After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles b. The newly admitted patient with a stage IV pressure ulcer on the coccyx c. The patient who has been receiving chemotherapy and has a temperature of 102° F d. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change

ANS: C Chemotherapy is an immunosuppressant. Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse should assess the other patients as soon as possible after assessing and implementing appropriate care for the immunosuppressed patient

When counseling an older patient about ways to prevent fractures, which information will the nurse include? a. Tack down scatter rugs in the home. b. Most falls happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Range-of-motion exercises should be taught by a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to have sexual intercourse. Which action should the nurse take? a. Discuss alternative methods of sexual expression. b. Teach about medication for erectile dysfunction (ED). c. Clarify that TURP does not commonly affect erection. d. Offer reassurance that fertility is not affected by TURP.

ANS: C ED is not a concern with TURP, although retrograde ejaculation is likely, and the nurse should discuss this with the patient. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns. DIF: Cognitive Level: Apply (application) REF: 1272 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When infants are seen for fractures, which nursing intervention is a priority? a. No intervention is necessary. It is not uncommon for infants to fracture bones. b. Assess the family's safety practices. Fractures in infants usually result from falls. c. Assess for child abuse. Fractures in infants are often nonaccidental. d. Assess for genetic factors.

ANS: C Fractures in infants warrant further investigation to rule out child abuse. Fractures in children younger than 1 year are unusual because of the cartilaginous quality of the skeleton; a large amount of force is necessary to fracture their bones. Infants should be cared for in a safe environment and should not be falling. Fractures in infancy are usually nonaccidental rather than related to a genetic factor. p1537

After a patient has a short-arm plaster cast applied in the emergency department, which statement by the patient indicates a good understanding of the nurse's discharge teaching? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site for the next 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. Which of the following should be included? a. Apply lotion or powder to minimize skin irritation. b. Remove harness several times a day to prevent contractures. c. Return to clinic every 1 to 2 weeks. d. Place diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.

ANS: C Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments.

The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. What should be included? a. Apply lotion or powder to minimize skin irritation. b. Remove the harness several times a day to prevent contractures. c. Return to the clinic every 1 to 2 weeks. d. Place a diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.

ANS: C Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness. The harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness. p1550

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Recheck the dressing in 1 hour for increased drainage.

ANS: C New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.4° F orally.

ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems

Which of the following is the primary method of treating osteomyelitis? a. Joint replacement b. Bracing and casting c. Intravenous antibiotic therapy d. Long-term corticosteroid therapy

ANS: C Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. The treatment of choice is antibiotics.

Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male patients with reproductive problems indicates that the nurse should provide more teaching? a. The UAP apply a cold pack to the scrotum for a patient with mumps orchitis. b. The UAP help a patient who has had a prostatectomy to put on antiembolism hose. c. The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter. d. The UAP encourage a high oral fluid intake for patient who had transurethral resection of the prostate yesterday.

ANS: C Paraphimosis can be caused by failing to replace the foreskin back over the glans after cleaning. The other actions by UAP are appropriate. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which type of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop c. Russell b. Bryant's d. Buck's extension

ANS: C Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position. Dunlop traction is an upper extremity traction used for fractures of the humerus. Bryant's traction is skin traction with the legs flexed at a 90-degree angle at the hip. Buck's extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, before surgery with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease. p1543

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that: a. traction is tried first. b. surgical intervention is needed. c. frequent, serial casting is tried first. d. children outgrow this condition when they learn to walk.

ANS: C Serial casting is begun shortly after birth before discharge from nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy.

The nurse is obtaining the pertinent health history for a man who is being evaluated for infertility. Which question focuses on a possible cause of infertility? a. "Are you circumcised?" b. "Have you had surgery for phimosis?" c. "Do you use medications to improve muscle mass?" d. "Is there a history of prostate cancer in your family?"

ANS: C Testosterone or testosterone-like medications may adversely affect sperm count. The other information will be obtained in the health history but does not affect the patient's fertility. DIF: Cognitive Level: Apply (application) REF: 1289 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. blood in the urine. . b. lower back or hip pain. c. force of urinary stream d. erectile dysfunction (ED).

ANS: C The American Urological Association Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, and so on. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH. DIF: Cognitive Level: Apply (application) REF: 1268 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers on the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

An important nursing consideration when caring for a child with juvenile idiopathic arthritis (JIA) is to: a. Apply ice packs to relieve stiffness and pain. b. Administer acetaminophen to reduce inflammation. c. Teach child and family the correct administration of medications. d. Encourage range-of-motion exercises during periods of inflammation.

ANS: C The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of a regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that nonsteroidal antiinflammatory drugs should not be given on an empty stomach and to be alert for signs of toxicity. Warm, moist heat is best for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects. Range-of-motion exercises should not be done during periods of inflammation. p1566

An important nursing consideration when caring for a child with JIA would be which of the following? a. Apply ice packs to relieve stiffness and pain. b. Administer acetaminophen to reduce inflammation. c. Teach child and family correct administration of medications. d. Encourage range-of-motion exercises during periods of inflammation.

ANS: C The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that NSAIDs should not be given on an empty stomach and to be alert for signs of toxicity.

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse positions an unconscious patient supine with the head elevated. c. The new nurse turns an unconscious patient to the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position when the blood pressure drops.

ANS: C The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness

The nurse uses the palms of the hands when handling a wet cast to: a. Assess dryness of the cast. c. Keep the patient's limb balanced. b. Facilitate easy turning. d. Avoid indenting the cast.

ANS: D Wet casts should be handled by the palms of the hands, not the fingers, to prevent creating pressure points. Assessing dryness, facilitating easy turning, or keeping the patient's limb balanced are not reasons for using the palms of the hand rather than the fingers when handling a wet cast. p1541

A nurse is conducting discharge teaching for parents of an infant with osteogenesis imperfecta (OI). Further teaching is indicated if the parents make which statement? a. "We will be very careful handling the baby." b. "We will lift the baby by the buttocks when diapering." c. "We're glad there is a cure for this disorder." d. "We will schedule follow-up appointments as instructed."

ANS: C The treatment for OI is primarily supportive. Although patients and families are optimistic about new research advances, there is no cure. The use of bisphosphonate therapy with IV pamidronate to promote increased bone density and prevent fractures has become standard therapy for many children with OI; however, long bones are weakened by prolonged treatment. Infants and children with this disorder require careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved, and held. Even changing a diaper may cause a fracture in severely affected infants. These children should never be held by the ankles when being diapered but should be gently lifted by the buttocks or supported with pillows. Follow-up appointments for treatment with bisphosphonate can be expected.p 1553

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

ANS: D Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

Which nursing intervention is appropriate to assess for neurovascular competency in a child who fell off the monkey bars at school and hurt his arm? a. The degree of motion and ability to position the extremity. b. The length, diameter, and shape of the extremity. c. The amount of swelling noted in the extremity and pain intensity. d. The skin color, temperature, movement, sensation, and capillary refill of the extremity.

ANS: D A neurovascular evaluation includes assessing skin color and temperature, ability to move the affected extremity, degree of sensation experienced, and speed of capillary refill in the extremity. The degree of motion in the affected extremity and ability to position the extremity are incomplete assessments of neurovascular competency. The length, diameter, and shape of the extremity are not assessment criteria in a neurovascular evaluation. Although the amount of swelling is an important factor in assessing an extremity, it is not a criterion for a neurovascular assessment. p1545

In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

ANS: D A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.

The health care provider prescribes the following interventions for a patient with acute prostatitis caused by Escherichia coli. Which intervention should the nurse question? a. Give trimethoprim/sulfamethoxazole 1 tablet daily for 28 days. b. Administer ibuprofen 400 mg every 8 hours as needed for pain. c. Instruct patient to avoid sexual intercourse until treatment is complete. d. Catheterize the patient as needed if symptoms of urinary retention develop.

ANS: D Although acute urinary retention may occur, insertion of a catheter through an inflamed urethra is contraindicated, and the nurse will anticipate that the health care provider will need to insert a suprapubic catheter. The other actions are appropriate. DIF: Cognitive Level: Apply (application) REF: 1282 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the left femur? a. Assess for hip contractures. b. Monitor for hip dislocation. c. Check the peripheral pulses. d. Ask about left hip pain level.

ANS: D Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.

A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.

ANS: D Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be "just not feeling well."

The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation

ANS: D During the first 100 days after a bone marrow transplant, patients are at high risk for life-threatening infections. The earliest sign of infection in an immunosuppressed patient can be a mild fever. Mucositis, confusion, and depression are possible clinical manifestations but are representative of less life-threatening complications.

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

ANS: D Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use. DIF: Cognitive Level: Apply (application) REF: 1435 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

What would cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia c. Increased respirations b. Cold toes d. "Hot spots" felt on cast surface

ANS: D If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so a window can be made in the cast to observe the site. The "five Ps" of ischemia from a vascular injury include pain, pallor, pulselessness, paresthesia, and paralysis. Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of too tight a cast and need further evaluation. Increased respirations may indicate a respiratory infection or pulmonary emboli. This should be reported, and the child should be evaluated. p1541

The nurse will anticipate that a 61-yr-old patient who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level will need teaching about a. cystourethroscopy. b. uroflowmetry studies. c. magnetic resonance imaging (MRI). d. transrectal ultrasonography (TRUS).

ANS: D In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to visualize the prostate for biopsy. Uroflowmetry studies help determine the extent of urine blockage and treatment, but there is no indication that this is a problem for this patient. Cystoscopy may be used before prostatectomy but will not be done until after the TRUS and biopsy. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process. DIF: Cognitive Level: Apply (application) REF: 1270 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

When giving home care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include? a. Keep the hand immobile to prevent soft tissue swelling. b. Keep the right shoulder elevated on a pillow or cushion. c. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury. d. Call the health care provider for increased swelling or numbness.

ANS: D Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.

A patient who has been diagnosed with stage 2 prostate cancer chooses the option of active surveillance. The nurse will plan to a. vaccinate the patient with sipuleucel-T (Provenge). b. provide the patient with information about cryotherapy. c. teach the patient about placement of intraurethral stents. d. schedule the patient for annual prostate-specific antigen testing.

