Medsurg Final

The 50-year-old female client is being evaluating for osteoporosis. Which data should the nurse assess? Select all that apply. 1. Family history of osteoporosis. 2. Estrogen or androgen deficit. 3. Exposure to secondhand smoke. 4. Level and amount of exercise. 5. Alcohol intake.

** 1. Clients are more prone to have osteoporosis if there is a genetic predisposition. **2. Clients who are deficient in either estrogen or androgen are at risk for osteoporosis. 3. Clients who smoke are more at risk for osteoporosis. Research does not show a correlation between osteoporosis and secondhand smoke. **4. Regular, weight-bearing exercise promotes healthy bones. **5. Clients who consume alcohol and have diets low in calcium are at a higher risk for osteoporosis.

Which staff nurse should the charge nurse assign to the client recovering from a repair of the hallux valgus? 1. A new graduate nurse. 2. An experienced nurse. 3. A nurse practitioner. 4. An unlicensed assistive personnel.

***1. A new graduate is the best choice for this client. The client's surgery (correction of a hammer toe) is not a high-risk procedure but requires assessment and pain management. 2. This client does not need a more experienced nurse. 3. A nurse practitioner does not need to be assigned to this client. 4. The UAP is not assigned the responsibility of managing the care of a client; the UAP works under the guidance of the nurse.

Two unlicensed assistive personnel (UAP) are using the transfer board to move the client from the bed to the wheelchair. Which action should the nursing take? 1. Take no action since this is the correct procedure for transferring a client. 2. Instruct the UAPs not to use a transfer board when moving the client. 3. Tell the UAPs to use the bed scale sling to move the client to the chair. 4. Request the UAPs to stop and come to the nurse's station immediately.

***1. The UAPs are transferring the client correctly and safely, so no action should be taken. The UAPs are adhering to the Patient Care Safety Standards by using approved equipment. 2. The nurse should encourage the use of appropriate equipment designed to protect the client and the staff from injury. 3. The bed scale sling is inappropriate to use when moving the client from the bed to a wheelchair. 4. There is no reason for the nurse to stop the UAPs since the task is being performed

The nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess first? 1. The client with a total knee replacement who is complaining of a cold foot. 2. The client diagnosed with osteoarthritis who is complaining of stiff joints. 3. The client who needs to receive a scheduled intravenous antibiotic. 4. The client diagnosed with back pain who is scheduled for a lumbar myelogram.

**1. A cold foot in a client who has had surgery may indicate a neurovascular compromise and must be assessed first. 2. A client with osteoarthritis is expected to have stiff joints. 3. A routine medication is not priority over a potential complication of surgery. 4. A routine diagnostic procedure does not have priority over a potential complication of surgery.

The client with a right AKA is being taught how to toughen the residual limb. Which intervention should the nurse implement? 1. Instruct the client to push the residual limb against a pillow. 2. Demonstrate how to apply an elastic bandage around the residual limb. 3. Encourage the client to apply vitamin B12 to the surgical incision. 4. Teach the client to elevate the residual limb at least three (3) times a day.

**1. Applying pressure to the end of the residual limb will help toughen the limb. Gradually pushing the residual limb against harder and harder surfaces is done in preparation for prosthesis training. 2. An Ace bandage applied distal to proximal will help decrease edema and help shape the residual limb into a conical shape. 3. Vitamin E oil will help decrease the angriness of the scar, but it will not help with residual limb toughening. 4. Elevating the residual limb will help decrease edema, but it will also cause a contracture if the residual limb is elevated after the first 24 hours.

The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with SLE who is complaining of chest pain. 2. The client diagnosed with MS who is complaining of pain at a "10." 3. The client diagnosed with myasthenia gravis who has dysphagia. 4. The client diagnosed with GB syndrome who can barely move his toes.

**1. Chest pain should be considered a priority regardless of the admitting diagnosis. Clients diagnosed with SLE can develop cardiac complications. 2. Pain at a "10" is a priority but not above chest pain. 3. Dysphagia is expected in clients diagnosed with MG. 4. Clients diagnosed with GB syndrome have ascending muscle weakness or paralysis, which could eventually result in the client being placed on a ventilator, but the problem currently is in the distal extremities (the feet) and is not priority over chest pain.

The 62-year-old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below-the-knee amputation. Which nursing intervention should the nurse implement? 1. Assess the client's nutritional status. 2. Refer the client to an occupational therapist. 3. Determine if the client is allergic to IVP dye. 4. Start a 22-gauge Angiocath in the right arm.

