Evolve Questions for Week #5 Quiz

Which finding does the nurse expect to observe in a client with suspected common chronic osteomyelitis? Erythema of the affected area Fever; temperature usually above 101° F (38° C) Ulceration of the skin Constant, localized, and pulsating bone pain

c

(week 4?) A client with amyotrophic lateral sclerosis is degenerating rapidly and will soon need respiratory support. What does the nurse plan to review with this client? Advance directives How to use the ventilator Funeral plans Nutritional support

a

A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? "I can go home the day of the procedure." "I can go home 48 hours after the procedure." "I'll have a drain in place after the procedure." "I'll need to wear special stockings after the procedure."

a

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? Observation of a large amount of serosanguineous or bloody drainage Mild to moderate pain controlled with prescribed analgesics Absence of erythema and tenderness at the surgical site Ability to flex and extend the right knee

a

An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? Ensure written consultation of two noninvolved physicians. Read the surgeon's consult to determine whether the client's condition is life-threatening. Sign the operative permit. Withhold surgery until the next of kin is notified.

a

Before administering low-molecular-weight heparin (LMWH) to an older adult client after total knee arthroplasty, the nurse notes that the client's platelet count is 50,000/mm3. What action is most important for the nurse to take? Notify the health care provider of the platelet count. Administer the prescribed LMWH on schedule. Assess the activated partial thromboplastin time (aPTT). Assess the international normalized ratio (INR).

a

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? Creatinine, 1.9 mg/dL Fasting glucose, 80 mg/dL Potassium, 3.9 mEq/L Sodium, 140 mEq/L

a

Which nursing intervention helps to reduce the incidence of osteomyelitis for a client receiving hemodialysis? Instructing the client to brush teeth after every meal Maintaining clean dressing change technique for long-term IV catheters Using clean technique Using Standard Precautions

a

Which risk factor is shared by clients who have osteoporosis or osteomalacia? High alcohol intake A history of smoking Inadequate exposure to sunlight Homelessness

a

A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? Drowsiness Hirsutism Hypertension Tachycardia

a. Tizanidine (Zanaflex, Sirdalud) is a centrally acting skeletal muscle relaxant, and drowsiness and sedation are common adverse effects. Tizanidine may cause alopecia (not hirsutism), hypotension (not hypertension), and bradycardia (not tachycardia).

A client has a grade III compound fracture of the right tibia. To prevent infection, which intervention does the nurse implement? Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. Use strict aseptic technique when cleaning the site. Leave the site open to the air to keep it dry. Assist the client to shower daily and pat the wound site dry.

b

A client returns to the neuromedicine floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? Administer pain medication. Assess airway and breathing. Assist with ambulation. Check the client's ability to void.

b

Which action does the nurse implement for a client with wound evisceration? Apply direct pressure to the wound. Cover the wound with a sterile, warm, moist dressing. Irrigate the wound with warm, sterile saline. Replace tissue protruding into the opening.

b

Which client is at greatest risk for slow wound healing? A 12-year-old healthy girl A 47-year-old obese man with diabetes A 48-year-old woman who smokes A 98-year-old healthy man

b

(week 4?) The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." "This was caused by getting too many x-rays as a child."

c

A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Instruct the client to quit smoking. Teach about the dangers of tobacco. Teach the importance of incentive spirometry. Tell the client where the smoking lounge is.

c

After gastric surgery, a client arrives in the postanesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant? Monitor respiratory rate and airway patency. Irrigate the nasogastric tube with saline. Position the client on the left side. Assess the client's pain level.

c

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? "I am taking vitamins." "I drink a glass of wine a night." "I had a heart attack 4 months ago." "I don't like latex balloons."

c

The nurse is caring for a middle-aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive coping strategies? "I'm letting my husband do most of the cooking, but I help plan the menus." "Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my home easier." "My husband is getting used to having sex only once a month." "I worry about what's going to happen to me if my husband cannot take care of me, but he says he'll hire someone if he must."

c

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? Nutritional therapy Occupational therapy Physical therapy Respiratory therapy

d

What pain management does a client who has been admitted to the postanesthesia care unit typically receive? Intramuscular nonopioid analgesics Intramuscular opioid analgesics Intravenous nonopioid analgesics Intravenous opioid analgesics

d

The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the health care provider will request which medication? Ascorbic acid (vitamin C) Ergocalciferol (Calciferol) Phenytoin (Dilantin) Prednisone (Deltasone)

b

In conducting a postoperative assessment of a client, what is important for the nurse to examine first? Breathing pattern Level of consciousness Oxygen saturation Surgical site

a

An older adult client is discharged from the hospital for treatment of osteoporosis. What does the nurse include in client teaching related to the client's home safety? "Use area rugs on tile floors." "Keep walkways free of clutter." "Walk slowly on wet floor areas after mopping." "Keep light low to prevent glare."