ANS: D Patients who opt for active surveillance need to have annual digital rectal examinations and prostate-specific antigen testing. Vaccination with sipuleucel-T, cryotherapy, and stent placement are options for patients who choose to have active treatment for prostate cancer. DIF: Cognitive Level: Understand (comprehension) REF: 1269 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which of the following terms is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? a. Scoliosis b. Ankylosis c. Lordosis d. Kyphosis

ANS: D Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine.

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours.

ANS: D Mild to moderate temperature elevations (less than 103° F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patient's health care provider or to use a cooling blanket for a moderate temperature elevation

In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care? a. Position the patient on the operative side only. b. Avoid administering narcotic pain medications. c. Keep the patient on strict bed rest. d. Instruct the patient to cough and deep breathe.

ANS: D Postoperative deep breathing and coughing is important to promote oxygenation and clearing of secretions. Pain medications will be given to lessen pain and allow for deep breathing and coughing. Strict bed rest is not instituted, because early ambulation will help lessen postoperative complications such as deep vein thrombosis. Prolonged lying on the operative side is avoided.

Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the health care provider? a. Bruising of the left thigh b. Complaints of left thigh pain c. Outward pointing toes on the left foot d. Prolonged capillary refill of the left foot

ANS: D Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.

After a transurethral resection of the prostate (TURP), a 64-yr-old patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse take first? a. Increase the flow rate of the bladder irrigation. b. Administer the prescribed IV morphine sulfate. c. Give the patient the prescribed belladonna and opium suppository. d. Manually instill and then withdraw 50 mL of saline into the catheter.

ANS: D The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse's first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot. DIF: Cognitive Level: Analysis (analyze) REF: 1272 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

ANS: D The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient. DIF: Cognitive Level: Apply (application) REF: 1436 OBJ: Special Questions: Prioritization TOP: Nursing Process: Analysis MSC: NCLEX: Physiological Integrity

Which assessment information collected by the nurse may present a contraindication to a testosterone replacement therapy (TRT)? a. The patient has noticed a decrease in energy level for a few years. b. The patient's symptoms have increased steadily over the past few years. c. The patient has been using sildenafil (Viagra) several times every week. d. The patient has had a gradual decrease in the force of his urinary stream.

ANS: D The decrease in urinary stream may indicate benign prostatic hyperplasia (BPH) or prostate cancer, which are contraindications to the use of testosterone replacement therapy (TRT). The other patient data indicate that TRT may be a helpful therapy for the patient. DIF: Cognitive Level: Apply (application) REF: 1269 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 4 year old is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations include which of the following? a. Encourage normal activity for as long as is possible. b. Explain the cause of the disease to the child and family. c. Prepare child and family for long-term, permanent disabilities. d. Teach family the care and management of the corrective appliance.

ANS: D The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome

A 4-year-old child is newly diagnosed with Legg-Calvé-Perthes disease. Nursing considerations should include which action? a. Encouraging normal activity for as long as is possible b. Explaining the cause of the disease to the child and family c. Preparing the child and family for long-term, permanent disabilities d. Teaching the family the care and management of the corrective appliance

ANS: D The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome. The initial therapy is rest and non-weight bearing, which helps reduce inflammation and restore motion. Legg-Calvé-Perthes is a disease with an unknown etiology. A disturbance of circulation to the femoral capital epiphysis produces an ischemic aseptic necrosis of the femoral head. The disease is self-limiting, but the ultimate outcome of therapy depends on early and efficient therapy and the child's age at onset.p 1555

A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to a. elevate the left leg. b. splint the lower leg. c. obtain information about the tetanus immunization status. d. check the popliteal, dorsalis pedis, and posterior tibial pulses.

ANS: D The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which instructions should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours. b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.

ANS: D The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The child should not engage in strenuous activity for the first few days. Rest with elevation of the extremity is encouraged. p1541

A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and have the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. turn the patient partially to each side with the assistance of another nurse. d. have the patient lift the buttocks by bending and pushing with the left leg.

ANS: D The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

The second day after admission with a fractured pelvis, a patient develops acute onset confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check pupil reaction to light. d. Assess the oxygen saturation.

ANS: D The patient's history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions also are appropriate but will be done after the nurse assesses gas exchange.

Which of the following is a physiologic effect of immobilization on children? a. Metabolic rate increases. b. Increased joint mobility can lead to contractures in a short time. c. Bone calcium increases, releasing excess calcium into the body (hypercalcemia). d. Venous stasis can lead to thrombi or emboli formation.

ANS: D The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi.

Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)? a. Bladder irrigation decreases the risk of postoperative bleeding. b. Hydration and urine output are maintained by bladder irrigation. c. Antibiotics are infused continuously through the bladder irrigation. d. Bladder irrigation prevents obstruction of the catheter after surgery.

ANS: D The purpose of bladder irrigation is to remove clots from the bladder and prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation. DIF: Cognitive Level: Understand (comprehension) REF: 1274 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

ANS: B Bladder spasms and lack of urine output indicate that the nurse needs to assess the continuous bladder irrigation for kinks and may need to manually irrigate the patient's catheter. The other information will also require actions, such as having the patient take deep breaths and cough and discussing the need for antihypertensive medication prescriptions with the health care provider, but the nurse's first action should be to address the problem with the urinary drainage system. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

After reviewing the electronic medical record shown in the accompanying figure for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse? a. Elevated temperature and pulse b. Bladder spasms and urine output c. Respiratory rate and lung crackles d. No prescription for antihypertensive drugs

Six weeks after a vasectomy, the patient has a sperm-free semen analysis result. What should the couple conclude? A. The patient is sterile. B. One additional semen free test is required. C. Alternative contraception is still required. D. Intercourse should be avoided for 2 more weeks.

Answer: A After vasectomy, the patient should not notice any difference in the look or feel of the ejaculate because its major component is seminal and prostatic fluid. The patient should use an alternative form of contraception until semen examination reveals no sperm. This usually requires at least 10 ejaculations or 6 weeks to evacuate sperm distal to the surgical site.

During the bath of a male patient, the nursing assistive personnel reports to you that the patient's foreskin cannot be retracted over the head of the penis. You recognize this condition as A. phimosis. B. prostatitis. C. priapism. D. epispadias.

Answer: A Phimosis is tightness or constriction of the foreskin around the head of the penis, which makes retraction difficult. Paraphimosis is tightness of the foreskin resulting in the inability to pull it forward from a retracted position and preventing normal return over the glans. Prostatitis is inflammation of the prostate, and epispadias occurs when the urethral opening is on the dorsal surface of the penis.

What is an erection lasting longer than 6 hours called? A. Priapism B. Peyronie's disease C. Hydrocele D. Hypospadias

Answer: A Priapism is a painful erection lasting longer than 6 hours. It is caused by an obstruction of the venous outflow in the penis. The condition may constitute a medical emergency. Causes of priapism include thrombosis of the corpus cavernosal veins, leukemia, sickle cell anemia, diabetes mellitus, degenerative lesions of the spine, neoplasms of the brain or spinal cord, vasoactive medications injected into the corpus cavernosa, and medications (e.g., sildenafil, cocaine, trazodone).

What is the primary purpose of a three-way urinary catheter after a transurethral resection of the prostate (TURP)? A. Promote hemostasis and drainage of clots B. Relieve bladder spasms C. Reduce edema D. Increase bladder tone

Answer: A A large three-way indwelling catheter with a 30-mL balloon is inserted into the bladder after the procedure to provide hemostasis and to facilitate urinary drainage. The bladder is irrigated, either continuously or intermittently, usually for the first 24 hours to prevent obstruction from mucus and blood clots.

A patient scheduled for a prostatectomy for prostate cancer expresses the fear that he will have erectile dysfunction. In responding to the patient, you should keep in mind that A. erectile dysfunction can occur even with a nerve-sparing procedure. B. retrograde ejaculation affects sexual functioning more frequently than erectile dysfunction. C. the most common complication of this surgery is postoperative bowel incontinence. D. preoperative sexual functioning is the most important factor in determining postoperative erectile dysfunction.

Answer: A A major complication after a prostatectomy (even with nerve-sparing procedures) is erectile dysfunction

An elderly male patient is experiencing difficulty in initiating voiding and a feeling of incomplete bladder emptying. What causes these symptoms in benign prostatic hyperplasia (BPH)? A. Obstruction of the urethra B. Untreated chronic prostatitis C. Decreased bladder compliance D. Excessive secretion of testosterone

Answer: A BPH is a benign enlargement of the prostate gland. The enlargement of the prostate gradually compresses the urethra, eventually causing partial or complete obstruction. Compression of the urethra ultimately leads to the development of clinical symptoms.

The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse? A) Provide a light blanket. B) Encourage a hot shower. C) Monitor temperature every hour. D) Turn up the thermostat in the patient's room.

Answer: A Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.

After you perform teaching regarding medication therapy for erectile dysfunction (ED), you know the teaching was successful when the patient states, A. "I will take the drug once each day about an hour before sexual activity." B. "I will take the drug two times each day but not more than three." C. "I can take the drug in the morning, and I will be able to have an erection anytime throughout the day." D. "There are no precautions to take while I am on this medication."

Answer: A Medication is taken orally about 1 hour before sexual activity, but not more than once each day. These drugs have been found to be generally safe and effective for the treatment of most types of ED.

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? A) A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F B) An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F C) A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F D) A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F

Answer: A Moderate fevers (up to 103°F) usually produce few problems in most patients and do not require antipyretic therapy. If the patient is very young or very old, is extremely uncomfortable, or has a significant medical problem (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. High fevers (above 104°F) should be treated with antipyretics. High fevers can damage body cells and cause delirium and seizures.

A patient with benign prostatic hyperplasia is scheduled for TURP. After you assess the patient's knowledge of the procedure and its effects on reproductive function, you determine a need for further teaching when the patient says, A. "It is possible that I'll be sterile after this procedure." B. "I understand that some retrograde ejaculation may occur." C. "I will have a catheter for several days to keep my urinary system open." D. "It is unlikely that I would become impotent from this procedure."