**1. For wound healing, a balanced diet with adequate protein and vitamins is essential, along with meals appropriate for type 2 diabetes. 2. An occupational therapist addresses activities of daily living and usually addresses upper extremity amputations. A referral to a physical therapist is most appropriate to address ambulating and transfer concerns. 3. There is no type of intravenous dye used in this surgical procedure, so this answer is not appropriate. 4. An 18-gauge catheter should be started because the client is going to surgery; the client may need a blood transfusion, which should be administered through an 18-gauge catheter.

The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications? 1. "Are you sexually active, and, if so, are you using birth control?" 2. "Have you discussed taking these drugs with your parents?" 3. "Which arm do you prefer to have an IV in for four (4) days?" 4. "Have you signed an informed consent for investigational drugs?"

**1. Immunosuppressive medications are considered class C drugs and should not be taken while pregnant. These drugs are teratogenic and carcinogenic, and the client is only 20 years old. 2. Any individual older than age 18 years is considered an adult and does not need to discuss treatment with her parents unless she chooses to do so. 3. The medications can be administered on an outpatient basis, but if an inpatient has intravenous therapy, then IV sites are changed every 72 hours and there is no guarantee an IV will last for four (4) days. 4. These are not investigational drugs and are standard therapy approved by the American College of Rheumatology and the Food and Drug Administration.

The client is scheduled for a magnetic resonance imaging (MRI) scan. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Prepare the client by removing all metal objects. 2. Inject the contrast into the intravenous site. 3. Administer a sedative to the client to decrease anxiety. 4. Explain why the client cannot have any breakfast.

**1. Metal objects such as jewelry and zippers can interfere with the magnetic imaging and pose a danger to the client as a result of the magnetic properties of the equipment. This intervention can be delegated to the UAP. 2. Injection of contrast is given in the radiology department. 3. UAPs are unable to administer medications in hospitals. 4. The nurse cannot delegate teaching to a UAP.

The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA). Which is a modifiable risk factor for developing OA? 1. Being overweight. 2. Increasing age. 3. Previous joint damage. 4. Genetic susceptibility.

**1. Obesity is a well-recognized risk factor for the development of OA and it is modifiable because the client can lose weight. 2. Increasing age is a risk factor, but there is nothing the client can do about getting older, except to die. 3 . Previous joint damage is a risk factor, but it is not modifiable, which means the client cannot do anything to change it. 4. Genetic susceptibility is a result of family genes, which the client cannot change; it is a nonmodifiable risk factor.

The nurse is preparing to administer morning medications. Which medication should the nurse administer first? 1. The pain medication to a client diagnosed with RA. 2. The diuretic medication to a client diagnosed with SLE. 3. The steroid to a client diagnosed with polymyositis. 4. The appetite stimulant to a client diagnosed with OA.

**1. Pain medication is important and should be given before the client's pain becomes worse. 2. Unless the client is in a crisis, such as pulmonary edema, this medication can wait. 3. Steroids do not have precedent over pain medication and should be administered with food. 4. Clients diagnosed with OA are usually overweight and do not require appetite stimulants. The nurse should question this medication before administering the medication.

The 32-year-old male client with a traumatic left AKA is being discharged from the rehabilitation department. Which discharge instructions should be included in the teaching? Select all that apply. 1. Report any pain not relieved with analgesics. 2. Eat a well-balanced diet and increase protein intake. 3. Be sure to attend all outpatient rehabilitation appointments. 4. Encourage the client to attend a support group for amputations. 5. Stay at home as much as possible for the first couple of months.

**1. Pain not relieved with analgesics could indicate complications or could be phantom pain. **2. A well-balanced diet promotes wound healing, especially a diet high in protein. **3. The client must keep appointments in outpatient rehabilitation to continue to improve physically and emotionally **4. A support group may help the client adjust to life with an amputation. 5. The client should be encouraged to get out as much as possible and live as normal a life as possible.

The nurse is admitting a client diagnosed with R/O SLE. Which assessment data observed by the nurse support the diagnosis of SLE? 1. Pericardial friction rub and crackles in the lungs. 2. Muscle spasticity and bradykinesia. 3. Hirsutism and clubbing of the fingers. 4. Somnolence and weight gain.

