Med Surg test 5

A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding?

Document this as an expected assessment finding.

The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient?

During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to.

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment?

When assisting with the resuscitation

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?

Notify the physician and continue to monitor the hourly urine output closely

A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have aperoneal nerve injury?

Numbness and burning of the foot

A nurse is providing discharge teaching for a patient who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend?

Patients general condition, balance, and weight-bearing prescription

A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis?

Perform meticulous foot care.

A nurse is providing a class on osteoporosis at the local seniors center. Which of the following statements related to osteoporosis is most accurate?

Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis.

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe?

Small frame, female gender, and Caucasian ethnicity

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply.

Stable blood pressure Sufficient oxygen saturation Adequate respiratory function

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?

Stand upright for 2 to 3 minutes prior to ambulating.

A patient presents to a clinic complaining of a leg ulcer that isnt healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what?

Staphylococcus aureus

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?

Sterile surfaces or articles may touch other sterile surfaces.

The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient?

Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

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?

Stress on the weakened bone must be avoided.

A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patients safety?

What prescription and nonprescription medications do you currently take?

A 77-year-old mans coronary artery bypass graft has been successful and discharge planning is underway. When planning the patients subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time?

When a follow-up evaluation in the clinical or home setting is done

Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?

1 foot

The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP?

Actions aimed at preventing surgical site infections

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient?

Adequate respiratory function

The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given on call to OR. When would be the best time to give this medication?

After being notified by the OR and before other preoperative preparations

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient?

Airway patency

The nurse is performing a preoperative assessment on a patient going to surgery. The patient informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties can the nurse anticipate for this patient?

Alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink

Which of the following patients should the nurse recognize as being at the highest risk for the development of osteomyelitis?

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

A nurse is caring for a patient with Pagets disease and is reviewing the patients most recent laboratory values. Which of the following values is most characteristic of Pagets disease?

An elevated serum alkaline phosphatase level and a normal serum calcium level

The OR will be caring for a patient who will receive a transsacral block. For what patient would the use of a transsacral block be appropriate for pain control?

An older adult man who will undergo an inguinal hernia repair

The patients surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication?

Anaphylaxis

The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery?

Anesthesia awareness

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next?

Assess the patients oxygen levels.

A nurse is caring for an adult patient diagnosed with a back strain. What health education should the nurse provide to this patient?

Avoid lifting more than one-third of body weight without assistance.

A nurse is reviewing a patients activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?

Bending down to put on socks

An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis?

Bone fracture

A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?

Bucks extension traction

A patient is scheduled for surgery the next day and the different phases of the patients surgical experience will require input from members of numerous health disciplines. How should the patients care best be coordinated?

By implementing an interdisciplinary approach to care

As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy?

By maintaining each of your patients privacy

A nurse is reviewing the pathophysiology that may underlie a patients decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?

Calcitonin

A patient tells the nurse that he has pain and numbness to his thumb, first finger, and second finger of the right hand. The nurse discovers that the patient is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the patient could possibly have what health problem?

Carpel tunnel syndrome

A nurse is caring for a patient who is being assessed following complaints of severe and persistent low back pain. The patient is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? that apply.

Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasound X-ray

A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse recognizes that the patient has likely sustained what?

Contusion

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident?

Day 5

The nurse is packing a patients abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patients abdomen 2 inches (5 cm) away from the wound. What should the nurse do?v

Discard the gauze packing and repack the wound with new Iodoform gauze.

While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patients weight. How should the nurse best respond?

Discourage the colleague from making such comments.

A patient presents at the clinic with complaints of morning numbness, cramping, and stiffness in his fourth and fifth fingers. What disease process should the nurse suspect?

Dupuytrens disease

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurses preoperative assessment of an elderly patient?

Elderly patients have less physiologic reserve than younger patients.

A nurse is caring for a patient who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure will the nurse implement to control the edema?

Elevate the foot on several pillows.

A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient may require blood transfusion during surgery. How can the nurse best ensure the patients safety if a blood transfusion is required?

Ensure that the patient has had a current cross-match.

A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patients affected limb are spastic. How does this change in muscle tone affect the patients traction prescription?

Extra weight is needed initially to keep the limb in proper alignment.

The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patients ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data?

Facilitate a detailed analysis of the patients electrolyte levels.

A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication?

Fat embolism syndrome

The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication?