Answer: A The patient will not be sterile; he may experience retrograde ejaculation and some erectile dysfunction. It is unlikely he will become impotent. He will need a catheter.

You notice that the patient's urinary drainage 4 hours after TURP is redder than 1 hour ago. What is your priority intervention? A. To increase the rate of bladder irrigation B. To manually irrigate the urinary catheter C. To notify the physician D. To obtain vital signs

Answer: A With CBI, irrigating solution is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally, urine drainage should be light pink without clots. Continuously monitor the inflow and outflow of the irrigant.

A patient asks you, "How can I decrease my risk of prostate cancer?" You teach the patient to avoid which foods (select all that apply)? A. Red meat B. High-fat dairy products C. Fruits D. Vegetables E. Chicken

Answer: A, B Dietary factors may be associated with prostate cancer. A diet high in red meat and high-fat dairy products, along with a low intake of vegetables and fruits, may increase the risk of prostate cancer.

Which factors place a patient at high risk for prostate cancer (select all that apply)? A. Age older than 65 years B. Asian or Native American ethnicity C. Personal history of BPH D. Brother diagnosed and treated for prostate cancer E. History of undescended testicle and testicular cancer

Answer: A,D Age, ethnicity, and family history are known risk factors for prostate cancer. The incidence of prostate cancer rises markedly after age 50, and more than 66% of men diagnosed are older than 65 years. The incidence of prostate cancer worldwide is higher among African Americans than in any other ethnic group. A family history of prostate cancer, especially first-degree relatives (fathers, brothers), is associated with an increased risk.

Which childhood disease is often associated with orchitis? A. Measles B. Mumps C. Strep throat D. Chickenpox

Answer: B Orchitis refers to an acute inflammation of the testis. In orchitis, the testis is painful, tender, and swollen. It usually occurs after an episode of bacterial or viral infection, such as mumps. The other disorders are not associated with mumps.

Which diagnostic evaluation is used for a patient with a suspected testicular cancer? A. Prostate-specific antigen (PSA) B. α-Fetoprotein (AFP) C. Complete blood cell count D. Urine and semen analyses

Answer: B Palpation of the scrotal contents is the first step in diagnosing testicular cancer. A cancerous mass is firm and does not transilluminate. Ultrasound of the testes is indicated when testicular cancer (e.g., palpable mass) is suspected or when persistent or painful testicular swelling is present. If testicular cancer is suspected, blood is obtained to determine the serum levels of AFP, lactate dehydrogenase (LDH), and human chorionic gonadotropin (hCG).

For the patient with inoperable prostate cancer, you expect the physician to order which type of hormone? A. Gonadotropin-releasing hormone B. Androgen deprivation C. Luteinizing hormone D. Estrogen

Answer: B Prostate cancer growth largely depends on androgens, and androgen deprivation is a primary therapeutic approach for some men with prostatic cancer. Hormone therapy, also known as androgen-deprivation therapy (ADT), focuses on reducing the levels of circulating androgens to diminish tumor growth.

Which fact in the patient's history could be related to the presence of testicular cancer? A. Epispadias B. Cryptorchidism C. Hernia repair D. Uncircumcised penis

Answer: B The incidence of testicular cancer is four times higher among white men (especially those of Scandinavian descent) than African American males. It occurs more commonly in the right testicle than the left. Testicular tumors are also more common in men who have had undescended testes (cryptorchidism) or have a family history of testicular cancer or anomalies. Epispadias and lack of circumcision are not related to testicular cancer. Hernia repair is related to future hernias, but not testicular cancer.

What is the most common cause of male infertility? A. A hydrocele B. A varicocele C. Alcohol use D. Epididymitis.

Answer: B The most common cause of male infertility is a varicocele, not a hydrocele. Other factors that influence the testes include infection such as epididymitis and alcohol use, but they are not the most common causes.

You have provided teaching to the male patient regarding a vasectomy procedure. Which statement by the patient indicates the teaching has been successful? A. "I will need to not eat or drink anything for 24 hours before the procedure." B. "The physician will use local anesthetic, and I will be awake." C. "I will be able to have unprotected intercourse in 3 weeks." D. "I acknowledge there is a risk of impotence."

Answer: B The procedure requires only 15 to 30 minutes and is usually performed with the patient under local anesthesia on an outpatient basis. Vasectomy is considered a permanent form of sterilization but does not affect the ability to achieve an erection. After vasectomy, the patient should not notice any difference in the look or feel of the ejaculate because its major component is seminal and prostatic fluid. The patient should use an alternative form of contraception until semen examination reveals no sperm. This usually requires at least 10 ejaculations or 6 weeks to evacuate sperm distal to the surgical site.

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? A) Administer aspirin on a scheduled basis around the clock. B) Provide acetaminophen every 4 hours to maintain consistent blood levels. C) Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. D) Provide drug interventions if complementary and alternative therapies have failed.

Answer: B Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.

A 73-year-old man admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the "stream is less than it used to be." You would give the patient anticipatory guidance that which condition is likely to be developing? A. A tumor of the prostate B. Benign prostatic hyperplasia C. Bladder atony because of age D. Age-related altered innervation of the bladder

Answer: B BPH is an enlarged prostate gland caused by an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men older than 50 years and 80% of men older than 80 years.

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? A) Pain level B) Intake and output C) Oxygen saturation D) Level of consciousness

Answer: B Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient.

The patient with epididymitis asks you when he can resume his exercise routine. You should respond with which piece of information? A. When there is no evidence of urethral discharge B. After 1 week of antibiotic therapy C. When scrotal pain has subsided D. As soon as he feels able

Answer: C Most tenderness subsides within 1 week, although swelling may last for weeks or months. One week of antibiotic therapy may not relieve pain and swelling. "When the patient feels able" is a vague response, and the patient should remain on rest until scrotal swelling has subsided. There may be no urethral discharge in epididymitis.

You should encourage a patient with bacterial prostatitis to A. remain on bed rest until antibiotic therapy has been in place for 72 hours. B. significantly increase fluid intake of noncaffeinated beverages. C. empty the bladder every hour with a straight catheter. D. weigh daily before the first voiding of the morning.

Answer: B Because the prostate can serve as a source of bacteria, fluid intake should be kept at a high level for all patients experiencing prostatitis. Nursing interventions are aimed at encouraging the patient to drink plenty of fluids. This is especially important for those with acute bacterial prostatitis because of the increased fluid needs associated with fever and infection. Bed rest is not indicated, and activity should be encouraged. The bladder should be emptied, although not with a catheter, and it is not necessary to do so every hour. Weight gain should be reported, but the patient does not need to weigh before voiding.

You are teaching the patient with BPH about interventions that can assist in alleviating symptoms. Which behavior in the patient indicates successful teaching? A. The patient increases use of decongestants. B. The patient decreases intake of caffeinated beverages and artificial sweeteners. C. The patient increases activities such as walking. D. The patient voids every 30 minutes.

Answer: B In some patients who have symptoms that appear and then disappear, a conservative treatment approach has value. Dietary changes (decreasing intake of caffeine and artificial sweeteners, limiting spicy or acidic foods), avoiding medications such as decongestants and anticholinergics, and restricting evening fluid intake may result in improvement of symptoms. A timed voiding schedule may reduce or eliminate symptoms, negating the need for further intervention, but 30 minutes is too frequent.

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? A) Serous B) Purulent C) Fibrinous D) Catarrhal

Answer: B Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.

A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? A) Warm, moist heat and massage B) Rest, ice, compression, and elevation C) Antipyretic and antibiotic drug therapy D) Active movement and exercise to prevent stiffness

Answer: B Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation. Heat may be applied 24 to 48 hours after the injury.

Which best indicates that treatment for cancer of the prostate is effective? A. Increase in urinary stream B. Decrease of PSA to 2 ng/mL C. Decreased blood in the urine D. White blood cell (WBC) count of 10,000/μL

Answer: B The PSA value is used to detect prostate cancer and to monitor the success of treatment. When treatment has been successful in removing prostate cancer, PSA levels should decrease and reach normal levels (less than 4 ng/mL). The regular measurement of PSA levels after treatment is important to evaluate the effectiveness of treatment and possible recurrence of prostate cancer.

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? A) Local response B) Systemic response C) Infectious response D) Acute inflammatory response

Answer: B The systemic response to inflammation includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in 2 to 3 weeks and usually leaves no residual damage.

What is the most significant factor in the development of clinical symptoms associated with BPH? A. Size of the prostate B. Location of the enlargement C. Age of the patient D. Length of the urethra

Answer: B There is no direct relationship between the size of the prostate and degree of obstruction. The location of the enlargement significantly affects development of obstructive symptoms. For example, it is possible for mild hyperplasia to cause severe obstruction, and it is possible for extreme hyperplasia to cause few obstructive symptoms.

A complication of prostatitis is A. prostatic cancer. B. benign prostatic hyperplasia. C. acute urinary retention. D. hydrocele.

Answer: C Acute urinary retention can develop in acute prostatitis, and it requires bladder drainage with suprapubic catheterization. Passage of a catheter through an inflamed urethra is contraindicated in acute prostatitis.

When providing patient teaching about medication therapy for BPH with 5α-reductase inhibitors such as finasteride (Proscar), what information should you include? A. Ninety percent of patients show improvement with the drug. B. The drug can be taken periodically as symptoms occur. C. Women who are pregnant should not handle the drug. D. Effects are seen in 1 week.

Answer: C Although more than 50% of men who are treated with the drug show symptom improvement, it takes about 6 months to be effective. The drug must be taken on a continuous basis to maintain therapeutic results. Women who may be or are pregnant should not handle tablets.

To decrease the patient's discomfort about care involving his reproductive organs, you should A. relate his sexual concerns to his sexual partner. B. arrange to have male nurses care for the patient. C. maintain a nonjudgmental attitude toward his sexual practices. D. use technical terminology when discussing reproductive function.

Answer: C Conducting routine health assessments on men places you in a unique position. It provides an opportunity to ask the patient questions pertaining to general health and to sexual health and function. Given the opportunity, men are less hesitant to answer these questions when they know that someone cares and can provide them with answers. You must remain nonjudgmental about sexual practices.