b

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? Balanced skin traction Buck's traction Overhead traction Plaster traction

b. Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength

c

The nurse is assessing a client with osteomalacia. Which findings does the nurse expect to observe? (Select all that apply.) Hyperparathyroidism Hyperuricemia Hypophosphatemia Looser's lines or zones Unsteady gait

c, d, e

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? Decrease expected blood loss during surgery Eliminate any risk of infection Ensure that the bowel is sterile Reduce the number of intestinal bacteria

d

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? Supplemental pain reduction is needed. One dose is needed. This is an acute emergency. The client will be hostile.

a

A client with a compound fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? Check the dorsalis pedis pulses. Immobilize the left leg with a splint. Administer the prescribed analgesic. Place a dressing on the affected area.

a

A client with a spinal cord tumor and a poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery will be "worth it." What is the nurse's best response? "It should help return bladder control." "Let me call the surgeon so you can ask the rest of your questions." "What do you think?" "What does your family think?"

a

A client's left arm is placed in a plaster cast. Which assessment does the nurse perform before the client is discharged? Assess that the cast is dry. Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. Check the fit of the cast by inserting a tongue blade between the cast and the skin. Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds.

a

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)

a

The nurse is instructing a client who has been prescribed calcium citrate (Citracal). Which instruction does the nurse include? "Take Citracal with food." "For best absorption, take Citracal with a carbonated beverage." "One third of the daily dose is best taken during the day." "Milk of Magnesia (MOM) should be taken with Citracal."

a

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? (Select all that apply.) Occupational therapist Physical therapist Psychologist Respiratory therapist Speech therapist

a, b, c

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? (Select all that apply.) Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Congestive heart failure Urinary tract infection (UTI) Osteomyelitis

a, b, e

As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? Contact the anesthesiologist. Contact the surgeon. Explain the procedure. Have the client sign the form.

b

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern? Crusting along the incision line Redness and swelling around the incision Sanguineous drainage at the suture site Serosanguineous drainage on the dressing

b

How does the nurse position a client with postoperative nausea and vomiting? Flat in bed, with the head in alignment with the body Prone, with the head of the bed flat Side-lying, with the head in a neutral position Supine in bed, with the neck flexed

c

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan? "Avoid contact sports." "Avoid rigorous exercise." "Wear helmets when riding a motorcycle." "Avoid driving in inclement weather."

c

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) "Standing for long periods of time will help to prevent low back pain." "Keep weight within 50% of ideal body weight." "Begin a regular exercise program." "When lifting something, the back should be straight and the knees bent." "Do not wear high-heeled shoes."

c, d, e

A client is in skeletal traction. Which nursing intervention ensures proper care of this client? Ensure that weights are attached to the bed frame or placed on the floor. Ensure that pins are not loose, and tighten as needed. Inspect the skin at least every 8 hours. Remove the traction weights only for bathing.

c. Skin should be inspected every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights are not allowed to be placed on the floor; weights should hang freely at all times. Pin sites should be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Weights must never be removed without a request from the health care provider.

A client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon? Swelling of the right lower extremity 1+ to 2+ bilateral palpable pedal pulses Pain of right lower extremity on movement Paresis of right lower extremity

d

A client is brought to the emergency department via ambulance after a motor vehicle crash. What condition does the nurse assess for first? Bleeding Head injury Pain Respiratory distress

d

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? "My spouse will be the only person to change my dressing." "I can't believe that this has happened to me. I can't stand to look at it." "I do not want any visitors while I'm in the hospital." "It will take me some time to get used to this."

d

Colostomy surgery is categorized as what type of surgery? Cosmetic Curative Diagnostic Palliative

d

The nurse is caring for a postoperative client with total joint arthroplasty. What actions does the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply.) Massage the legs. Keep the legs slightly abducted. Use the knee gatch on the bed. Apply elastic stockings. Administer anticoagulants.

d, e Massaging the legs could cause a blood clot to dislodge and should be avoided. Legs are kept slightly abducted to prevent adduction. Using the knee gatch can constrict circulation in the popliteal area and should be avoided.

An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? Cyclobenzaprine (Flexeril) Ibuprofen (Advil) Meperidine (Demerol) Patient-controlled analgesia (PCA) with morphine

d. Muscle relaxants such as cyclobenzaprine are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. Ibuprofen is used to treat mild to moderate pain; bone pain is very acute. Meperidine should never be used for older adults.