**1. SLE can affect any organ. It can cause pericarditis and myocardial ischemia as well as pneumonia or pleural effusions. 2. Muscle spasticity occurs in MS, and bradykinesia occurs in Parkinson's disease. 3. Hirsutism is an overgrowth of hair. Spotty areas of alopecia occur in SLE, and clubbing of the fingers occurs in chronic pulmonary or cardiac diseases. 4. Weight loss and fatigue are experienced by clients diagnosed with SLE.

The nurse is discussing the importance of an exercise program for pain control to a client diagnosed with OA. Which intervention should the nurse include in the teaching? 1. Wear supportive tennis shoes with white socks when walking. 2. Carry a complex carbohydrate while exercising. 3. Alternate walking briskly and jogging when exercising. 4. Walk at least 30 minutes three (3) times a week.

**1. Safety should always be discussed when teaching about exercises. Supportive shoes will prevent shin splints. Colored socks have dye and may cause athlete's foot, which is why white socks are recommended. 2. Clients with diabetes mellitus should carry complex carbohydrates with them. 3. Osreoarthritis occurs most often in weightbearing joints. Exercise is encouraged, but jogging increases stress on these joints. 4. For exercising to help pain control, the client must walk daily, not three (3) times a week. Walking at least 30 minutes three (3) times a week is appropriate for weight loss.

The client diagnosed with SLE is being discharged from the medical unit. Which discharge instructions are most important for the nurse to include? Select all that apply. 1. Use a sunscreen of SPF 30 or greater when in the sunlight. 2. Notify the HCP immediately when developing a low-grade fever. 3. Some dyspnea is expected and does not need immediate attention. 4. The hands and feet may change color if exposed to cold or heat. 5. Explain the client can be cured with continued therapy.

**1. Sunlight or UV light exposure has been shown to initiate an exacerbation of SLE, so the client should be taught to protect the skin when in the sun. **2. A fever may be the first indication of an exacerbation of SLE. 3. Dyspnea is not expected and could signal respiratory involvement. **4. Raynaud's phenomenon is a condition in which the digits of the hands and feet turn red, blue, or white in response to heat or cold and stress. It occurs with some immune inflammatory processes. 5. SLE is a chronic disease and there is no known cure.

The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client? 1. "Have you made any special arrangements for your amputated limb?" 2. "What types of food would you like to eat while you're in the hospital?" 3. "Would you like a rabbi to visit you while you are in the recovery room?" 4. "Will you start checking your other foot at least once a day for cuts?"

**1. The Jewish faith believes all body parts must be buried together. Therefore, many synagogues will keep amputated limbs until death occurs. 2. Specific foods are important, but not while the client is in the operating room. 3. Spiritual issues are important for the nurse to discuss with the client, but the operating room should be concerned with disposition of the amputated limb. 4. Addressing teaching issues is important, but the most important concern is disposition of the amputated limb.

The nurse is teaching a class to pregnant teenagers. Which information is most important when discussing ways to prevent osteoporosis? 1. Take at least 1,200 mg of calcium supplements a day. 2. Eat foods low in calcium and high in phosphorus. 3. Osteoporosis does not occur until around age 50 years. 4. Remain as active as possible until the baby is born

**1. The National Institutes of Health (NIH) recommends a daily calcium intake of 1,200 to 1,500 mg/day for adolescents, young adults, and pregnant and lactating women 2. The pregnant teenager should eat foods high in calcium. 3. Osteoporosis may not occur before age 50 years, but taking calcium throughout the life span will help prevent it. Remember, teenagers tend to focus on the present, not the future, so the most important intervention to teach them is to take calcium supplements. 4. Activity will not help prevent osteoporosis in the teenager; the teenager must take calcium supplements.

Which foods should the nurse recommend to a client when discussing sources of dietary calcium? 1. Yogurt and dark-green, leafy vegetables. 2. Oranges and citrus fruits. 3. Bananas and dried apricots. 4. Wheat bread and bran.

**1. The best dietary sources of calcium are milk and other dairy products. Other sources include oysters; canned sardines or salmon; beans; cauliflower; and dark-green, leafy vegetables. 2. These foods are high in vitamin C. 3. These foods are high in potassium. 4. These foods are recommended for a high-fiber diet.

The client is prescribed Fosamax, a bisphosphonate. Which information should the nurse teach? 1. Take this medication with a full glass of water. 2. Take with breakfast to prevent gastrointestinal upset. 3. Use sunscreen to prevent sensitivity to sunlight. 4. This medication increases calcium reabsorption.