Flash pulmonary edema

A patient presents at a clinic complaining of pain in his heel so bad that it inhibits his ability to walk. The patient is subsequently diagnosed with plantar fasciitis. This patients plan of care should include what intervention?

Gently stretching the foot and the Achilles tendon

A 20 year-old is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The patient has an open fracture of his tibia. The wound is highly contaminated and there is extensive soft-tissue damage. How would this patients fracture likely be graded?

Grade III

Radiographs of a boys upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture?

Greenstick

The nurse is planning the care of a patient who has type 1 diabetes and who will be undergoing knee replacement surgery. This patients care plan should reflect an increased risk of what postsurgical complications? Select all that apply.

Hypoglycemia Acidosis Glucosuria

An older adult womans current medication regimen includes alendronate (Fosamax). What outcome would indicate successful therapy?

Increased bone mass

A nurse is emptying an orthopedic surgery patients closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurses best action?

Inform the surgeon of this finding.

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patients accompanying documentation includes which of the following?

Informed consent

You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information?

Instruct the patient to stop taking St. Johns wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents.

A nurse is caring for a patient who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention?

Intermittent application of heat to the patients back

An older adult patient experienced a fall and required treatment for a fractured hip on the orthopedic unit. Which of the following are contributory factors to the incidence of falls and fractured hips among the older adult population? Select all that apply.

Loss of visual acuity Adverse medication effects Slowed reflexes Muscle weakness

A patient is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results is most suggestive of this diagnosis?

Low serum calcium and low phosphorus level

An OR nurse will be participating in the intraoperative phase of a patients kidney transplant. What action will the nurse prioritize in this aspect of nursing care?

Monitoring the patients physiologic status

A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication?

Obstructed arterial blood flow to the forearm and hand

During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?

Offer the patient a bedpan or urinal.

The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following?

Palliative

The nurse is caring for a patient who is scheduled to have a needle biopsy of the pleura. The patient has had a consultation with the anesthesiologist and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest?

Paravertebral block

A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge?

Patient can demonstrate safe use of assistive devices.

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.

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital- based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructors best response?

Patients admitted to the hospital for surgery usually have multiple health needs.

The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is this nurse solely responsible?

Performing documentation

Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture?

Place a pillow between the patients legs when turning.

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?

Place saline-soaked sterile dressings on the wound

A patient is on call to the OR for an aortobifemoral bypass and the nurse administers the ordered preoperative medication. After administering a preoperative medication to the patient, what should the nurse do?

Place the bed in a low position with the side rails up.

A 25-year-old man is involved in a motorcycle accident and injures his arm. The physician diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this patient. What sequela of intra-articular fractures should the nurse describe regarding this patient?

Post-traumatic arthritis

The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis?

Protect the affected leg from internal rotation.

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply.

Provide all discharge instructions in writing. Provide the nurses or surgeons contact information. Give prescriptions to the patient.

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?

Pulmonary embolism

A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session?

Reporting signs of impaired circulation

The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?

Restrain the patient.

A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patients care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?

Risk for Impaired Skin Integrity

A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius?

Risk for Infection

While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?

Risk for Peripheral Neurovascular Dysfunction

A patient presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

Sciatica

A 32-year-old patient comes to the clinic complaining of shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons and the patient is diagnosed with impingement syndrome. What action should the nurse recommend in order to promote healing?

Support the affected arm on pillows at night.

The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia?

The patient must never be left unattended by the nurse.

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital?

The patient should not drive herself home.

A nurse is assessing a patient who is receiving traction. The nurses assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding?v

The patients tibial nerve is functional.

The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patients signature on a consent form. Which comment by the patient would best indicate informed consent?

The physician is going to remove my uterus and told me about the risk of bleeding.

The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement?

Use a tone that decreases the patients anxiety.

The nurse is helping to set up Bucks traction on an orthopedic patient. How often should the nurse assess circulation to the affected leg?

Within 30 minutes, then every 1 to 2 hours

A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurses best action?

Assess the surgical site and the affected extremity.

A nurse is assessing a patient who reports a throbbing, burning sensation in the right foot. The patient states that the pain is worst during the day but notes that the pain is relieved with rest. The nurse should recognize the signs and symptoms of what health problem?

Mortons neuroma

An elderly patients hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurses priority assessment?

Signs of neurovascular compromise

The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit?

