Exam 2

The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) -Decreased sensory function -Excruciating pain -Loss of motion -Capillary refill less than 3 seconds -2+ peripheral pulses in the affected distal pulse

-Decreased sensory function -Excruciating pain -Loss of motion

assessment of nuerovascular changes

-Pain -Poikilothermia (takes on ambient temperature) -Pallor -Pulselessness -Paresthesia - Paralysis

Mickey, a 6-year-old child with a congenital heart disorder is admitted with congestive heart failure. Digoxin (lanoxin) 0.12 mg is ordered for the child. The bottle of Lanoxin contains .05 mg of Lanoxin in 1 ml of solution. What amount should the nurse administer to the child?

2.4mL

Mario has burn injury. After 48 hours, the physician orders for Mario 2 liters of IV fluid to be administered q12 h. The drop factor of the tubing is 10 gtt/ml. The nurse should set the flow to provide

28 gtt/min

A nurse is caring for a patient whose cancer metastasis has resulted in bone pain. Which of the following are typical characteristics of bone pain? A) A dull, deep ache that is boring in nature B) Soreness or aching that may include cramping C) Sharp, piercing pain that is relieved by immobilization D) Spastic or sharp pain that radiates

A dull, deep ache that is boring in nature

Which assessment findings indicate to the nurse that a client may have peripheral neurovascular dysfunction? Select all that apply.

Absence of feeling Weakness in motion Capillary refill of 4 to 5 seconds Cool skin Pain

A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis?

Absence of feeling, capillary refill of 4 to 5 seconds and cool skin

The nurse is providing care to a client following a knee arthroscopy. Which of the following would the nurse expect to include in the client's plan of care?

Administering the prescribed analgesic

Which of the following patients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A) A middle-age adult who takes ibuprofen daily for rheumatoid arthritis B) An elderly patient with an infected pressure ulcer in the sacral area C) A 17-year-old football player who had orthopedic surgery 6 weeks prior D) An infant diagnosed with jaundice

An elderly patient with an infected pressure ulcer in the sacral area

A client has undergone arthroscopy. After the procedure, the site where the arthroscope was inserted is covered with a bulky dressing. The client's entire leg is also elevated without flexing the knee. What is the appropriate nursing intervention required in caring for a client who has undergone arthroscopy?

Apply a cold pack at the insertion site

A bone biopsy has just been completed on a patient with suspected bone metastases. What assessment should the nurse prioritize in the immediate recovery period? A) Assessment for dehiscence at the biopsy site B) Assessment for pain C) Assessment for hematoma formation D) Assessment for infection

Assessment for pain

Cleo is diagnosed with osteoporosis. Which electrolytes are involved in the development of this disorder?

Calcium and phosphorus

Which nursing assessment finding would be indicative of compartment syndrome in the client with a cast applied to the left forearm 3 hours earlier?

Capillary refill of left fingers greater than 3 seconds

Which of the following is an indicator of neurovascular compromise?a) Warm skin temperature b) Pain on active stretch c) Capillary refill of more than 3 seconds d) Diminished pain

Capillary refill of more than 3 seconds

The nurse recognizes what groups of people are at an increased risk for infection? Select all that apply

Clients with impaired skin Older adults Debilitated clients

The nurse is performing an assessment of a patient's musculoskeletal system and is appraising the patient's bone integrity. What action should the nurse perform during this phase of assessment? A) Compare parts of the body symmetrically. B) Assess extremities when in motion rather than at rest. C) Percuss as many joints as are accessible. D) Administer analgesia 30 to 60 minutes before assessment.

Compare parts of the body symmetrically.

A nurse is performing a musculoskeletal assessment of a patient with arthritis. During the passive range of motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of which of the following?

Crepitus

Document this an expected assessment finding (normal drainage of 200 to 500mL in the first 24 hrs is expected)

Document this an expected assessment finding (normal drainage of 200 to 500mL in the first 24 hrs is expected)

The nurse is performing a neurovascular assessment of a client's injured extremity. Which of the following would the nurse report?

Dusky or mottled skin color

A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurse's choice of interventions?

Improving the patient's level of function

The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend?

