FLEX ON EM
A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse should monitor for which high-risk area for pressure and breakdown? 1.Right heel 2.Left heel 3.Scapulae 4.Back of the head
1
The nurse is planning to teach a client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan? 1."Use a sling on the left arm." 2."Lift the left arm up over the head." 3."Lift the right arm up over the head." 4."Make a fist with the hand of the casted arm."
2
A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? 1."I need to avoid getting the cast wet." 2."I will use my fingertips to lift and move the leg." 3."I need to cover the casted leg with warm blankets." 4."I can use a padded coat hanger end to scratch under the cast."
1
A client who has experienced a stroke (brain attack) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is no longer sufficient. Which device would suit the client better if greater support and stability is needed? 1.Quad cane 2.Wheelchair 3.Wooden crutch 4.Lofstrand crutch
1
A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. Which action should the nurse implement? 1.Administer an analgesic. 2.Immobilize the knee temporarily. 3.Notify the health care provider immediately. 4.Put the client's knee through full passive range of motion.
1
The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room? 1.Anesthesia consent 2.Consent for the procedure 3.Administration of an analgesic 4.Explanation of the procedure to the client
1
The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. 1.Keep the cast and extremity elevated. 2.The cast needs to be kept clean and dry. 3.Allow the wet cast 24 to 72 hours to dry. 4.Expect tingling and numbness in the extremity. 5.Use a hair dryer set on a warm to hot setting to dry the cast. 6.Use a soft padded object that will fit under the cast to scratch the skin under the cast.
123
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse should respond knowing that which can occur if the crutches rest underneath the arm? 1.A fall and further injury 2.Injury to the brachial plexus nerves 3.Skin breakdown in the area of the axilla 4.Impaired range of motion while the client ambulates
2
A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The nurse should take which action? 1.Administer an analgesic. 2.Notify the registered nurse. 3.Check the circulation again in 30 minutes. 4.Provide range-of-motion exercises to the fingers of the left hand.
2
A client with possible rib fracture has never had a chest x-ray. The nurse should plan to tell the client which statement about the procedure? 1."The x-ray stimulates a small amount of pain." 2."It is necessary to remove jewelry and any other metal objects." 3."The client will be asked to breathe in and out during the x-ray." 4."The x-ray technologist will stand next to the client during the x-ray."
2
The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client? 1.Calcium level of 9 mg/dL 2.Uric acid level of 8 mg/dL 3.Creatinine level of 1 mg/dL 4.Phosphorus level of 3 mg/dL
2
The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which in the care of the client? Select all that apply. 1.Ensure the client doesn't bend the hips beyond 120 degrees. 2.Ensure the client doesn't sit or stand for long periods of time. 3.Ensure the client engages in rigorous exercise to maintain strength. 4.Ensure the client doesn't cross the legs past the midline of the body. 5.Ensure the client uses assistive/adaptive devices with activities of daily living.
245
1.A short leg cast 2.A long leg cast 3.A hip spica cast 4.A body jacket cast
3
A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? 1.Using a footboard 2.Providing an overhead trapeze 3.Slightly elevating the foot of the bed 4.Slightly elevating the head of the bed
3
The nurse is providing care for the client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? 1.Elevating the limb for 24 hours 2.Monitoring vital signs every 4 hours 3.Administering intramuscular opioid analgesics 4.Monitoring the site for swelling, bleeding, hematoma
3
The nurse is talking to a client who underwent a below-the-knee amputation 2 days earlier. The client says to the nurse, "I hate looking at this; I feel that I'm not even myself anymore." The nurse understands that the client is experiencing which problem? 1.Self-care deficit 2.Ineffective coping 3.Disturbed body image 4.Ineffective health maintenance
3
The nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse should encourage the client to increase intake of which food? 1.Fish 2.Turkey 3.Cheese 4.Sweet potatoes
3
The nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which is a sign/symptom associated with this disorder? 1.Morning stiffness 2.Positive rheumatoid factor 3.An elevated sedimentation rate 4.Dull aching pain in the affected joints
4
A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. How should the nurse correctly respond to this question? 1.In 24 hours 2.In 48 hours 3.In approximately 8 hours 4.Within 20 to 30 minutes of application
4
A client has slight weakness in the right leg. Which type of mobility device would benefit the client the most? 1.Walker 2.Wooden crutch 3.Lofstrand crutch 4.Straight-leg cane
4
A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care? 1.Assist the client in keeping her legs as close together as possible. 2.Ensure the client receives her daily tablet of enoxaparin (Lovenox). 3.Remind the client to use a handrail if she is lowering her hips into a 120-degree flexion. 4.Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively.