Close monitoring of neurologic status

A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication?

Compartment syndrome

A nurse admits a patient who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse is aware that this description likely indicates which type of fracture?

Compound

When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply.

Disturbed sensory perception related to anesthetic Risk of latex allergy response related to surgical exposure Anxiety related to surgical concerns

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what?

Hemorrhage and shock

The surgical nurse is preparing to send a patient from the presurgical area to the OR and is reviewing the patients informed consent form. What are the criteria for legally valid informed consent? Select all that apply.

Consent must be freely given. Consent must be obtained by a physician. Signature must be witnessed by a professional staff member.

A patient has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care?

Constipation Related to Vertebral Fracture

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what?

A clear understanding of the need to self-dose

A nurses assessment of a patients knee reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran 10 miles and now it really hurts to stand up. The nurse should plan care based on the belief that the patient has experienced what?

A second-degree strain

The surgical nurse is admitting a patient from postanesthetic recovery following the patients below-the- knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and shouldkeep which of the following at the bedside?

A tourniquet

An intraoperative nurse is applying interventions that will address surgical patients risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.

A) Absence of reflexes B) Diminished ability to communicate C) Loss of pain sensation

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia?

A 74-year-old woman with a low body mass index

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?

Assess the pin insertion site every 8 hours.

A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention?

Application of a cast

A patient has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurses initial postsurgical assessment were unremarkable but the patient has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurses initial action?

Apply a tourniquet

A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action?

Applying a cold pack to the injured site

A nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following? Select all that apply.

Applying ice Compression dressings Resting the affected extremity Elevating the injured limb

A young patient is being treated for a femoral fracture suffered in a snowboarding accident. The nurses most recent assessment reveals that the patient is uncharacteristically confused. What diagnostic test should be performed on this patient?

Arterial blood gases

The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session.

As soon as possible before the surgical procedure

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk?

Atelectasis

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

An older adult patient has fallen in her home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the patients presurgical care, the nurse should be aware of the patients heightened risk of what complication?

Avascular necrosis

An emergency department patient is diagnosed with a hip dislocation. The patients family is relieved that the patient has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurses statement?

Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved.

A patient has presented to the emergency department with an injury to the wrist. The patient is diagnosed with a third-degree strain. Why would the physician order an x-ray of the wrist?

Avulsion fractures are associated with third-degree strains.

The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction?

Balanced traction allows for greater patient movement and independence than other forms of traction.

A nurse is reviewing the care of a patient who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug?

Cyclobenzaprine

A patient has been admitted to the medical unit for the treatment of Pagets disease. When reviewing the medication administration record, the nurse should anticipate what medications? Select all that apply.

Calcitonin Bisphosphonates

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.

Calcium Vitamin D

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take?

Call the physician to review the procedure with the patient.

A nurse is teaching a patient with osteomalacia about the role of diet. What would be the best choice for breakfast for a patient with osteomalacia?

Cereal with milk, a scrambled egg, and grapefruit

A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply?

Clearly explain any information that the patient seeks.

A patient has sustained a long bone fracture and the nurse is preparing the patients care plan. Which of the following should the nurse include in the care plan?

Monitor temperature and pulses of the affected extremity.

A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply.

Deep vein thrombosis Compartment syndrome Fat embolism

The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response?

Dehydration is a contributory factor to the formation of deep vein thrombi.

A patient has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery?

Delayed wound healing

A patients electronic health record notes that the patient has hallux valgus. What signs and symptoms would the nurse expect this patient to manifest?

Deviation of a great toe laterally

A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patients postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care?

Disturbed Body Image

40. The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication?

Encourage early ambulation.

A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?

Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists.

The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?

Encourage the patient to use the incentive spirometer every 2 hours.

A patient is being treated for a fractured hip and the nurse is aware of the need to implement interventions to prevent muscle wasting and other complications of immobility. What intervention best addresses the patients need for exercise?

Encouraging frequent use of the overbed trapeze

A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals?

Encouraging the patient to turn from side to side and to assume a prone position

A patient with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the patient to do?

Engage in exercises that strengthen the unaffected muscles.

The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia?

Ensure that IV fluids are warmed to the patients body temperature.

A nurse is planning the care of an older adult patient with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?

Ensuring adequate exposure to sunlight

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply.

Establishing an IV line Verifying the surgical site with the patient Taking measures to ensure the patients comfort

Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative care in this collaborative manner?