What is the first step in the identification of the cause of male infertility? A. Estrogen levels B. Progesterone levels C. Semen analysis D. Time to ejaculation

Answer: C The first test in an infertility study is a semen analysis. The test determines the sperm concentration, motility, and morphology

A 62-year-old man is seen at the health clinic because he is concerned about a gradual decrease in sexual performance. The nursing history does not identify any specific risk factors related to erectile dysfunction. What is your priority at this time? A. Consult with the health care provider about testing the patient for hypogonadism. B. Refer the patient to a qualified therapist to explore possible psychologic causes of decreased function. C. Explain normal age-related changes in sexual performance to the patient. D. Discuss the variety of aids and devices available to increase sexual performance.

Answer: C Normal physiologic age-related changes are associated with changes in erectile function and may be an underlying cause of ED for some men.

You expect which finding in a patient as a complication of prostatic hyperplasia? A. Dysuria B. Hematuria C. Urinary retention D. Urinary frequency

Answer: C Obstructive symptoms caused by prostate enlargement include a decrease in the caliber and force of the urinary stream, difficulty in initiating voiding, intermittency (stopping and starting stream several times while voiding), and dribbling at the end of urination. These symptoms result from urinary retention.

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? A) Increased platelet count B) Increased blood urea nitrogen C) Increased number of band neutrophils D) Increased number of segmented myelocytes

Answer: C The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? A) White blood cell (WBC) count of 8000/ìL; temperature of 101 F B) White blood cell (WBC) count of 4000/ìL; temperature of 100 F C) White blood cell (WBC) count of 8500/ìL; temperature of 98.4 F D) White blood cell (WBC) count of 16,500/ìL; temperature of 98.8 F

Answer: C This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/ìL. An elevated WBC count and elevated temperature are indicators of infection.

During the first 4 hours after TURP, the patient receives 1200 mL of bladder irrigation solution, and his urine output is 1000 mL. What is your priority intervention? A. Slowing the rate of bladder irrigation B. Continuing to observe the patient C. Checking catheter patency D. Encouraging oral fluids

Answer: C You should continuously monitor the inflow and outflow of the irrigant. If outflow is less than inflow, assess the catheter for kinks or clots. If the outflow is blocked and patency cannot be reestablished by manual irrigation, stop the CBI and notify the physician.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? A) Take the antibiotic until the wound feels better. B)Take the analgesic every day to promote adequate rest for healing. C) Be sure to wash hands after changing the dressing to avoid infection. D) Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. E) Notify the health care provider of redness, swelling, and increased drainage.

Answer: C, D Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing.

When working in the emergency department you recognize the need for immediate diagnosis and treatment of the patient with A. orchitis. B. phimosis. C. epididymitis. D. testicular torsion.

Answer: D Torsion constitutes a surgical emergency. If the blood supply to the affected testicle is not restored within 4 to 6 hours, testicular ischemia will occur, leading to necrosis and possible removal.

What should you explain to the patient who has had a vasectomy? A. The procedure blocks the production of sperm B. Erectile dysfunction is temporary and will return with sexual activity. C. The ejaculate will be about half the volume it was before the procedure. D. An alternative form of contraception will be necessary for 6 to 8 weeks.

Answer: D After a vasectomy, the patient should use an alternative form of contraception until semen examination reveals no sperm. This usually requires at least 10 ejaculations or 6 weeks to evacuate sperm distal to the surgical site.

In assessing a patient for testicular cancer, you understand that the manifestations of this disease often include A. acute back spasms and testicular pain. B. rapid onset of scrotal swelling and fever. C. fertility problems and bilateral scrotal tenderness. D. painless mass and heaviness sensation in the scrotal area.

Answer: D Clinical manifestations of testicular cancer include a painless lump in the scrotum, scrotal swelling, and a feeling of heaviness. The scrotal mass usually is not tender and is very firm. Some patients complain of a dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum.

A priority nursing diagnosis for the patient with bacterial prostatitis is A. activity intolerance related to fatigue. B. sexual dysfunction related to painful ejaculation. C. deficient fluid volume related to decreased fluid intake. D. impaired urinary elimination related to urethral compression.

Answer: D Acute urinary retention can develop in acute prostatitis, and it requires bladder drainage with suprapubic catheterization. The patient may experience fatigue, but this is not the priority. Sexual dysfunction can occur, but the pain occurs after ejaculation. Fluid volume should be increased.

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? A) Fever and chills B) Increased blood pressure C) Increased respiratory rate D) General malaise and fatigue

Answer: D An immunosuppressed individual may have the classic symptoms of inflammation or infection masked by the inability to launch a normal immune response. Therefore, in this person, early symptoms may be malaise, fatigue, or "just not feeling well."

Postoperatively, a patient who has had a laser prostatectomy has continuous bladder irrigation with a three-way urinary catheter with a 30-mL balloon. When he complains of bladder spasms with the catheter in place, you should A. deflate the catheter balloon to 10 mL to decrease bulk in the bladder. B. deflate the catheter balloon and then reinflate it to ensure that it is patent. C. encourage the patient to try to have a bowel movement to relieve colon pressure. D. explain that this feeling is normal and that he should not try to urinate around the catheter.

Answer: D Bladder spasms occur as a result of irritation of the bladder mucosa from the insertion of the resectoscope, presence of a catheter, or clots leading to obstruction of the catheter. Instruct the patient not to urinate around the catheter because this increases the likelihood of spasm.

You recognize the need to begin testosterone therapy when testosterone levels drop below A. 750 ng/dL. B. 500 ng/dL. C. 400 ng/dL. D. 250 ng/dL.

Answer: D Normal testosterone levels can range from 280 to 1100 ng/dL. Replacement therapy may be considered when levels are below 250 ng/dL.

A 45-year-old man asks you if it is advisable to have his prostate-specific antigen (PSA) level tested, because his father and brother have prostate cancer. What is your response? A. "You should wait until you are age 50." B. "You should have a transurethral resection of the prostate as a preventive measure." C. "You should have a voiding cystourethrogram yearly." D. "You should have annual PSA levels assessed and a digital examination of the prostate."

Answer: D The American Cancer Society recommends an annual digital rectal examination (DRE) and a blood test for PSA beginning at age 50 for men who are at average risk for prostate cancer. During DRE, an abnormal prostate may feel hard, nodular, and asymmetric.

A patient has been recently diagnosed with chronic fatigue syndrome and asks the nurse about the cause of this illness. What is the nurse's best response? A. "The provider will be able to tell you when the lab results are back." B. "An exact cause may not be determined, but a treatment plan will be discussed." C. "Stress is the main cause; a referral to a counselor may be helpful." D. "This is considered a psychiatric illness requiring behavioral medicine."

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response? A. "Your iron level is low. This is known as anemia." B. "Your immobility in the hospital is known as deconditioning." C. "Your poor appetite is known as malnutrition." D. "Your medications have caused drug induced weakness."

The nurse is caring for a patient diagnosed with amyotrophic lateral sclerosis. The nurse should review for which priority problem? A. Fatigue B. Bradypnea C. Hypertension D. Fall risk

The nurse is reviewing for fatigue in a patient diagnosed with multiple sclerosis. Which self-reporting tool is best for the nurse to utilize? A. Multidimensional Assessment of Fatigue (MAF) B. Fatigue Severity Scale (FSS) C. Brief Fatigue Inventory (BFI) D. Multidimensional Fatigue Inventory (MFI)

While completing an admission history for a 73-year-old man with osteoarthritis admitted for knee arthroplasty, the nurse asks about the patient's perception of the reason for admission. The nurse expects the patient to relate which response to this question? A Recent knee trauma B Debilitating joint pain C Repeated knee infections D Onset of "frozen" knee joint

B Debilitating joint pain The most common reason for knee arthroplasty is debilitating joint pain despite attempts to manage it with exercise and drug therapy. Recent knee trauma, repeated knee infections, and onset of "frozen" knee joint are not primary indicators for a knee arthroplasty.

A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement, if made by the patient to the nurse, indicates understanding of the procedure? A. "The bone density in my heel will be measured." B. "This procedure will not cause any pain or discomfort." C. "I will not be exposed to any radiation during the procedure." D. "I will need to remove my hearing aids before the procedure."

B. "This procedure will not cause any pain or discomfort." Dual-energy x-ray absorptiometry (DXA) is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound (QUS) evaluates density, elasticity, and strength of bone using ultrasound of the calcaneus (heel). Magnetic resonance imaging would require removal of objects such as hearing aids that have metal parts.

Which information in a 67-year-old woman's health history will alert the nurse to the need for a more focused assessment of the musculoskeletal system? a. The patient sprained her ankle at age 13. b. The patient's mother became shorter with aging. c. The patient takes ibuprofen (Advil) for occasional headaches. d. The patient's father died of complications of miliary tuberculosis.

B. A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient's current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.

During a health screening event which assessment finding would alert the nurse to the possible presence of osteoporosis in a white 61-year-old female? A. The presence of bowed legs B. A measurable loss of height C. Poor appetite and aversion to dairy products D. Development of unstable, wide-gait ambulation

B. A measurable loss of height A gradual but measurable loss of height and the development of kyphosis or "dowager's hump" are indicative of the presence of osteoporosis in which the rate of bone resorption is greater than bone deposition. Bowed legs may be caused by abnormal bone development or rickets but is not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative it is present. A wide gait is used to support balance and does not indicate osteoporosis.

A male patient complains of fever, dysuria, and cloudy urine. What additional information may indicate that these manifestations may be something other than a urinary tract infection (UTI)? A. E. coli bacteria in his urine B. A very tender prostate gland C. Complaints of chills and rectal pain D. Complaints of urgency and frequency

B. A very tender prostate gland A tender and swollen prostate is indicative of prostatis, which is a more serious male reproductive problem because an acute episode can result in chronic prostatis and lead to epididymitis or cystitis. E. coli in his urine, chills and rectal pain, and urgency and frequency are all present with a UTI and not specifically indicative of prostatis.