**1. The client needs to take this medication with a full glass of water and remain upright for at least 30 minutes to reduce the risk of esophagitis. 2. This medication should be taken before breakfast on an empty stomach. 3. This medication does not cause photosensitivity. 4. This medication decreases calcium reabsorption by decreasing the activity of osteoclasts.

The nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is most appropriate for the client? 1. The client will maintain function of the leg. 2. The client will ambulate with assistance. 3. The client will be turned every two (2) hours. 4. The client will have no infection.

**1. The expected outcome for a client with a fracture is maintaining the function of the extremity. 2. Ambulation with assistance is not the best goal. 3. This is a nursing intervention, not a client goal. 4. Infection is not the highest priority problem for a client with a fracture.

Which signs/symptoms indicate to the nurse the client has developed osteoporosis? 1. The client has lost one (1) inch in height. 2. The client has lost 12 pounds in the last year. 3. The client's hands are painful to the touch. 4. The client's serum uric acid level is elevated.

**1. The loss of height occurs as vertebral bodies collapse. 2. Weight loss is not a sign of osteoporosis. 3. This may indicate rheumatoid arthritis but not osteoporosis. 4. This is a sign of gout

The client with RA has nontender, movable nodules in the subcutaneous tissue over the elbows and shoulders. Which statement is the scientific rationale for the nodules? 1. The nodules indicate a rapidly progressive destruction of the affected tissue. 2. The nodules are small amounts of synovial fluid that have become crystallized. 3. The nodules are lymph nodes which have proliferated to try to fight the disease. 4. The nodules present a favorable prognosis and mean the client is better.

**1. The nodules may appear over bony prominences and resolve simultaneously. They appear in clients with the rheumatoid factor and are associated with rapidly progressive and destructive disease. 2. There is a proliferation of the synovial membrane in RA, which leads to the formation of pannus and the destruction of cartilage and bone, but synovial fluid does not crystallize to form the nodules. 3. The nodules are not lymph nodes. Lymph nodes may enlarge in the presence of disease, but they do not proliferate (multiply). 4. The nodes indicate a progression of the disease, not an improving prognosis.

The nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? Select all that apply. 1. Numbness and mottled cyanosis. 2. Paresthesia and paralysis. 3. Proximal pulses and point tenderness. 4. Coldness of the extremity and crepitus. 5. Palpable radial pulse and functional movement

**1. The nurse should assess for numbness and mottled cyanosis, which might indicate nerve damage. **2. The presence of paresthesia and paralysis indicates impaired circulation. 3. Pulses should be assessed but not proximal to the fracture. Pulses distal to the fracture should be assessed. Point tenderness should be expected. ** 4. Coldness indicates decreased blood supply. Crepitus indicates air in subcutaneous tissue and is not expected. 5. Palpable radial pulses and functional movement do not indicate a complication has occurred.

The unlicensed assistive personnel (UAP) reports a client with a fractured femur has "globs" floating in the urinal. What intervention should the nurse implement first? 1. Assess the client for dyspnea and altered mental status. 2. Obtain an arterial blood gas and order a portable chest x-ray. 3. Call the HCP for a ventilation/perfusion scan. 4. Instruct the UAP keep the client on strict bedrest.

**1. The nurse should assess the client for signs of hypoxia from a fat embolism, which is what the nurse should anticipate from "globs" in the urine. 2. Arterial blood gases and portable chest x-ray will be done, but they will not be done first. 3. A ventilation/perfusion scan not the highest priority for the client. Assessment for complications is priority. 4. The UAP should keep the client on strict bedrest, but the nurse's first intervention is to assess the client. The client is unstable and the nurse should assess the client first, then maintain strict bedrest.

The client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? 1. Assess the nailbeds for capillary refill time. 2. Remove the client's clothing from the arm. 3. Call radiology for a STAT x-ray of the extremity. 4. Prepare the client for the application of a cast.

**1. The nurse should assess the nailbeds for the capillary refill time. A prolonged time (greater than three [3] seconds) indicates impaired circulation to the extremity. 2. Clothing may need to be removed but not before assessment. 3. An x-ray will be done, but is not the highest priority action. 4. A cast may or may not be applied, depending on the type and location of the fracture.