4
A client is experiencing an acute exacerbation of bursitis. The nurse encourages the client to avoid which least likely helpful measure until the current episode is resolved? 1.Resting the joint 2.Applying moist heat 3.Elevation of the joint 4.Active intermittent range of motion
4
A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? 1.Telling the client that the saw makes a frightening noise 2.Reassuring the client that no one has had an arm lacerated yet 3.Stating that the hot cutting blades cause burns only very rarely 4.Showing the client the cast cutter and explaining how it works
4
A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. How should the nurse tell the client to provide greater reassurance? 1.Canes prevent falls, not cause them. 2.The physical therapist will determine if the cane is inadequate. 3.The cane would help to break a fall, even if the client does slip. 4.The cane has a flared tip with concentric rings to provide stability.
4
The nurse is caring for a client with osteoarthritis. The nurse monitors the client, knowing that which is a sign/symptom associated with the disorder? 1.An elevated platelet count 2.Symmetrical joint discomfort 3.Elevated antinuclear antibody levels 4.Pain that increases with activity and is relieved by rest
4
The nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which is a primary prevention measure? 1.Selecting shoes that have firm nonskid soles 2.Applying nonskid strips on areas that get wet 3.Installing telephones in several rooms of the house 4.Maintaining body weight at or above minimum recommended levels
4
The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? 1.Try to manually reduce the fracture. 2.Assist the person to get up and walk to the sidewalk. 3.Leave the person for a few moments to call an ambulance. 4.Stay with the person and encourage the person to remain still.
4
The nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which vitamin? 1.Vitamin A 2.Vitamin B 3.Vitamin C 4.Vitamin D
4
A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which to maintain client safety after this procedure? 1.Head of bed flat 2.Overhead trapeze 3.Pillows under the length of the legs 4.Logrolling technique for repositioning
2
The nurse is caring for a client with fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? 1.Elevating the limb and applying ice to the affected leg 2.Elevating the limb and covering the limb with bath blankets 3.Keeping the leg horizontal and applying ice to the affected leg 4.Placing the leg in a slightly dependent position and applying ice
1
The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? 1.Pork 2.Seafood 3.Sardines 4.Plain yogurt
1
The nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client makes which statement? 1."I will use a raised toilet seat." 2."I will bend carefully to put on socks and shoes." 3."I will sit in chairs without arms for better mobility." 4."I will exercise the leg past the point of 90-degree flexion."
1
The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury? 1.Leakage of clear fluid from the nose 2.Inability to breathe through one nare 3.Hematoma formation around the eyes 4.Edema noted around the nose and eyes
1
The nurse is caring for a client following total hip replacement who has a wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate? 1.Document the findings. 2.Place the leg in a flat position. 3.Check the client's blood pressure. 4.Immediately notify the health care provider.
1
The nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority assessment? 1.Calf pain 2.Heel breakdown 3.Bladder distention 4.Extremity shortening
1
The nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse should be especially concerned with which finding? 1.An oral temperature of 101° F orally 2.Complaints of discomfort during repositioning 3.Old bloody drainage outlined on the surgical dressing 4.Discomfort during coughing and deep breathing eercises
1
A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? 1.Allows bony healing to begin before surgery 2.Provides rigid immobilization of the fracture site 3.Lengthens the fractured leg to prevent severing of blood vessels 4.Provides comfort by reducing muscle spasms and provides fracture immobilization
4
A client has a newly fractured fibula that is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch-walking gait before discharge? 1.Two-point gait 2.Three-point gait 3.Swing-through gait 4.Four-point alternate gait
2
A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if which action is noted? 1.The client holds the walker using the handgrips. 2.The client advances the walker with reciprocal motion. 3.The client leans forward slightly when advancing the walker. 4.The client supports body weight on the hands while advancing the weaker leg.