Evidence-based practice

The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patients room and finds him resting in bed with his residual limb supported on pillow. What is the nurses most appropriate action?

Explain the risks of flexion contracture to the patient.

The orthopedic nurse should assess for signs and symptoms of Volkmanns contracture if a patient has fractured which of the following bones?

Humerus

The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patients care, the nurse should address the consequences of the patients aging cardiovascular system. These include an increased risk of which of the following?

Hypervolemia

You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient?

Hypostatic pulmonary congestion

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply.

Hypotension Dysrhythmias Hypertension

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient?

Hypothermia

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs?

Hypovolemic shock

The intraoperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication?

Hypoxia

A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patients statements would indicate to the nurse that the patient requires further teaching?

I will need my husband to assist me in getting off the low toilet seat at home.

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?

Ill eat plenty of fruits and vegetables.

A nurse is providing care for a patient who has a recent diagnosis of Pagets disease. When planning this patients nursing care, interventions should address what nursing diagnoses? Select all that apply.

Impaired Physical Mobility Acute pain disturbed auditory sensory perception risk for injury

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

Improving the patients level of function

A patient has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication?

Inadequate immobilization

As an intraoperative nurse, you know that the patients emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patients ability to influence outcome?

Incorporate cultural and religious considerations, as appropriate.

A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture?

Increase fluid intake and perform prescribed foot exercises.

The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patients lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

Increased warmth of the calf

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patients medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?

Infection

The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patients age and increased body mass index mean that she is at increased risk for what complication in the postoperative period?

Infection

A nurse is discussing conservative management of tendonitis with a patient. Which of the following may be an effective approach to managing tendonitis?

Intermittent application of ice and heat

An older adult patient sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize which of the following aspects of care?

Intravenous administration of antibiotics

A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the teams next step in the care of this patient?

Intubating

A nurse is preparing to discharge a patient from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage which of the following?

Keep an elastic compression bandage on the ankle.

A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?

Keep the patient positioned supine.

A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?

Keep the patients hips in abduction at all times.

A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patients cast care?

Keep your right leg elevated above heart level.

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions?

Keeping the patient warm

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?

Knots in the rope should not be resting against pulleys.

The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply.

Laboratory reports Nurses notes Verification form

An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The patients description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the patient likely has experienced what injury?

Lateral collateral ligament injury

The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit?

Latex allergy

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis.

A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner?

Lithotomy position

A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do?

Maintain consistent traction tension while repositioning.

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?

Maintaining a patent airway

A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care?

Maintaining spinal alignment

A nurse is providing care for a patient who has osteomalacia. What major goal will guide the choice of medical and nursing interventions?

Maintenance of adequate levels of activated vitamin D

A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?

Make sure you dont bring your knees close together.

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR?

Mask covering the nose and mouth

A patient has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the patients shoulder. The projection appears to be at the distal end of the humerus. The nurse should suspect the presence of which of the following?

Osteochondroma

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?

Osteomyelitis

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The patient should undergo diagnostic testing for what health problem?

Osteomyelitis

A patient with diabetes has been diagnosed with osteomyelitis. The nurse notes that the patients right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis?

Osteomyelitis with vascular insufficiency

The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?

Pain, hypoxia, or bladder distention

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment?

Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss.

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient?

Postoperative delirium

The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis?

Pouring solution onto a sterile field cloth

A patient was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the patient tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action?

Prepare the patient for opening or bivalving of the cast.

The circulating nurse will be participating in a 78-year-old patients total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR?

Pressure points should be assessed and well padded.

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.

Preventing additional injury Providing support Controlling movement

A patient is scheduled for a bowel resection in the morning and the patients orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect?

Preventing potential contamination of the peritoneum

You are caring for a male patient who has had spinal anesthesia. The patient is under a physicians order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physicians order. What rationale for complying with this order should the nurse explain to the patient?

Preventing the onset of a headache

A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team?

Promote the patients highest possible level of function

A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patients dorsalis pedis or posterior tibial pulse and the patients foot is pale. What is the nurses most appropriate action?

Promptly inform the primary care provider.

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action?

Quickly attempt to determine the cause of hemorrhage.

The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?

Red, warm, tender incision

As a perioperative nurse, you know that the National Patient Safety Goals have the potential to improve patient outcomes in a wide variety of health care settings. Which of these Goals has the most direct relevance to the OR?