A female patient with a long-standing history of rheumatoid arthritis has sought care because of increasing stiffness in her right knee that has culminated in complete fixation of the joint. The nurse would document the presence of which problem? A. Atrophy B. Ankylosis C. Crepitation D. Contracture

B. Ankylosis Ankylosis is stiffness or fixation of a joint, whereas contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a flabby appearance of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies movement.

A 73-year-old male patient admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the "stream is less than it used to be." The nurse should give the patient anticipatory guidance that what condition may be developing? A. A tumor of the prostate B. Benign prostatic hyperplasia C. Bladder atony because of age D. Age-related altered innervation of the bladder

B. Benign prostatic hyperplasia Benign prostatic hyperplasia is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men over age 50 and 80% of men over age 80. Only about 16% of men develop prostate cancer. Bladder atony and age-related altered innervations of the bladder do not lead to a weakened stream.

Which action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the orthopedic clinic? a. Grade leg muscle strength for a patient with back pain. b. Obtain blood sample for uric acid from a patient with gout. c. Perform straight-leg-raise testing for a patient with sciatica. d. Check for knee joint crepitation before arthroscopic surgery.

B. Drawing blood specimens is a common skill performed by UAP in clinic settings. The other actions are assessments and require registered nurse (RN)-level judgment and critical thinking.

A 45-year-old man reports having recent problems attaining an erection. Which medication will the nurse further explore as the possible etiology of this patient's sexual dysfunction? A. Furosemide (Lasix) B. Fluoxetine (Prozac) C. Clopidogrel (Plavix) D. Nitroglycerin (Nitrostat)

B. Fluoxetine (Prozac) Fluoxetine is a selective serotonin reuptake inhibitor used in the treatment of depression. A common adverse effect of this medication is sexual problems (impotence, delayed or absent orgasm, delayed or absent ejaculation, decreased sexual interest) in nearly 70% of men and women.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. Which symptom will the nurse most likely find on physical examination of the patient? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg

B. Localized pain and warmth Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized, not generalized throughout the leg.

The nurse determines that dietary teaching for a 75-year-old patient with osteoporosis has been successful when the patient selects which highest-calcium meal? A. Chicken stir-fry with 1 cup each onions and green peas, and 1 cup of steamed rice B. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk D. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

C. A sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium, but not as much as the sardines, yogurt, and milk

Chemotaxis is a mechanism that A. Causes the transformation of monocytes into macrophages B. Slows the blood flow in a damaged area allowing migration of leukocytes into tissue C. Attracts the accumulation of neutrophils and monocytes to an area of injury D. Involves a pathway of chemical processes resulting in cellular lysis

C. Attracts the accumulation of neutrophils and monocytes to an area of injury

A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia

C. Back or neck pain Osteoporosis with resultant fractures is a frequent and serious complication of systemic corticosteroid therapy. The ribs and vertebrae are affected the most, and patients should be observed for signs of compression fractures (back and neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of the Achilles tendon. The highest risk is in people age 60 and older and in people taking corticosteroids. Antipsychotics and antidepressants may cause tardive dyskinesia, which is characterized by involuntary movements of the tongue and face.

To accurately monitor progression of a symptom of decreased urinary stream, the nurse should encourage the patient to have which primary screening measure done on a regular basis? A. Uroflowmetry B. Transrectal ultrasound C. Digital rectal examination (DRE) D. Prostate-specific antigen (PSA) monitoring

C. Digital rectal examination (DRE) Digital rectal examination is part of a regular physical examination and is a primary means of assessing symptoms of decreased urinary stream, which is often caused by benign prostatic hyperplasia in men over 50 years of age. The uroflowmetry helps determine the extent of urethral blockage and the type of treatment needed but is not done on a regular basis. Transrectal ultrasound is indicated with an abnormal DRE and elevated PSA to differentiate between BPH and prostate cancer. The PSA monitoring is done to rule out prostate cancer, although levels may be slightly elevated in patients with BPH.

During the healing phase of inflammation, regeneration of cells would be most likely to occur in A. Neurons B. Skeletal muscle C. Lymph glands D. Cardiac muscle

C. Lymph glands

The patient has had cardiovascular disease for some time and has now developed erectile dysfunction. He is frustrated because he cannot take erectogenic medications because he takes nitrates for his cardiac disease. What should the nurse do first to help this patient? A. Give the patient choices for penile implant surgery. B. Recommend counseling for the patient and his partner. C. Obtain a thorough sexual, health, and psychosocial history. D. Assess levels of testosterone, prolactin, LH, and thyroid hormones.

C. Obtain a thorough sexual, health, and psychosocial history. The nurse's first action to help this patient is to obtain a thorough sexual, health, and psychosocial history. Alternative treatments for the cardiac disease would then be explored if that had not already been done. Further examination or diagnostic testing would be based on the history and physical assessment, including hormone levels, counseling, or penile implant options.

Results from outpouring of fluid that has low cell and protein content; seen in early stages of inflammation or when injury is mild. (examples = skin blisters, pleural effusion) A. Purulent B. Hemorrhagic C. Serous D. Catarrhal E. Fibrinous

C. Serous

The patient has a low-grade carcinoma on the left lateral aspect of the prostate gland and has been on "watchful waiting" status for 5 years. Six months ago his last prostate-specific antigen (PSA) level was 5 ng/mL. Which manifestations now indicate that the prostate cancer may be growing and he needs a change in his care (select all that apply)? A. Casts in his urine B. Presence of α-fetoprotein C. Serum PSA level 10 ng/mL D. Onset of erectile dysfunction E. Nodularity of the prostate gland

C. Serum PSA level 10 ng/mL E. Nodularity of the prostate gland The manifestations of increased PSA level along with the new nodularity of the prostate gland potentially indicate that the tumor may be growing. Casts in the urine, presence of α-fetoprotein, and new onset of erectile dysfunction do not indicate prostate cancer growth.

The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate? A. Serum calcium B. Serum creatinine C. Serum phosphate D. Serum alkaline phosphatase

C. Serum phosphate Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min).

A patient is one day postoperative following a transurethral resection of the prostate (TURP). Which event is not an expected normal finding in the care of this patient? A. The patient requires two tablets of Tylenol #3 during the night. B. The patient complains of fatigue and claims to have minimal appetite. C. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased. D. The patient has expressed anxiety about his planned discharge home the following day.

C. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased. A decrease or cessation of output in a patient with CBI requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the patient or irrigating the catheter. Complaints of pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the patient's CBI.

A patient with an inflammation has a high eosinophil count. The nurse recognizes that this finding most likely indicates that A. The inflammation has become chronic with persistent tissue damage B. Humoral and cell-mediated immunity is being stimulated C. Tissue damage has been caused by an allergen-antibody reaction D. The inflammatory response has been stimulated by infection

C. Tissue damage has been caused by an allergen-antibody reaction

Which is a defining attribute unique to a malignant neoplasm? a) Involves a cellular mutation b) Represents surveillance failure c) Exhibits a shorter than typical cellular lifespan d) Capable of metastasis

Capable of metastasis Malignant neoplasia are unique in their ability to metastasize and invade surrounding tissue. Malignant cells have a longer than typical lifespan and are poorly differentiated. Cellular mutation leads to both benign and malignant neoplasia, both of which represent a surveillance failure.

Which of the following statements is essential when teaching a patient who has received an injection of iodine-131? a) "Do not share a toilet with anyone else for 3 days." b) "You need to save all your urine for the next 7 days." c) "You need to avoid contact with everyone except family members until the radiation device is removed." d) "No special precautions are needed, because this is a weak type of radiation."

Do not share a toilet with anyone else for 3 days." The radiation source is an unsealed isotope that is eliminated from the body mainly through urine and feces. This material is radioactive for about 48 hours after instillation. The patient should not share a toilet with others for 3 days to ensure the isotope has been completely eliminated and is no longer radioactive. Saving the urine is not necessary. Contact should be avoided with anyone who may be ill or immunocompromised. Patients are instructed to avoid crowded areas but isolation is not necessary.

The nurse is caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new order to be "up in chair today before noon." What action should the nurse take to protect the knee joint while carrying out the order? A Administer a dose of prescribed analgesic before completing the order. B Ask the physical therapist for a walker to limit weight bearing while getting out of bed. C Keep the continuous passive motion machine in place while lifting the patient from bed to chair. D Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting.

D Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting. The nurse should apply a knee immobilizer for stability before assisting the patient to get out of bed. This is a standard measure to protect the knee during movement following surgery. Although an analgesic should be given before the patient gets up in the chair for the first time, it will not protect the knee joint. Full weight bearing is begun before discharge, so a walker will not be used if the patient did not need one before the surgery. The CPM machine is not kept in place while the patient is getting up to the chair.

The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to A avoid crossing his legs. B use a toilet elevator on toilet seat. C notify future caregivers about the prosthesis. D maintain hip in adduction and internal rotation.

D maintain hip in adduction and internal rotation. The patient should not force hip into adduction or force hip into internal rotation as these movements could displace the hip replacement. Avoiding crossing the legs, using a toilet elevator on a toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

Arrive later at the site of injury. Their primary role is related to humoral and cell-mediated immunity. A. Chemotaxis B. Monocytes C. Neutrophils D. Lymphocytes

D. Lymphocytes

The nurse coordinates postoperative care for a 70-year-old man with osteoarthritis after prostate surgery. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? A. Teach the patient how to perform Kegel exercises. B. Provide instructions to the patient on catheter care. C. Administer oxybutynin (Ditropan) for bladder spasms. D. Manually irrigate the urinary catheter to determine patency.

D. Manually irrigate the urinary catheter to determine patency. The nurse may delegate the following to an LPN/LVN: monitor catheter drainage for increased blood or clots, increase flow of irrigating solution to maintain light pink color in outflow, administer antispasmodics and analgesics as needed. A registered nurse may not delegate teaching, assessments, or clinical judgments to a LPN/LVN.

A 67-year-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse would place highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.

D. Perform frequent position changes and range-of-motion exercises. The patient is at risk for atelectasis of the lungs and for contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion (ROM) exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest, and dangling the legs every 2 to 4 hours may be too painful. The priority is position changes and ROM exercises.

The nurse who notes that a 59-year-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about a. discography studies. b. myelographic testing. c. magnetic resonance imaging (MRI). d. dual-energy x-ray absorptiometry (DXA).