2
A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which as a high-risk area for pressure and breakdown? 1.Scapulae 2.Left heel 3.Right heel 4.Back of the head
2
A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required if the client makes which statement? 1."I will soak the skin and then wash it gently." 2."I need to scrub the skin vigorously with soap and water." 3."I need to apply an emollient lotion to enhance softening." 4."I need to use a sunscreen on the skin if it will be directly exposed to the sun."
2
A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client? 1.Having another nurse tilt the client to the side 2.Asking the client to pull up on a trapeze to lift the hips off the bed 3.Pushing down on the mattress of the bed while administering care 4.Asking the client to lift up by digging into the mattress with the unaffected leg
2
A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? 1.Feelings of isolation 2.Inability to tolerate activity 3.Concerns about appearance 4.Inability to physically move about
3
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? 1.Infection under the cast 2.The anxiety of the client 3.Impaired tissue perfusion 4.The newness of the fracture
3
A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site? 1.Dry, sterile dressings 2.Hydrocolloid dressings 3.Moist, sterile saline dressings 4.Half-strength povidone-iodine (Betadine) dressings
3
A client is treated in the health care provider's office for a sprained ankle. Before sending the client home, the nurse plans to reinforce instructions to the client about which item to avoid in the next 24 hours? 1.Resting the foot 2.Application of an Ace wrap 3.Application of a heating pad 4.Elevating the ankle on a pillow while sitting or lying down
3
A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? 1.Giving pin care once a shift 2.Massaging the skin of the right leg with lotion every 8 hours 3.Inspecting the skin on the right leg at least once every 8 hours 4.Releasing the weights on the right leg for range-of-motion exercises daily
3
A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on performing which action? 1.Performing pin site care 2.Explaining to the client the upcoming pin care procedure 3.Ensuring that the weights on the traction setup are hanging free 4.Providing for diversion such as watching television or reading a newspaper
3
A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. How should the nurse interpret this injury? 1.Strain 2.Sprain 3.Fracture 4.Contusion
3
A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. How should the nurse answer this question for the client? 1.Every other hour for 60 minutes 2.For 30 minutes out of every hour 3.As much as tolerated while in bed 4.For 3 hours at a time, followed by 1 hour of rest
3
A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client? 1."There is no reason to be concerned. I have seen lots of these procedures." 2."Skeletal traction is much more effective than skin traction in your situation." 3."You have concerns about skeletal versus skin traction for your type of fracture?" 4."Your fracture is very unstable. You will die if you don't have this surgery performed."
3
A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes? 1.Pain 2.Hemorrhage 3.Edema of the stump 4.Separation of wound edges
4
A health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which to enhance compliance with therapy? 1.Decrease fluid intake. 2.Decrease dietary fiber. 3.Chew the tablet thoroughly. 4.Take the medication following a meal.
4
The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint? 1.Obtain a walker to minimize weight bearing by the client on the affected leg. 2.Apply an Ace wrap around the dressing and put ice on the knee while sitting. 3.Lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. 4.Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting.
4
This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's symptoms are indicative of which complication? 1.Fat embolism 2.Venous thrombosis 3.Volkmann's thrombosis 4.Compartment syndrome
4
An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the priority relates to addressing which client problem? 1.Risk for constipation 2.Impaired tissue integrity 3.Risk for activity intolerance 4.Disturbed thought processes
1
The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by performing which action? 1.Monitoring for signs of dyspnea 2.Monitoring the client's temperature regularly 3.Maintaining external rotation of the right leg 4.Educating the client to report paresthesia of the right lower leg
1
A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm? 1.Heat 2.Cold 3.Analgesics 4.Prescribed intermittent traction
2
The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? 1.The brace should be applied directly next to the skin. 2.The device is applied before getting out of bed in the morning. 3.The Velcro closures should be fairly loose to avoid constriction. 4.Areas of skin redness at the edges of the brace indicate a good, snug fit.
2
A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? 1."It is a normal response and indicates the presence of phantom limb pain." 2."It is a normal response and indicates the presence of phantom limb sensation." 3."It is an abnormal response and indicates that the client is in denial about the limb loss." 4."It is an abnormal response and indicates that the client needs more psychological support."