Reduce the risk of fires

A nurse is planning the care of an older adult patient who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage which of the following? Select all that apply.

Regular bone density testing A high-calcium diet Use of falls prevention precautions Weight-bearing exercise

A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative care?

Risk for Infection related to reduced immune function

The health care team is caring for a patient with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What is the usual treatment for osteomalacia caused by malabsorption?

Supplemental calcium and increased doses of vitamin D

A nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. What should the nurse teach the patient?

Support the affected extremity with external supports such as splints.

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The childs parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?

Surgery should be done without informed consent.

The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia?

Tachycardia

Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurses assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain?

Take opioid analgesics as ordered.

The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?

Teach the patient to perform ankle and foot exercises within the limitations of traction.

A nurse is caring for a patient receiving skeletal traction. Due to the patients 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?

Teach the patient to perform deep breathing and coughing exercises.

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area?

That preoperative teaching was performed

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response?

The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications.

A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient?

The cast will only have full strength when dry.

The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon?

The elderly patient has reduced ability to adjust rapidly to emotional and physical stress.

An orthopedic nurse is caring for a patient who is postoperative day one following foot surgery. What nursing intervention should be included in the patients subsequent care?

The foot should be elevated in order to prevent edema.

An elite high school football player has been diagnosed with a shoulder dislocation. The patient has been treated and is eager to resume his role on his team, stating that he is not experiencing pain. What should the nurse emphasize during health education?

The importance of adhering to the prescribed treatment and rehabilitation regimen

The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patients diagnosis of type 1 diabetes affect the care that the nurse plans?

The nurse should assess the patients blood glucose levels vigilantly.

The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing?

The patient

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply.

The patient expresses interest in the dressing change. The patient is willing to look at the incision during a dressing change. The patient assists in opening the packages of dressing material for the nurse.

A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?

The patient has vomited three times in the past 12 hours.

The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?

The patient is in pain.

The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?

The patient may be at risk for malignant hyperthermia.

In anticipation of a patients scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient?

The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

34. A rehabilitation nurse is working with a patient who has had a below-the-knee amputation. The nurse knows the importance of the patients active participation in self-care. In order to determine the patients ability to be an active participant in self-care, the nurse should prioritize assessment of what variable?

The patients attitude

The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply.

The patients preoperative level of consciousness The presence of family and/or significant others The patients full name

A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement?

The physical therapist will likely help you get up using a walker the day after your surgery.

You are the nurse caring for an unconscious trauma victim who needs emergency surgery. The patient is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fianc. Who should be asked to sign the surgery consent form?

The son

A patient waiting in the presurgical holding area asks the nurse, Why exactly do they have to put a breathing tube into me? My surgery is on my knee. What is the best rationale for intubation during a surgical procedure that the nurse should describe?

The tube provides an airway for ventilation.

You are caring for an 88-year-old woman who is scheduled for a right mastectomy. You know that elderly patients are frequently more anxious prior to surgery than younger patients. What would you increase with this patient to decrease her anxiety?

Therapeutic touch

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?

Third intention

The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of what purpose of the preadmission assessment should the nurse be aware?

Verifies completion of preoperative diagnostic testing

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, I dont know why youre focusing on my breathing. My surgery is on my hip, not my chest. What rationale for these instructions should the nurse provide?

To promote optimal lung expansion

The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?

Trace the outline of the drainage on the dressing for future comparison.

A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patients signs and symptoms?

Traumatic hip dislocation

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the patients nerve damage. What surgical position places the patient at highest risk for nerve damage?

Trendelenburg

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?

Turn the patient completely to one side.

A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions?

Turning from side to side

A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patients plan of care. What intervention is most justified in the care of this patient?

Use of a pressure-relieving mattress

The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the patients pain and anxiety?

Use of guided imagery along with pain medication

A nurse is preparing to discharge an emergency department patient who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the patient to do?

Use the arm for light activities within the range of motion.

A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting coffee-ground like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled?

Without delay because the bleed is emergent

The patient scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the patients concern?

You will eventually be able to withstand full weight-bearing after the amputation.

The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, I dont want to use my pain meds because theyll make me dependent and I wont get better as fast. Which response is most important when explaining the use of pain medication?

You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time.

One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient?

You will need to have food and fluid restricted before surgery so you are not at risk for choking.