D. The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.

A 54-year-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. Two additional follow-up scans will be required. B. There will be only mild pain associated with the procedure. C. The procedure takes approximately 15 to 30 minutes to complete. D. The patient will be asked to drink increased fluids after the procedure.

D. The patient will be asked to drink increased fluids after the procedure. Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans and no pain are associated with bone scans that take 1 hour of lying supine.

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? a. Elevate the patient's head. b. Suction the patient's mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver.

In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake

A patient is admitted to the emergency department with a left femur fracture. Which information obtained by the nurse is most important to report to the health care provider? a. Ecchymosis of the left thigh b. Complaints of severe thigh pain c. Slow capillary refill of the left foot d. Outward pointing toes on the left foot

c. Slow capillary refill of the left foot Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? a. Vital signs baseline or stable b. Minimal nausea and vomiting c. Wants to go to the bathroom at home d. Responsible adult taking patient home e. Comfortable after IV opioid 15 minutes ago

a, b, & d Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

Social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem.

a, b, c, d, e Rationale: Social problems related to chronic neurologic disease may include changes in roles and relationships (e.g., divorce, job loss, role changes); other psychologic problems (e.g., depression, loss of self-esteem) also may have social effects.

A patient with *Parkinson's disease* is admitted to the hospital for *treatment of pneumonia*. Which nursing interventions will be included in the plan of care (select all that apply)? a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. c. Serve high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms.

a, b, d a. Provide an elevated toilet seat. b. Cut patient's food into small pieces. d. Place an armchair at the patient's bedside. Because the patient with Parkinson's disease has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's disease is a steadily progressive disease without acute exacerbations.

While the nurse is collecting a health history on a patient admitted for colon cancer, which of the following questions should the nurse ask as a priority? a. "Have you noticed any blood in your stool?" b. "Have you been experiencing nausea?" c. "Do you have back pain?" d. "Have you noticed any swelling in your abdomen?"

a. "Have you noticed any blood in your stool?"

A patient being evaluated for breast cancer is not certain whether she and her family should participate in a genetic screening plan since no one can guarantee the results. What is the nurse's best response? a. "If you have a family history of breast cancer, the chances for you to have this type of cancer increases." b. "The decision is up to you in the final analysis." c. "If there is no family history, then there is no need to go through the process." d. "If your insurance will pay for the screening, then there is no associated risk."

a. "If you have a family history of breast cancer, the chances for you to have this type of cancer increases."

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? a. Administering adequate analgesics to promote relief or control of pain b. Asking the patient to demonstrate the postoperative exercises every 1 hour c. Giving the patient positive feedback when the activities are performed correctly d. Warning the patient about possible complications if the activities are not performed

a. Administering adequate analgesics to promote relief or control of pain Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. c. Auscultate the bowel sounds. b. Listen to the lung sounds. d. Check pupil reaction to light.

a. Inspect the oral mucosa. *Phenytoin* can cause *gingival hyperplasia*, but does not affect bowel sounds, lung sounds, or pupil reaction to light.

After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. Oxygen saturation of 85% b. Respiratory rate of 13/min c. Temperature of 100.4F d. Blood pressure of 90/60 mmHg

a. Oxygen saturation of 85% Rationale: During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory compromise. This necessitates prompt intervention.

A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. When the patient arrives on the orthopedic unit after surgery, the nurse should a. assess the surgical site for hemorrhage. b. remove the prosthesis and wrap the site. c. place the patient in a side-lying position. d. keep the residual limb elevated on a pillow.

a. assess the surgical site for hemorrhage. The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. Unless contraindicated, the patient will be placed in a prone position for 30 minutes several times a day to prevent hip flexion contracture.

A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) a."The beads are used to directly deliver antibiotics to the site of the infection." b."There are no effective oral or IV antibiotics to treat most cases of bone infection." c."This is the safest method of delivering long-term antibiotic therapy for a bone infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." e."The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics."

a."The beads are used to directly deliver antibiotics to the site of the infection." d."The beads are an adjunct to debridement and oral and IV antibiotics for deep infections." Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of IV and oral antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may be implanted during surgery to aid in combating the infection.

What do you tell the patient with chronic bacterial prostatitis who is undergoing antibiotic therapy (select all that apply)? A. Hospitalization is required of all patients. B. Pain will lessen after treatment has ended. C. The course of treatment usually is 2 to 4 weeks. D. Long-term therapy may be indicated for immunocompromised patients. E. If the condition is unresolved and untreated, the patient is at risk for prostate cancer.

answer: B, D Patients with chronic bacterial prostatitis are usually given antibiotics for 4 to 12 weeks. However, antibiotics may be given for a lifetime if the patient is immunocompromised. Although patients with chronic bacterial prostatitis tend to experience a great amount of discomfort, the pain resolves as the infection is treated. If the patient with acute bacterial prostatitis has high fever or other signs of impending sepsis, hospitalization and intravenous antibiotics are prescribed.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take? a. Observe output from the surgical drain. b. Administer prescribed pain medication. c. Instruct the patient about benefits of early ambulation. d. Change the dressing and document the wound appearance.

b. Administer prescribed pain medication. The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

Which action will the urgent care nurse take for a patient with a possible knee meniscus injury? a. Encourage bed rest for 24 to 48 hours. b. Apply an immobilizer to the affected leg. c. Avoid palpation or movement of the knee. d. Administer intravenous opioids for pain management.

b. Apply an immobilizer to the affected leg. A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration. Nonsteroidal antiinflammatory drugs (NSAIDs) are usually recommended for pain management.

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? a. Assess the patient's pain. b. Assess the patient's vital signs. c. Check the rate of the IV infusion. d. Check the physician's postoperative orders.

b. Assess the patient's vital signs. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

When caring for a patient who is using Buck's traction after a hip fracture, which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Remove and reapply traction periodically. b. Ensure the weight for the traction is hanging freely. c. Monitor the skin under the traction boot for redness. d. Check for intact sensation and movement in the affected leg.

b. Ensure the weight for the traction is hanging freely UAP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment of skin integrity and circulation should be done by the registered nurse (RN).

A patient with prostate cancer is taking hormonal therapy to control tumor growth. He reports that his left calf is swollen and painful. Which of the following would be the nurse's best action? a. Instruct the patient to keep the leg elevated. b. Measure the calf circumference and compare the measurement with the right calf circumference measurement. c. Apply ice to the calf after a 10-minute massage of the area. d. Document assessment findings as an expected response with estrogen therapy.

b. Measure the calf circumference and compare the measurement with the right calf circumference measurement.

Which information obtained by the nurse about a patient with a lumbar vertebral compression fracture requires an immediate report to the health care provider? a. Patient refuses to be turned due to back pain. b. Patient has been incontinent of urine and stool. c. Patient reports lumbar area tenderness to palpation. d. Patient frequently uses oral corticosteroids to treat asthma.

b. Patient has been incontinent of urine and stool. Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention.

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? a. Blood administration b. Restoring circulating volume c. An ECG to check circulatory status d. Return to surgery to check for internal bleeding

b. Restoring circulating volume The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

A patient with *Parkinson's disease* has *bradykinesia*. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward.

b. Suggest that the patient rock from side to side to initiate leg movement. *Rocking the body* from side to side *stimulates balance* and improves mobility.

Which of the following options should the nurse incorporate into the plan of care as a primary prevention strategy for reduction of the risk for cancer? a. Yearly mammography for women aged 40 years and older b. Using skin protection during sun exposure while at the beach c. Colonoscopy at age 50 and every 10 years as follow-up d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over

b. Using skin protection during sun exposure while at the beach

In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom? a.The patient experiences a single episode of emesis. b.The patient is unable to move the lower extremities. c. The patient is nauseated and has not voided in 4 hours. d. The patient complains of pain at the bone graft donor site.

b.The patient is unable to move the lower extremities. After spinal fusion surgery, the nurse should frequently monitor peripheral neurologic signs. Movement of the arms and legs and assessment of sensation should be unchanged in comparison with the preoperative status. These assessments are usually repeated every 2 to 4 hours during the first 48 hours after surgery, and findings are compared with those of the preoperative assessment. Paresthesias, such as numbness and tingling sensation, may not be relieved immediately after surgery. The nurse should document any new muscle weakness or paresthesias and report this to the surgeon immediately.

Discharge criteria for the Phsae II patient include (select all that apply): a. no nausea or vomiting b. ability to drive self home c. no respiratory depression d. written discharge instructions understood e. opioid pain medication given 45 minutes ago

c, d, & e Rationale: Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient's ability to void (if appropriate with regard to surgical procedure or orders); patient's ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.

In providing care for patients with chronic, progressive neurologic disease, what is the major goal of treatment that the nurse works toward? a. Meet the patient's personal care needs. b. Return the patient to normal neurologic function. c. Maximize neurologic functioning for as long as possible. d. Prevent the development of additional chronic diseases.

c. Many chronic neurologic diseases involve progressive deterioration in physical or mental capabilities and have no cure, with devastating results for patients and families. Health care providers can only attempt to alleviate physical symptoms, prevent complications, and assist patients in maximizing function and self-care abilities for as long as possible.

Which finding in a patient with a Colles' fracture of the left wrist is most important to communicate immediately to the health care provider? a. Swelling is noted around the wrist. b. The patient is reporting severe pain. c. The wrist has a deformed appearance. d. Capillary refill to the fingers is prolonged.

d. Capillary refill to the fingers is prolonged. Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.

When a patient is admitted to the PACU, what are the priority interventions the nurse performs? a. Assess the surgical site, no tine presence and character of drainage b. Assess the amount of urine output and the presence of bladder distention c. Assess for airway potency and quality of expirations, and obtain vital signs. d. Review results of intraoperative laboratory values and medications received.

c. Assess for airway potency and quality of expirations, and obtain vital signs. Rationale: Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? a. Recheck in 1 hour for increased drainage. b. Notify the surgeon of a potential hemorrhage. c. Assess the patient's blood pressure and heart rate. d. Remove the dressing and assess the surgical incision.

c. Assess the patient's blood pressure and heart rate. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? a. Monitor the patient's pain. b. Do the admission vital signs. c. Assist the patient to take deep breaths and cough. d. Change the dressing when there is excess drainage.

c. Assist the patient to take deep breaths and cough. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.