2
A client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse should anticipate which observation on inspection of the client's leg? 1.Shortening, abduction, and internal rotation 2.Shortening, adduction, and external rotation 3.Lengthening, abduction, and internal rotation 4.Lengthening, adduction, and external rotation
2
A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated with which action? 1.Applying heat 2.Bending or lifting 3.Maintaining bed rest 4.Taking Ibuprofen (Motrin IB)
2
A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? 1.The cast will be bivalved. 2.A window will be cut in the cast. 3.The cast will be replaced with an air splint. 4.Extra padding will be put over this area of the cast.
2
A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? 1.Massaging the skin at the rim of the cast 2.Petaling the cast edges with adhesive tape 3.Using a rough file to smooth the cast edges 4.Applying lotion to the skin at the rim of the cast
2
A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs should best be addressed by referral to which service? 1.Surgeon 2.Social worker 3.Physical therapist 4.Clinical nurse specialist
2
During admission data collection, the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area? 1.Sensation and reflexes 2.Balance and coordination 3.Bowel and bladder control 4.Muscle strength and flexibility
2
The nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome? 1.Cold, bluish fingers 2.Numbness and tingling in the fingers 3.Pain that increases when the arm is dependent 4.Pain that is relieved only by an opioid analgesic
2
The nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client's casted extremity for which reason? 1.The skin under the cast is at high risk for infection. 2.Compartment syndrome may lead to irreversible nerve and muscle tissue injury. 3.Alterations in the neurovascular status of the fingers may be early signs of fat embolism. 4.The client is at high risk of neurovascular compromise until the cast is completely dry.
2
The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate? 1.Contact the health care provider. 2.Petal the cast edges with adhesive tape. 3.Massage the skin at the edges of the cast. 4.Place a small face cloth in the cast around the edges of the cast.
2
The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome? 1.A bone fragment has injured the nerve supply in the area. 2.Bleeding and swelling cause increased pressure in an area that cannot expand. 3.An injured artery causes impaired arterial perfusion through the compartment. 4.The fascia expands with injury, causing pressure on underlying nerves and muscles.
2
The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? 1.Holds the cane on the right side 2.Moves the cane when the right leg is moved 3.Leans on the cane when the right leg swings through 4.Keeps the cane 6 inches out to the side of the right foot
2
The nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse could place the client at increased risk for disturbed thought processes? 1.Relatives at the bedside 2.Eyeglasses left at home 3.Familiar hospital setting 4.Hearing aid available and in working order
2
The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? 1. 3 inches to the front and side of the client's toes 2. 8 inches to the front and side of the client's toes 3. 15 inches to the front and side of the client's toes 4. 20 inches to the front and side of the client's toes
2
The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? 1.Trochanter roll to prevent abduction while turning 2.Pillow to keep the right leg abducted during turning 3.Pillow to keep the right leg adducted during turning 4.Trochanter roll to prevent external rotation while turning
2
A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which? 1.Pressure on the spinal cord 2.Pressure on the spinal nerve root 3.Muscle spasm in the area of the herniated disk 4.Excess cerebrospinal fluid production in the area
3
A postoperative client received a spinal anesthetic. The client has not experienced pain because the anesthetic has not yet worn off. The nurse will monitor the client closely for pain and provide the client with which instruction? 1."I will be bringing your pain medication at 10:00 pm." 2."You will not feel pain because of the spinal anesthesia." 3."You will need to let me know when you start to get feeling back in your legs." 4."You will not be able to take pain medication until you have been up to the bathroom."
3
The nurse is caring for a client with a diagnosis of osteoarthritis. Which would be least helpful for the client? 1.Gentle regular exercise 2.A warm bath or shower early in the day 3.Increasingly vigorous and high-impact exercise 4.An individualized program of pain medication administration
3
The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first? 1.Provide pin care. 2.Call the health care provider (HCP). 3.Check the client's alignment in bed. 4.Medicate the client with an analgesic.
3
The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next? 1.Provide pin care. 2.Medicate the client. 3.Notify the registered nurse. 4.Remove 2 pounds of weight from the traction.
3
The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? 1.Dependent edema 2.Diminished distal pulse 3.Presence of a "hot spot" on the cast 4.Coolness and pallor of the extremity
3
The nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle crash. The nurse reviews the health care provider's (HCP) prescriptions and notes that the HCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure. 1 2 3 4
3
The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints? 1.Footboards 2.Large pillows 3.Small pillows 4.Soft mattress
3
The nurse reinforces cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further teaching if the client makes which statement about the casting? 1.The cast will give off heat as it dries. 2.The cast edges may be trimmed with a cast knife. 3.The client may bear weight on the cast in 30 minutes. 4.A stockinette will be placed over the leg area to be casted.