The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the discharge teaching? 1. "I need to keep my leg elevated on two pillows for the first 24 hours." 2. "I must wear my sequential compression device all the time." 3. "I can remove the cast for one (1) hour so I can take a shower." 4. "I will be able to walk on my cast and not have to use crutches

**1. This is a correct intervention. The leg should be elevated for at least the first 24 hours. If edema is present, the client needs to keep it elevated longer. 2. Sequential compression devices work to prevent deep vein thrombosis and the client does not wear one of these at home. 3. The client will not be able to remove the cast for any reason. The cast must be cut off. 4. Clients with casts can only ambulate if they have a walking cast or boot. This information is not in the stem of the question.

Which intervention is an example of a secondary nursing intervention when discussing osteoporosis? 1. Obtain a bone density evaluation test. 2. Perform non-weight-bearing exercises regularly. 3. Increase the intake of dietary calcium. 4. Refer clients to a smoking cessation program.

**1. This is an example of a secondary nursing intervention, which includes screening for early detection. 2. The client should perform weight-bearing exercises, which promote osteoblast activity helping to maintain bone strength and integrity. This is a primary nursing intervention. 3. Increasing dietary calcium may be a primary intervention to help prevent osteoporosis or a tertiary intervention, which helps treat osteoporosis. 4. Smoking cessation is a primary intervention, which will help prevent the development of osteoporosis.

Which statement by the client prescribed calcitonin, a thyroid hormone, indicates to the nurse the teaching has been effective? 1. "I should administer the mediation in a different nostril each day." 2. "I need to drink a lot of water when I take my medicine." 3. "I have to dilute the medication with vitamin D before I take it." 4. "This medication will help the calcium leave my bones."

**1. This medication is administered intranasally. Alternating nostrils will decrease the risk of nasal irritation. 2. This intervention should be implemented for Fosamax, a bisphosphonate, not calcitonin, thyroid hormone. 3. Clients do not dilute their medication. Vitamin D is not used as a diluent for medication. 4. Calcium should be retained in the bone to maintain bone strength; medications are not administered to encourage loss from

The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Help the client with a 2-day postop amputation put on the prosthesis. 2. Request the UAP double-check a unit of blood to be hung. 3. Change the surgical dressing on the client with a Syme's amputation. 4. Ask the UAP to take the client to the physical therapy department.

1. A client who is only two (2) days postoperative amputation is not putting on a prosthesis. 2. Two (2) registered nurses must double-check a unit of blood prior to infusing the blood. 3. The surgical dressing is changed by the surgeon or the nurse; Syme's amputation is above the ankle, just removing the foot. **4. The unlicensed assistive personnel (UAP) could take a client to another department in the hospital.

To which member of the health-care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub? 1. Physiatrist. 2. Social worker. 3. Physical therapist. 4. Counselor.

1. A physiatrist is a physician who specializes in physical medicine and rehabilitation,but the nurse should not refer the client to this person just because the client is having difficulty with transfers. 2. The social worker does not address this type of physical problem. Social workers address issues concerning finances, placement, and acquiring assistive devices. **3. The physical therapist is able to help the client with transferring, ambulation, and other lower extremity difficulties. 4. A counselor is not able to help the client learn how to get in and out of the bathtub

Which client problem is priority for a client diagnosed with RA? 1. Activity intolerance. 2. Fluid and electrolyte imbalance. 3. Alteration in comfort. 4. Excessive nutritional intake.

1. Activity intolerance is an appropriate client problem, but it is not priority over pain. 2. The client with RA does not experience fluid and electrolyte disturbance. **3. The client diagnosed with RA has chronic pain; therefore, alteration in comfort is a priority problem. 4. Clients diagnosed with RA usually experience anorexia and weight loss, unless they are taking long-term steroids.

The nurse is discussing autoimmune diseases with a class of nursing students. Which signs and symptoms are shared by rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)? 1. Nodules in the subcutaneous layer and bone deformity. 2. Renal involvement and pleural effusions. 3. Joint stiffness and pain. 4. Raynaud's phenomenon and skin rash.

1. Nodules and bony deformity are symptoms of RA but not of SLE. 2. Organ involvement occurs in SLE but not RA. **3. Joint stiffness and pain are symptoms occuring in both diseases. 4. Raynaud's phenomenon and skin rashes are associated with SLE.

The nurse is preparing to administer subcutaneous Lovenox, a low molecular weight heparin. Which intervention should the nurse implement? 1. Monitor the client's serum aPTT. 2. Encourage oral and intravenous fluids. 3. Do not eat foods high in vitamin K. 4. Administer in the anterolateral upper abdomen.