Isometric

The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?

It will be alright for your friends to sign your cast

An older adult patient has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the patient's spine. The nurse should document the presence of which of the following? A) Scoliosis B) Epiphyses C) Lordosis D) Kyphosis

Kyphosis

The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? A) Osteoporosis B) Kyphosis C) Lordosis D) Scoliosis

Lordosis

A patient is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results is most suggestive of this diagnosis? A) High chloride, calcium, and magnesium B) High parathyroid and calcitonin levels C) Low serum calcium and magnesium levels D) Low serum calcium and low phosphorus level

Low serum calcium and low phosphorus level

A client has undergone bone biopsy. Which nursing action should the nurse provide after the procedure?

Monitor the site for bleeding, swelling and hematoma formation

The nurse is performing an assessment for a patient who may have peripheral neurovascular dysfunction. What signs does the patient present with that indicate circulation is impaired? (Select all that apply.)

Pale, cyanotic, or mottled color Cool temperature of the extremity More than 3-second capillary refill

A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge?Patient is able to perform transfers safely.

Patient is able to perform transfers safely

A patient presents to a clinic complaining of a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what? A) Staphylococcus aureus B) Proteus C) Pseudomonas D) Escherichia coli

Staphylococcus aureus

A patient stepped on an acorn while walking barefoot in the backyard and developed an infection progressing to osteomyelitis. What microorganism does the nurse understand is most likely the cause?

Staphylococcus aureus

A 59-years old patient with lung cancer and metastases to the bone is in the hospital for pain management. The patient rates the pain 10 on a scale of 0(no pain) to 10 (severe pain). The BEST goal for the nurse diagnosis of alteration is comfort is that the patient will?

State that all pain is relieved

A nurse is caring for a patient receiving skeletal traction. Due to the patient's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A) Perform chest physiotherapy once per shift and as needed. B) Teach the patient to perform deep breathing and coughing exercises. C) Administer prophylactic antibiotics as ordered. D) Administer nebulized bronchodilators and corticosteroids as ordered.

Teach the patient to perform deep breathing and coughing exercises.

When a hospitalized patient is in contact precautions, which of the following responses is necessary? a) The patient should be in a room with negative air pressure. b) Masks are worn when caring for the patient. c) The patient should be placed in a private room when possible. d) The patient's door should be closed.

The patient should be placed in a private room when possible.

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

Thick yellow drainage from the pin sites

The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion.

White blood cell count

An older client's serum calcium level is 8.7 mg/dL. What possible etiologies does the nurse consider for this result? (Select all that apply.) a. Good dietary intake of calcium and vitamin D b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteomalacia d. Potential for metastatic cancer or Paget's disease e. Recent bone fracture in a healing stage

b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteomalacia

To reduce the risk of treatment methicillin resistant staphylococcus aureus from an infectious wound which of the following standard precautions should be implemented?

contact

The client immobilized skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse formulates which of the following nursing diagnoses for this client?

diversional activity deficit

A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication?

fever

Which assessment finding would cause the nurse to suspect compartment syndrome in the client following a bone biopsy?

increased diameter of the calf

The nurse is required to manage and minimize sepsis in a patient with severe infection. Which of the following would be an appropriate nursing intervention? a) Limit the patient's food intake b) Limit the patient's fluid intake c) Monitor the patient's vital signs d) Encourage the patient to perform mild activity

monitor the patient's vital signs

A client with an abdominal cholecystectomy returns from surgery with a Jackson-Pratt drain. The chief purpose of the Jackson-Pratt drain is to:

provide for wound drainage

A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient's care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses? A) Risk for Impaired Skin Integrity B) Risk for Falls C) Risk for Imbalanced Fluid Volume D) Risk for Aspiration

risk for impaired skin integrity

A nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the management of activity and mobility in this patient? A) Stress on the weakened bone must be avoided. B) Increased heart rate enhances perfusion and bone healing. C) Bed rest results in improved outcomes in patients with osteomyelitis. D) Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

stress on the weakened bone must be avoided

A 16-year-old patient is seen in the emergency room for a knee injury that happened during a basketball game. Diagnostic tests reveal torn cords of fibrous connective tissue that connect muscles to bones. The nurse knows that the patient had sustained a tear of the?