3
The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? 1.Take a set of vital signs. 2.Call the radiology department. 3.Immobilize the leg before moving the client. 4.Reassure the client that everything will be fine.
3
The nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed in which position? 1.Flat with the knee gatch raised 2.In semi-Fowler's position with the foot of the bed flat 3.In high-Fowler's position with the foot of the bed flat 4.In semi-Fowler's position with the knee gatch slightly raised
4
The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement? 1."I'm doing this, so I can go home soon." 2."It hurts, but things always have to hurt at my age." 3."If I don't do this, that therapist gets really angry at me." 4."I'm doing these exercises so I can begin to fasten my buttons and dress myself again."
4
The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? 1.Pulling up on the trapeze 2.Flexing and extending the feet 3.Doing quadriceps-setting and gluteal-setting exercises 4.Performing active range of motion (ROM) to the right ankle and knee
4
The nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further teaching if the client makes which statement? 1."I should avoid walking on wet, slippery floors." 2."I'm not supposed to scratch the skin underneath the cast." 3."It's all right to wipe dirt off the top of the cast with a damp cloth." 4."If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."
4
The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? 1.Keep the leg in a level position. 2.Elevate the leg for 3 hours, and put it flat for 1 hour. 3.Keep the leg level for 3 hours, and elevate it for 1 hour. 4.Elevate the leg on pillows continuously for 24 to 48 hours.
4
The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones? 1.Shoulder and humerus 2.Bones of the hands and feet 3.Anterior rib cage and sternum 4.Axial skeleton including the vertebrae
4
The nurse is caring for a client diagnosed with Paget's disease. The nurse understands that this condition usually affects which bones? 1.Shoulder and humerus 2.Bones of hands and feet 3.Anterior rib cage and sternum 4.Axial skeleton including vertebrae
4
The nurse is caring for a client who had a below-the-knee amputation of the right leg. A cast that was placed on the residual limb has fallen off. Which action should the nurse take immediately? 1.Contact the surgeon. 2.Document the findings. 3.Replace the cast with a new one. 4.Wrap the residual limb with an elastic compression bandage.
4
The nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse should immediately perform which action? 1.Applies ice to the site 2.Calls the health care provider 3.Applies a dry sterile dressing and elevates it on one pillow 4.Rewraps the residual limb with an elastic compression bandage
4
The nurse is caring for a client who has just had rotator cuff repair. The client asks the nurse how soon he can resume his tai chi classes. The nurse should make which statement to the client? 1."You will never be able to do tai chi again!" 2."Tai chi is good for you, so you can start any time." 3."Tai chi uses only your leg muscles, so it would be all right." 4."You shouldn't be doing any exercises that require the use of your upper arms until you have been cleared to do so by the health care provider."
4
The nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the nurse's initial action? 1.Reassess the vital signs. 2.Perform a neurological assessment. 3.Place the client in a supine position. 4.Place the client in a Fowler's position.
4
The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action? 1.Elevate the casted leg. 2.Contact the health care provider. 3.Administer another dose of pain medication. 4.Check the neurovascular status of the toes on the casted leg.
4
The nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which nursing intervention should be included in the plan of care to assist the client with positioning in bed? 1.Use the assistance of four nurses to reposition the client. 2.Place a draw sheet under the client for pulling the client up in bed. 3.Encourage the client to pull up by pushing with the unaffected leg on the bed mattress. 4.Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.
4
The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data would be included? 1.The client's fear related to the use of the crutches 2.The client's feelings about the restricted mobility 3.The client's understanding of the need for increased mobility 4.The client's vital signs, muscle strength, and previous activity level
4
The nurse is reinforcing discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the need for further teaching? 1."I need to report bleeding gums or tarry stools." 2."I need to report fever, redness, or increased pain." 3."I need to tell my other doctors about the metal implant." 4."I don't need to be worried if the shape of my knee changes."
4
The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching? 1."I should elevate my arm to reduce the swelling." 2."I should use a sling to limit movement and keep my arm elevated." 3."I should return to the health care provider in about 10 days to have the sutures removed." 4."I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."
4