The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check the O2 saturation. d. Observe for facial asymmetry.

c. Check the O2 saturation. The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses O2 saturation.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action will the nurse take first? History ∙ Age 23 years ∙ Right lower leg injury Physical Assessment ∙ Reports severe right lower leg pain ∙ Reports feeling short of breath ∙ Bone protruding from right lower leg Diagnostic Exams ∙ CBC: WBC 9400/µL; Hgb 11.6 g/dL ∙ Right leg x-ray; right tibial fracture a. Administer the prescribed morphine 4 mg IV. b. Contact the operating room to schedule surgery. c. Check the patient's O2 saturation using pulse oximetry. d. Ask the patient about the date of the last tetanus immunization.

c. Check the patient's O2 saturation using pulse oximetry. Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation.

30. To reduce the risk for falls in the patient with Parkinson's disease, what should the nurse teach the patient to do? a. Use an elevated toilet seat. b. Use a walker or cane for support. c. Consciously lift the toes when stepping. d. Rock side to side to initiate leg movements.

c. The shuffling gait of PD causes the patient to be off balance and at risk for falling. Teaching the patient to use a wide stance with the feet apart, to lift the toes when walking, and to look ahead helps to promote a more balanced gait. Use of an elevated toilet seat and rocking from side to side will enable a patient to initiate movement. Canes and walkers are difficult for patients with PD to maneuver and may make the patient more prone to injury.

When a patient arrives in the emergency department with a facial fracture, which action will the nurse take first? a. Assess for nasal bleeding and pain. b. Apply ice to the face to reduce swelling. c. Use a cervical collar to stabilize the spine. d. Check the patient's alertness and orientation.

c. Use a cervical collar to stabilize the spine. Patients who have facial fractures are at risk for cervical spine injury, and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to: a. increase the rate of IV fluids b. obtain vital signs, including O2 saturation c. position patient in lateral recovery position d. administer antiemetic medication as ordered

c. position patient in lateral recovery position Rationale: If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as a.hypertension. b.thyroid problems. c.diabetes mellitus. d.chronic bronchitis.

c.diabetes mellitus The nurse should question the patient about past medical problems because certain illnesses are known to affect the musculoskeletal system directly or indirectly. These diseases include tuberculosis, poliomyelitis, diabetes mellitus, parathyroid problems, hemophilia, rickets, soft tissue infection, and neuromuscular disabilities.

The bone cells that function in the resorption of bone tissue are called a.osteoids b.osteocytes c.osteoclasts d.osteoblasts

c.osteoclasts Osteoclasts participate in bone remodeling by assisting in the breakdown of bone tissue.

The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home." c. "Early ambulation will help you get rid of your syncope and pain." d. "Early walking is the best way to prevent postoperative complications."

d. "Early walking is the best way to prevent postoperative complications." The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

d. Advancing age

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? a. Check his chart for intraoperative complications. b. Check which medications were used for anesthesia. c. Check the effectiveness of the analgesics he has received. d. Check his preoperative assessment for previous delirium or dementia.

d. Check his preoperative assessment for previous delirium or dementia. If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium.

Which nursing diagnosis is of *highest priority* for a patient with *Parkinson's disease* who is *unable to move the facial muscles*? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

d. Imbalanced nutrition: less than body requirements The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing.

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? a. Manage patient pain. b. Control the bleeding. c. Maintain fluid balance. d. Manage oxygenation status.

d. Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

The nurse is caring for a patient who received a recent bone marrow transplant. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation

d. Mild temperature elevation

After change-of-shift report, which patient should the nurse assess first? a. Patient with a repaired mandibular fracture who is complaining of facial pain b. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated c. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity d. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf

d. Patient with repaired right femoral shaft fracture who is complaining of tightness in the calf Calf swelling after a femoral shaft fracture suggests hemorrhage and risk for compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention.

A 62-yr-old patient who has *Parkinson's* disease is taking *bromocriptine (Parlodel)*. Which information obtained by the nurse may indicate a *need for a decrease* in the dosage? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg.

d. The patient's blood pressure is 92/52 mm Hg. *Hypotension* is an *adverse* effect of *bromocriptine*, and the nurse should check with the health care provider before giving the medication.

In caring for a patient admitted with lung cancer, which of the following should the nurse expect to find on assessment? a. No use of accessory muscles during respirations b. Orthostatic hypotension upon change of positioning c. Clear sputum d. Weight loss compared to last admission

d. Weight loss compared to last admission

A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: a. perform a straight catheterization to measure the amount of urine in the bladder b. notify the physician and anticipate obtaining blood work to evaluate renal function c. continue to monitor the patient because this is a normal finding during this time period d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound

d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound Rationale: Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

A clinic nurse is conducting a staff in-service for other clinic staff regarding the signs and symptoms of a rhabdomyosarcoma tumor. Which should be included in the teaching session (Select all that apply)? a. Bone fractures b. Abdominal mass c. Sore throat and ear pain d. Headache e. Ecchymosis of conjunctiva

ANS: B, C, E The initial signs and symptoms of rhabdomyosarcoma tumors are related to the site of the tumor and compression of adjacent organs. Some tumor locations, such as the orbit, manifest early in the course of the illness. Other tumors, such as those of the retroperitoneal area, only produce symptoms when they are relatively large and compress adjacent organs. Unfortunately, many of the signs and symptoms attributable to rhabdomyosarcoma are vague and frequently suggest a common childhood illness, such as "earache" or "runny nose." An abdominal mass, sore throat and ear pain, and ecchymosis of conjunctiva are signs of a rhabdomyosarcoma tumor. Bone fractures would be seen in osteosarcoma and a headache is a sign of a brain tumor. Ch48 Musculoskeletal/Articular Dysfunction p1563

2. Immobilization causes which of the following effects on metabolism? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased production of stress hormones

ANS: B Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased food intake

Which condition can result from the bone demineralization associated with immobility? a. Osteoporosis b. Urinary retention c. Pooling of blood d. Susceptibility to infection

ANS: A Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the respiratory and renal systems. p1534

When assessing the child with osteogenesis imperfecta, the nurse should expect to observe: a. Discolored teeth. b. Below-normal intelligence. c. Increased muscle tone. d. Above-average stature.

ANS: A Children with osteogenesis imperfecta have incomplete development of bones, teeth, ligaments, and sclerae. Teeth are discolored because of abnormal enamel. Despite their appearance, children with osteogenesis imperfecta have normal or above-normal intelligence. The child with osteogenesis imperfecta has weak muscles and decreased muscle tone. Because of compression fractures of the spine, the child appears short. p 1553

An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. The nurse's approach should include: a. Answering questions with straightforward honesty. b. Avoiding discussing the seriousness of the condition. c. Explaining that, although the amputation is difficult, it will cure the cancer. d. Assisting the adolescent in accepting the amputation as better than a long course of chemotherapy.

ANS: A Honesty is essential to gain the cooperation and trust of the child. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared in advance for the surgery so that there is time for reflection about the diagnosis and subsequent treatment. This allows questions to be answered. To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery. p1562

Which term is used to describe a type of fracture that does not produce a break in the skin? a. Simple b. Compound c. Complicated d. Comminuted

ANS: A If a fracture does not produce a break in the skin, it is called a simple or closed fracture. A compound or open fracture is one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue. These are rare in children. p1538

A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. Which of the following should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub leg. c. Apply powder to absorb material. d. Carefully pick material off leg.

ANS: A Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely.

Immobilization causes which of the following effects on the cardiovascular system? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes

ANS: A The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi.

A school-age child is diagnosed with systemic lupus erythematosus (SLE). The nurse should plan to implement which interventions for this child (Select all that apply)? a. Instructions to avoid exposure to sunlight b. Teaching about body changes associated with SLE c. Preparation for home schooling d. Restricted activity

ANS: A, B Key issues for a child with SLE include therapy compliance; body-image problems associated with rash, hair loss, and steroid therapy; school attendance; vocational activities; social relationships; sexual activity; and pregnancy. Specific instructions for avoiding exposure to the sun and ultraviolet B light, such as using sunscreens, wearing sun-resistant clothing, and altering outdoor activities, must be provided with great sensitivity to ensure compliance while minimizing the associated feeling of being different from peers. The child should continue school attendance in order to gain interaction with peers and activity should not be restricted, but promoted. Ch48 Musculoskeletal/Articular Dysfunction p1568

Which of the following is an advantage to using a fiberglass cast instead of a plaster of Paris cast? a. Cheaper b. Dries rapidly c. Molds closely to body parts d. Smooth exterior

ANS: B A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry.

An adolescent is in traction. The purpose of the traction is to fatigue the muscle and reduce muscle spasm so that the bones can be realigned. Nursing actions should include which of the following? a. Maintain continuous traction until muscle spasm ceases. b. Maintain continuous traction to prevent muscle from contracting. c. Release traction every hour to allow muscle to briefly regain its contractibility. d. Release traction once every 8 hours to allow muscle to briefly regain its contractibility.

ANS: B When the muscles are stretched, muscle spasm ceases and permits realignment of the bone ends. The continued maintenance of traction is important during this phase because releasing the traction allows the muscle's normal contracting ability to again cause of malpositioning of the bone ends.

The primary method of treating osteomyelitis is: a. Joint replacement. b. Bracing and casting. c. Intravenous antibiotic therapy. d. Long-term corticosteroid therapy.

ANS: C Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and long-term corticosteroids are not indicated for infectious processes. p1560

Which of the following medications is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? a. Aspirin b. Corticosteroids c. Cytotoxic drugs such as methotrexate d. Nonsteroidal antiinflammatory drugs (NSAIDs)

ANS: D NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children.

Which of the following is a type of skin traction with legs in an extended position? a. Dunlop b. Bryant c. Russell d. Buck extension

ANS: D Buck extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calvé-Perthes disease.