1. An aPTT is used to determine therapeutic levels of unfractionated heparin. Laboratory studies such as aPTT are not monitored when administering subcutaneous Lovenox, a low molecular weight heparin. Atherapeutic level will not be achieved as a result of a short half-life. 2. Oral fluids do not need to be increased because of this medication. 3. Vitamin K is the antidote for warfarin (Coumadin), an oral anticoagulant. It does not affect Lovenox. **4. Administering the medication in the prescribed areas, the "love handles," ensures safety and decreases the risk of abdominal trauma.

Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply. 1. Apply an immobilizer snugly to prevent edema. 2. Apply an ice pack for 10 minutes and remove for 20 minutes. 3. Place the extremity in the dependent position to allow drainage. 4. Obtain an x-ray of the ankle after applying the immobilizer. 5. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.

1. An immobilizer should not be applied snugly. There should be enough room to allow for edema and adequate perfusion of the tissues. **2. Ice packs should be applied 10 minutes on and 20 minutes off. This allows for vasoconstriction and decreases edema. Ice is a nonpharmacological pain management technique. 3. An injured extremity should be elevated above the level of the heart to decrease edema and pain. 4. An x-ray should be done before the immobilizer is in place, not after. **5. Anytime trauma occurs, tetanus should be considered. In an open fracture, this is an appropriate treatment.

The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse? 1. Administer methotrexate, an antineoplastic medication, IV. 2. Assess the lung sounds of a client with RA who is coughing. 3. Demonstrate how to use clothing equipped with Velcro fasteners. 4. Discuss methods of birth control compatible with treatment medications.

1. Antineoplastic medications can be administered only by a registered nurse who has been trained in the administration and disposal of these medications. 2. Assessment cannot be assigned to a licensed practical nurse. **3. The licensed practical nurse (LPN) can demonstrate how to use adaptive clothing. 4. This is teaching requiring knowledge of medications and interactions and should not be assigned to an LPN.

The clinic nurse assesses a client with complaints of pain and numbness in the left hand and fingers. Which question should the nurse ask the client? 1. "Do you smoke or use any type of tobacco products?" 2. "Do you have to wear gloves when you are out in the cold?" 3. "Do you do repetitive movements with your left fingers?" 4. "Do you have tremors or involuntary movements of your hand?"

1. Assessing for smoking is evaluation for Raynaud's disease. 2. Exposure to cold is appropriate to assess for Raynaud's disease. **3. Repetitive movements are appropriate to assess for carpal tunnel syndrome. Clients with this disorder experience pain and numbness. 4. Tremors or involuntary movements could indicate Parkinson's disease.

The nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a nonmodifiable risk factor? 1. Calcium deficiency. 2. Tobacco use. 3. Female gender. 4. High alcohol intake

1. Calcium deficiency is a modifiable risk factor, which means the client can do something about this factor—namely, increase the intake of calcium—to help prevent the development of osteoporosis. 2. Smoking is a modifiable risk factor because the client can quit smoking. **3. A nonmodifiable risk factor is a factor the client cannot do anything to alter or change. Approximately 50% of all women will experience an osteoporosis-related fracture in their lifetime. 4. The client can quit drinking alcohol; therefore, this is a modifiable risk factor

The client diagnosed with OA is a resident in a long-term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel (UAP)? 1. Allow the client to stay in bed until the pain becomes bearable. 2. Tell the UAP to give the client a bed bath this morning. 3. Try to encourage the client to get up and go to the shower. 4. Notify the family the client is refusing to be bathed.

1. Clients with OA should be encouraged to move, which will decrease the pain. 2. A bed bath does not require as much movement from the client as getting up and walking to the shower. **3. Pain will decrease with movement, and warm or hot water will help decrease the pain. The worst thing the client can do is not move. 4. Notifying the family will not address the client's pain, and the client has a right to refuse a bath, but the nursing staff must explain why moving and bathing will help decrease the pain.

Which information should the nurse teach the client regarding sports injuries? 1. Apply heat intermittently for the first 48 hours. 2. An injury is not serious if the extremity can be moved. 3. Only return to health-care provider if the foot becomes cold. 4. Keep the injury immobilized and elevated for 24 to 48 hours.