(week 4?) The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? "Riluzole should be taken with food." "I plan to take riluzole once daily." "I will call the health care provider if my pulse goes below 50." "I will need frequent checks of my liver enzymes."

d. Riluzole (Rilutek) may cause liver toxicity, and liver enzymes will need to be checked frequently. This drug should be taken twice a day without food and when the stomach is empty. Riluzole may cause tachycardia, not bradycardia.

In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? Chair pad Thromboembolism-deterrent (TED) hose Trapeze Water bottle

a

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Patent airway Indication of allergies Level of consciousness Loss of sensation

a

The nurse reviews with a client a routine discharge teaching plan concerning postoperative care. Which statement by the client indicates that teaching was effective? "I may need to restrict my activities for several months." "The dressing should stay in place unless it gets wet." "The incision needs to be cleaned every 4 hours with hydrogen peroxide." "The wound will completely heal in about 2 months."

a

Which intervention does the nurse suggest to a client with a leg amputation to help cope with loss of the limb? Talking with an amputee close to the client's age who has had the same type of amputation Drawing a picture of how the client sees him- or herself Talking with a psychiatrist about the amputation Engaging in diversional activities to avoid focusing on the amputation

a

Which instructions for joint protection does the nurse recommend for a client with a connective tissue disease? (Select all that apply.) Use long-handled devices such as a reacher. When getting out of bed, use fingers to push off. Sit in a low back chair. Bend at the waist while keeping the back straight. Use adaptive devices such as Velcro closures Turn a doorknob clockwise.

a, d

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? Keep the client's heels off the bed at all times. Re-position the client every 3 to 4 hours. Administer preventive pain medication before deep-breathing exercises. Prohibit the use of antiembolic stockings.

a. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. Re-positioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown.

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? "Use pain medication as prescribed to control pain." "Clean the pin site when any drainage is noticed." "Wear the same clothing that is normally worn." "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."

a. The client should be taught the correct use of prescribed pain medication to control pain. Pin sites must be cleaned at least every 8 hours and as needed to reduce the risk for infection, not when any drainage is noticed. The client will have to adjust the type of clothing worn while the device is in place. If signs and symptoms of infection develop around the pin sites, the client must notify the health care provider immediately; it places the client at risk for osteomyelitis.

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which actions would be best for the RN to accomplish? Reinforce the need to cough and deep-breathe every 2 to 4 hours. Develop the discharge teaching plan in conjunction with the client. Administer narcotic pain medications before assisting the client with ambulation. Listen for bowel sounds and monitor the abdomen for distention and pain.

b

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. 2, 4, 3, 1 3, 4, 1, 2 1, 4, 3, 2 4, 1, 2, 3

b

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? Neck pain is at a level 7 on a 0-to-10 scale. The client is reporting difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms. Serosanguineous fluid oozes onto the neck dressing.

b

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will prescribe which medication? Dopamine hydrochloride (Inotropin) Nifedipine (Procardia) Methylprednisolone (Solu-Medrol) Ziconotide (Prialt)

b

The nurse is caring for an older adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? "I do not know how long my wife will be able to take care of me at home." "The bus is coming to pick me up from the senior center three times a week so I can play cards." "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." "I do not know how much longer my neighbor can continue to help clean my house."

b

The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis? Consuming 12 ounces of carbonated beverages daily Working at a desk and playing the piano for a hobby Having a hysterectomy and taking estrogen replacement therapy Consuming one alcoholic drink per week

b

The nurse refers a client with an amputation and the client's family to which community resource? American Amputee Society (AAS) Amputee Coalition of America (ACA) Community Workers for Amputees (CWA) National Amputee of America Society (NAAS)

b

Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Obtain the medical history from a client who is scheduled for a total hip replacement. Assess the client who is being admitted for an elective laparoscopic cholecystectomy.

b

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? "A callus is quickly deposited and transformed into bone." "A hematoma forms at the site of the fracture." "Calcium and vascular proliferation surround the fracture site." "Granulation tissue reabsorbs the hematoma and deposits new bone."

b. In stage 1, within 24 to 72 hours after a fracture, a hematoma forms at the site of the fracture because bone is extremely vascular. This then prompts the formation of fibrocartilage, providing the foundation for bone healing. Stage 2 of bone healing occurs within 3 days to 2 weeks after the fracture, when granulation tissue begins to invade the hematoma. Stage 3 of bone healing occurs as a result of vascular and cellular proliferation. In stage 4 of a healing fracture, callus is gradually reabsorbed and transformed into bone.

Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the health care provider? Thighs have multiple oozing abrasions. Serum potassium level is 7 mEq/L. The client is describing pain as level 4 (0-to-10 scale). Hemoglobin level is 12.0 g/dL.

b. The elevated potassium level may indicate that the client has rhabdomyolysis and acute tubular necrosis caused by the crush injury. Further assessment and treatment are needed immediately to prevent further kidney damage or cardiac dysrhythmias.

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit? Pain at the surgical site Requirement for verbal stimuli to awaken Snoring sounds when inhaling Sore throat on swallowing

c

A client who recently underwent total hip arthroplasty and is on anticoagulants is preparing for discharge from the hospital. Which information is most important for the nurse to provide to the client and caregiver? Use an abduction pillow between the legs. Keep heels off the bed. Avoid using a straight razor. Re-orient frequently.

c

At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? An allergy to iodine and shellfish Being nauseated after a previous surgery Having a small glass of juice at 7:00 a.m. Expressing anxiety about the surgery

c

Five RNs have been floated to the postanesthesia care unit for the day. A 16-year-old diabetic client has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the floating RN with which kind of experience to care for this new client? RN who usually works on the inpatient pediatric unit RN who provides education to diabetic clients in a clinic RN who has 5 years of experience in the delivery room RN who ordinarily works as a scrub nurse in the OR

c

The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? Age 59 years General anesthesia complications experienced by the client's brother Diet-controlled diabetes mellitus Ten pounds over the client's ideal body weight

c

The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50 beats/min. The client demonstrates flaccid paralysis below the level of injury. The client's chest moves very little with each respiration. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg.

c

The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? "I will take off my stockings one to three times a day for 30 minutes." "My stockings are too loose." "These stockings will prevent blood clots." "These stockings help promote blood flow."

c

The nurse is teaching a client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates a correct understanding of the nurse's instruction? "I can no longer become pregnant." "If I become pregnant, I cannot give birth." "I may still be able to get pregnant." "My children will be paralyzed."

c

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? Heart rate of 58 beats/min Pale, cool extremities Respiratory rate of 6 breaths/min Suppressed gag reflex

c

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Frequent ambulation Encouraging nutrition Regular turning and re-positioning Special pressure-relief devices

c

Why is it important to wear sterile gloves during a dressing change? They protect the client from infection. They protect the nurse from infection. They protect both the client and the nurse from infection. Their use prevents lawsuits.

c

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Insert a straight catheter. Help the client sit up. Loosen the client's clothing.

c. The client is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the client to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain.

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential

d

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? Hospital library Internet Provider's office National Spinal Cord Injury Association

d

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? Getting the client up in a chair Keeping the client in the Trendelenburg position Lifting the client in unison with other health care personnel Log rolling the client

d

A client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? "Simple fracture involves a break in the bone, with skin contusions." "Compound fracture does not extend through the skin." "Simple fracture is accompanied by damage to the blood vessels." "Compound fracture involves a break in the bone, with damage to the skin."

d

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? Use electric clippers to cut hair at the surgical site. Start an infusion of lactated Ringer's solution at 75 mL/hr. Administer one-half of the client's usual lispro insulin dose. Draw blood for glucose, electrolyte, and complete blood count values.

d

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? "Every injury is different, and it is too soon to have any real answers right now." "Only time will tell." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the health care provider."

d

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? Call the legal department to draft the paperwork. Document this in the chart. Thank the person and do nothing else. Talk to the client.

d

In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? Call admissions. Cancel the surgery. Contact the surgeon. Talk to the operating team.

d

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? "I will wake up with a tube in my throat." "I will have a bandage on my chest." "My family will not be able to see me right away." "Pain medication will take away my pain."

d

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? "Begin driving 1 week after discharge." "Avoid using a pillow under the head while sleeping." "Swimming is recommended to keep active." "Keep straws available for drinking fluids."

d

The nurse plans to refer a client diagnosed with osteoporosis to which community resource? American Bone Society CanSurmount I Can Cope National Osteoporosis Foundation

d

The nurse prepares to perform a neurovascular assessment on a client with closed multiple fractures of the right humerus. Which technique does the nurse use? Inspect the abdomen for tenderness and bowel sounds. Auscultate lung sounds. Assess the level of consciousness and ability to follow commands. Assess sensation of the right upper extremity.

d

Which is the best way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease? Increase nutritional intake of calcium. Engage in high-impact exercise, such as running. Increase nutritional intake of phosphorus. Walk for 30 minutes three times a week.

d

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

d