Which of the following would cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia b. Cold toes c. Increased respirations d. "Hot spots" felt on cast surface

ANS: D If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so that a window can be made in the cast to observe the site.

Which medication is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? a. Aspirin b. Corticosteroids c. Cytotoxic drugs such as methotrexate d. Nonsteroidal antiinflammatory drugs (NSAIDs)

ANS: D NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children. Aspirin, once the drug of choice, has been replaced by the NSAIDs because they have fewer side effects and easier administration schedules. Corticosteroids are used for life-threatening complications, incapacitating arthritis, and uveitis. Methotrexate is a second-line therapy for JIA. p1565

The nurse is teaching the parents of a 7-year-old child who has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which of the following instructions should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours. b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.

ANS: D The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return.

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which information will the nurse teach? a. "Check and clean the pin insertion sites daily." b. "Remove the external fixator for your shower." c. "Remain on bed rest until bone healing is complete." d. "Take prophylactic antibiotics until the fixator is removed."

a. "Check and clean the pin insertion sites daily." Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given during external fixator use.

Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? a. Assess for hip pain. b. Assess for contractures. c. Check peripheral pulses. d. Monitor for hip dislocation.

a. Assess for hip pain. Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.

A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? a. Check the patient's prescribed weight-bearing status. b. Use a mechanical lift to transfer the patient to the chair. c. Delegate the transfer to nursing assistive personnel (NAP). d. Decrease the pain medication before getting the patient up.

a. Check the patient's prescribed weight-bearing status. The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer.

A patient who has had open reduction and internal fixation (ORIF) of left lower leg fractures continues to complain of severe pain in the leg 15 minutes after receiving the prescribed IV morphine. Pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patient's blood pressure.

a. Notify the health care provider. The patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

Which nursing action for a patient who has had right hip arthroplasty can the nurse delegate to experienced unlicensed assistive personnel (UAP)? a. Reposition the patient every 1 to 2 hours. b. Assess for skin irritation on the patient's back. c. Teach the patient quadriceps-setting exercises. d. Determine the patient's pain intensity and tolerance.

a. Reposition the patient every 1 to 2 hours. Repositioning of orthopedic patients is within the scope of practice of UAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

The occupational health nurse will teach the patient whose job involves many hours of typing to a. obtain a keyboard pad to support the wrist. b. do stretching exercises before starting work. c. wrap the wrists with compression bandages every morning. d. avoid using nonsteroidal antiinflammatory drugs (NSAIDs) for pain.

a. obtain a keyboard pad to support the wrist. Repetitive strain injuries caused by prolonged work at a keyboard can be prevented by using a pad to keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting work. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to decrease swelling.

Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective? a. "I should elevate my residual limb on a pillow 2 or 3 times a day." b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." c. "I should change the limb sock when it becomes soiled or each week." d. "I should use lotion on the stump to prevent skin drying and cracking."

b. "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage hip flexion contracture.

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. "You will not be able to serve a tennis ball again." b. "You will begin work with a physical therapist tomorrow." c. "Keep the shoulder immobilizer on for the first 4 days to minimize pain." d. "The surgeon will use the drop-arm test to determine the success of surgery."

b. "You will begin work with a physical therapist tomorrow." Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion. The drop-arm test is used to test for rotator cuff injury but not after surgery. The patient may be able to return to tennis after rehabilitation.

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which nursing assessment finding indicates a potential complication of the fracture? a. The patient states the pelvis feels unstable. b. Abdomen is distended and bowel sounds are absent. c. The patient complains of pelvic pain with palpation. d. Ecchymoses are visible across the abdomen and hips.

b. Abdomen is distended and bowel sounds are absent. The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer prescribed PRN O2 at 4 L/min. c. Check the patient's legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

b. Administer prescribed PRN O2 at 4 L/min. The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism.

The day after a having a right below-the-knee amputation, a patient complains of pain in the missing right foot. Which action is most important for the nurse to take? a. Explain the reasons for the pain. b. Administer prescribed analgesics. c. Reposition the patient to assure good alignment. d. Inform the patient that this pain will diminish over time.

b. Administer prescribed analgesics. Acute phantom limb sensation is treated as any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. Alignment is important but is unlikely to relieve the pain. Although the pain may decrease over time, it currently requires treatment.

Which nursing intervention will be included in the plan of care after a patient with a right femur fracture has a hip spica cast applied? a. Avoid placing the patient in prone position. b. Ask the patient about abdominal discomfort. c. Discuss remaining on bed rest for several weeks. d. Use the cast support bar to reposition the patient.

b. Ask the patient about abdominal discomfort. Assessment of bowel sounds, abdominal pain, and nausea and vomiting will detect the development of abdominal cast syndrome. To avoid breakage, the cast support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

A patient who is to have no weight bearing on the left leg is learning to walk using crutches. Which observation by the nurse indicates the patient can safely ambulate independently? a. The patient moves the right crutch with the right leg and then the left crutch with the left leg. b. The patient advances the left leg and both crutches together and then advances the right leg. c. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. d. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

b. The patient advances the left leg and both crutches together and then advances the right leg. Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid brachial plexus damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull on shoes and socks. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing teeth.

b. The patient leans over to pull on shoes and socks. Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which of these prescribed interprofessional interventions will the nurse implement first? a. Send the patient for ankle x-rays. b. Wrap the ankle and apply an ice pack. c. Administer naproxen (Naprosyn) 500 mg PO. d. Give acetaminophen with codeine (Tylenol #3).

b. Wrap the ankle and apply an ice pack. Immediate care after a sprain or strain injury includes application of cold and use of compression to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

A patient has a long-arm plaster cast applied for fracture immobilization. Until the cast has completely dried, the nurse should a. keep the left arm in dependent position. b. avoid handling the cast using fingertips. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

b. avoid handling the cast using fingertips. Until a plaster cast has dried, using the palms rather than the fingertips to handle the cast helps prevent creating protrusions inside the cast that could place pressure on the skin. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

The nurse will instruct the patient with a fractured left radius that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

b. for at least 3 weeks. Bone healing starts immediately after the injury, but because ossification does not begin until 3 weeks after injury, the cast will need to be worn for at least 3 weeks. Complete union may take up to 1 year. Resolution of swelling does not indicate bone healing.

The nurse's discharge teaching for a patient who has had a repair of a fractured mandible will include information about a. administration of nasogastric tube feedings. b. how and when to cut the immobilizing wires. c. the importance of high-fiber foods in the diet. d. the use of sterile technique for dressing changes.

b. how and when to cut the immobilizing wires. The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw.

Which statement by the patient indicates a good understanding of the nurse's teaching about a new short-arm synthetic cast? a. "I can get the cast wet as long as I dry it right away with a hair dryer." b. "I should avoid moving my fingers and elbow until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery? a. "This procedure will correct the deformities in my fingers." b. "I will not have to do as many hand exercises after the surgery." c. "I will be able to use my fingers with more flexibility to grasp things." d. "My fingers will appear more normal in size and shape after this surgery."

c. "I will be able to use my fingers with more flexibility to grasp things." The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? a. "You are upset, but you may lose the foot anyway." b. "Many people are able to function with a foot prosthesis." c. "Tell me what you know about your options for treatment." d. "If you do not want an amputation, you do not have to have it."

c. "Tell me what you know about your options for treatment." The initial nursing action should be to assess the patient's knowledge and feelings about the available options. Discussion about the patient's option to refuse the procedure, seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current knowledge and emotional state.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a long-arm cast and a sling. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers of the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

c. Assess the left axilla and change absorbent dressings as needed. The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

Which information will the nurse teach seniors at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs in the home. b. Expect most falls to happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Get instruction in range-of-motion exercises from a physical therapist.

c. Buy shoes that provide good support and are comfortable to wear. Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

When giving home care instructions to a patient who has comminuted left forearm fractures and a long-arm cast, which information should the nurse include? a. Keep the left shoulder elevated on a pillow or cushion. b. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). c. Call the health care provider for numbness of the hand. d. Keep the hand immobile to prevent soft tissue swelling.

c. Call the health care provider for numbness of the hand. Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.

c. The right arm appears shorter than the left. A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to a. elevate the right leg. b. splint the lower leg. c. assess the pedal pulses. d. verify tetanus immunization.

c. assess the pedal pulses. The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus immunizations should be obtained if there is an open wound.

A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a. loosen the traction and help the patient turn onto the unaffected side. b. place a pillow between the patient's legs and turn gently to each side. c. have the patient lift the buttocks slightly by using a trapeze over the bed. d. turn the patient partially to each side with the assistance of another nurse.

c. have the patient lift the buttocks slightly by using a trapeze over the bed. The patient can lift the buttocks slightly off the bed by using a trapeze. This will not affect the fracture fragments on the right leg. Turning the patient will tend to move the fracture fragments, causing pain and possible nerve impingement. Disconnecting the traction will interrupt the weight needed to decrease muscle spasms.

A patient who arrives at the emergency department experiencing severe left knee pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. a knee immobilizer. b. gentle knee flexion. c. monitored anesthesia care. d. physical activity restrictions.

c. monitored anesthesia care. The first goal of interprofessional management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care, formerly called conscious sedation. Immobilization, gentle range-of-motion exercises, and discussion about activity restrictions will be implemented after the patella is realigned.

The nurse is caring for a patient who is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction? a. "I should not cross my legs while sitting." b. "I will use a toilet elevator on the toilet seat." c. "I will have someone else put on my shoes and socks." d. "I can sleep in any position that is comfortable for me."

d. "I can sleep in any position that is comfortable for me." The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching.

Which action will the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty? a. Avoid extension of the right knee beyond 120 degrees. b. Use a compression bandage to keep the right knee flexed. c. Teach about the need to avoid weight bearing for 4 weeks. d. Start progressive knee exercises to obtain 90-degree flexion.

d. Start progressive knee exercises to obtain 90-degree flexion. After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Surgeon orders allow weight bearing as tolerated after this procedure; protected weight bearing is not needed.

The day after a 60-yr-old patient has open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, the nurse identifies the priority nursing diagnosis as a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

d. risk for infection related to disruption of skin integrity. A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are mobilized starting the first postoperative day, so the other problems caused by immobility are not as likely.

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