1. Ice should be applied intermittently for the first 48 hours. Heat can be used later in the recovery process. 2. Severe injury can be present even with some range of motion. 3. The client needs to return if the injury does not improve and if the foot gets cold. **4. The leg should be iced, elevated, and immobilized for 48 hours.

The nurse is caring for a client with a right below-the-knee amputation. There is a large amount of bright red blood on the client's residual limb dressing. Which intervention should the nurse implement first? 1. Notify the client's surgeon immediately. 2. Assess the client's blood pressure and pulse. 3. Reinforce the dressing with additional dressing. 4. Check the client's last hemoglobin and hematocrit level

1. If the client is hemorrhaging, the surgeon needs to be notified, but hemorrhaging has not been determined. **2. Determining if the client is hemorrhaging is the first intervention. The nurse should check for signs of hypovolemic shock: decreased BP and increased pulse. 3. Reinforcing the dressing helps decrease bleeding, but the nurse must assess first. 4. Checking the client's laboratory results is an appropriate intervention, but it is not the first intervention.

An 88-year-old client is admitted to the orthopedic floor with the diagnosis of fractured pelvis. Which intervention should the nurse implement first? 1. Insert an indwelling catheter. 2. Administer a Fleet's enema. 3. Assess abdomen for bowel sounds. 4. Apply Buck's traction.

1. Inserting an indwelling catheter is a good intervention, but it is not the first intervention. A tear or injury to the bladder should be suspected. 2. Administering a Fleet's enema should not be implemented until internal bleeding has been ruled out. **3. Assessing the bowel sounds should be the first intervention to determine if an ileus has occurred. This is a common complication of a fractured pelvis. 4. Buck's traction is not used to treat a fractured pelvis. It is used to treat a fractured hip.

The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention? 1. The client complains of joint stiffness and the knees feel warm to the touch. 2. The client has experienced one (1)-kg weight loss and is very tired. 3. The client requires a heating pad applied to the hips and back to sleep. 4. The client is crying, has a flat facial affect, and refuses to speak to the nurse

1. Joint stiffness and joints warm to the touch are expected in clients diagnosed with RA. 2. Clients diagnosed with RA have bilateral and symmetrical stiffness, edema, tenderness, and temperature changes in the joints. Other symptoms include sensory changes, lymph node enlargement, weight loss, fatigue, and pain. A one (1)-kg weight loss and fatigue are expected. 3. The use of heat is encouraged to provide comfort for a client diagnosed with RA. **4. The client has the signs and symptoms of depression. The nurse should attempt to intervene with therapeutic conversation and discuss these findings with the HCP.

The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider immediately? 1. Localized edema and discoloration occurring hours after the injury. 2. Generalized weakness and increasing sensitivity to touch. 3. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain. 4. Pain relieved after taking four (4) mg hydromorphone, a narcotic analgesic

1. Localized edema and discoloration hours after the injury are normal occurrences after a fracture. 2. Generalized weakness and increasing tenderness are common and not life threatening. **3. If the nurse cannot hear the pedal pulse with a Doppler and the client's pain is increasing, the nurse should notify the health-care provider. These are signs of neurovascular compromise. 4. Pain management is a desired outcome demonstrated by pain relieved after medication administration.

The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests should the nurse expect the health-care provider to order to R/O osteoarthritis? 1. Full-body magnetic resonance imaging scan. 2. Serum studies for synovial fluid amount. 3. X-ray of the affected joints. 4. Serum erythrocyte sedimentation rate (ESR).

1. MRIs are not routinely ordered for diagnosing OA. 2. There is no serum laboratory test to measure synovial fluid in the joints. **3. X-rays reveal loss of joint cartilage, which appears as a narrowing of the joint space in clients diagnosed with OA. 4. An ESR is a diagnostic laboratory test for rheumatoid arthritis, not osteoarthritis

The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an alternative form of treatment for OA? 1. "I take medication every two (2) hours for my pain." 2. "I use a heating pad when I go to bed at night." 3. "I wear a copper bracelet to help with my OA." 4. "I always wear my ankle splints when I sleep."

1. Medication is a standard therapy and is not considered an alternative therapy. 2. A heating pad is an accepted medical recommendation for the treatment of pain for clients with OA. **3. Alternative forms of treatment have not been proved efficacious in the treatment of a disease. The nurse should be nonjudgmental and open to discussions about alternative treatment, unless it interferes with the medical regimen. 4. Conservative treatment measures for OA include splints and braces to support inflamed joints.