tendon

A client experiences a musculoskeletal injury that involves the structure that connects a muscle to the bone. The nurse understands that this injury involves which of the following?

tendon

what is disease?

the infected host displays a decline in wellness caused by the infection

A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care? A) Apply occlusive dressings to the pin sites. B) Encourage the patient to push up with the elbows when repositioning. C) Encourage the patient to perform isometric exercises once a shift. D) Assess the pin insertion site every 8 hours.

assess the pin insertion site every 8 hours

A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?

high seat commode

A client has undergone an external fixation. Which actions would be the priority for this client? -Maintaining pin care. -Planning the client's diet. -Monitoring the client's urine output -Monitoring the client's blood pressure.

maintaining pin care

What is colonization?

multiplication of a microorganism after it has attached to host tissues or other surfaces

Which nursing intervention is appropriate for a client with skeletal traction?

pin care

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client? A. A room with air exhaust directly to the outdoor environment B. A room with another non surgical client C. A room in the ICU D. A room that is within view of the nurses' station

A room with air exhaust directly to the outdoor environment

The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. The nurse should question the patient about her intake of what nutrients? Select all that apply. A) Calcium B) Simple carbohydrates C) Vitamin D D) Protein E) Soluble fiber

A) Calcium C) Vitamin D

A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply. A) Preve nting additional injury B) Immobilizing prior to surgery C) Providing support D) Controlling movement E) Promoting bone remodeling

A) Preventing additional injury C) Providing support D) Controlling movement

A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?

autologous blood donation

Which of the following are methods to reduce the risk of needlestick injury? (Select all that apply.) a.Recap the needle after giving an injection. b.Have sharps boxes emptied when three-quarters full. c.Use two hands to dispose of sharps into the disposal. d.Never force a needle into the sharps disposal. e.Clearly mark sharps disposal containers. f.Use needleless devices whenever possible.

b.Have sharps boxes emptied when three-quarters full. d.Never force a needle into the sharps disposal. e.Clearly mark sharps disposal containers. f.Use needleless devices whenever possible.

Which assessment finding indicates circulatory constriction in a male client with a newly applied long leg cast?

blanching or cyanosis

Nurse Michelle is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication

bone fracture

A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrients? Select all that apply. A) Vitamin B12 B) Potassium C) Calcitonin D) Calcium E) Vitamin D

calcium vitamin D

Which of the following terms refers to a state of microorganisms being present within a host without causing host interference or interaction? a) Infection b) Susceptible c) Colonization d) Immune

colonization

what is infection?

indicates host interaction with the organism

The nurse is caring for a client who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting?

Performing hand hygiene before and after contact with every client

A client with a sports injury undergoes a diagnostic arthroscopy of the left knee. Which of the following comments by the client following the procedure should the nurse address first?

Wrap the joint in compression dressing

A client is suspected of sepsis from a postsurgical incision infection. What characteristic of sepsis would the nurse recognize? Select all that apply. a) Temperature of 102°F b) Heart rate of 120 beats/minute c) Blood pressure of 120/80 mm Hg d) Respiratory rate of 24 breaths/minute e) PaCO2 of 42 mm Hg

a) Temperature of 102°F b) Heart rate of 120 beats/minute d) Respiratory rate of 24 breaths/minute

A nurse is performing a nursing assessment of a patient suspected of having a musculoskeletal disorder. What is the primary focus of the nursing assessment with a patient who has a musculoskeletal disorder? A) Range of motion B) Activities of daily living C) Gait D) Strength

activities of daily living

A patient is admitted for pain management due to lung cancer with metastasis of the bone. With a nursing diagnosis of alteration in comfort, the nurse would anticipate the best shot-term goal for this patient would be to?

not complain of pain

A nurse is caring for a patient who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the patient faces a high risk of what infectious complication?

osteomyleitis

A nurse's assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patient's electronic health record? A) Lordosis B) Kyphosis C) Scoliosis D) Muscular dystrophy

scoliosis