The nurse is assessing a client with cutaneous lupus erythematosus. Which intervention should be implemented? . Use astringent lotion on the face and skin. 2. Inspect the skin weekly for open areas or rashes. 3. Dry the skin thoroughly by patting. 4. Apply anti-itch medication between the toes.

1. Moisturizing lotions, not astringents, are applied. Astringent lotions have an alcohol base, which is drying to the client's skin. 2. The skin should be inspected daily for any breakdown or rashes. **3. The skin should be washed with mild soap, rinsed, and patted dry. Rubbing can cause abrasions and skin breakdown. 4. The stem does not tell the test taker the client is itching, and SLE does not have itching as a symptom. Lotions are not usually applied between the toes because this fosters the development of a fungal infection between the toes.

The HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication? 1. It will help decrease the inflammation in the joints. 2. It improves tissue function and retards breakdown of cartilage. 3. It is a potent medication which decreases the client's joint pain. 4. It increases the production of synovial fluid in the joint.

1. NSAIDs or glucocorticoids help decrease inflammation of the joints. **2. This is the rationale for administering these medications. 3. Narcotic and nonnarcotic analgesics help decrease the client's pain. 4. There is no medication at this time to help increase synovial fluid production, but surgery can increase the viscosupplementation in the joint

The client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an adverse effect of the medication? 1. The client complains of nausea and vomiting. 2. The client is drinking two (2) glasses of milk a day . 3. The client has a runny nose and nasal itching. 4. The client has had numerous episodes of nosebleeds.

1. Nausea and vomiting may occur during initial stages of therapy, but they will disappear as treatment continues. 2. The client should be sure to consume adequate amounts of calcium and vitamin D while taking calcitonin. 3. Rhinitis (runny nose) is the most common side effect with calcitonin nasal spray along with itching, sores, and other nasal symptoms. **4. Nosebleeds are adverse effects and should be reported to the client's HCP.

The client is being evaluated for osteoporosis. Which diagnostic test is the most accurate when diagnosing osteoporosis? 1. X-ray of the femur. 2. Serum alkaline phosphatase. 3. Dual-energy x-ray absorptiometry (DEXA). 4. Serum bone Gla-protein test.

1. Osteoporotic changes do not occur in the bone until more than 30% of the bone mass has been lost. 2. This serum blood study may be elevated after a fracture, but it does not help diagnose osteoporosis. **3. This test measures bone density in the lumbar spine or hip and is considered to be highly accurate. 4. This test is most useful to evaluate the effects of treatment, rather than as an indicator of the severity of bone disease.

The client has been diagnosed with OA for the last seven (7) years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem should the nurse identify? 1. Severe pain. 2. Body image disturbance. 3. Knowledge deficit. 4. Depression.

1. Pain is a physiological problem, not a psychosocial problem. 2. A client with OA does not have bone deformities; therefore, body image disturbance is not appropriate. 3. After seven (7) years of OA and multiple treatment modalities, knowledge deficit is not appropriate for this client. **4. The client experiencing chronic pain often experiences depression and hopelessness.

The client diagnosed with RA has developed swan-neck fingers. Which referral is most appropriate for the client? 1. Physical therapy. 2. Occupational therapy. 3. Psychiatric counselor. 4. Home health nurse.

1. Physical therapists work with gait training and muscle strengthening. Generally the physical therapist works on the lower half of the body. **2. The occupational therapist assists the client in the use of the upper half of the body, fine motor skills, and activities of daily living. This is needed for the client with abnormal fingers. 3. A counselor can help the client discuss feelings about body image, loss of function, and role changes, but the best referral is to the occupational therapist. 4. The client may need a home health nurse eventually, but first the client should be assisted to remain as functional as possible.

A person's right thumb was accidentally severed with an axe. The amputated right thumb was recovered. Which action by the nurse preserves the thumb so it could possibly be reattached in surgery? 1. Place the right thumb directly on some ice. 2. Put the right thumb in a glass of warm water. 3. Wrap the thumb in a clean piece of material. 4. Secure the thumb in a plastic bag and place on ice

1. Placing the amputated part directly on ice will cause vasoconstriction and necrosis of viable tissue. 2. Warm water will cause the amputated part to disintegrate and lose viable tissue. 3. Wrapping the amputated part in a piece of material will not help preserve the thumb so it can be reconnected. **4. Placing the thumb in a plastic bag will protect it and then placing the plastic bag on ice will help preserve the thumb so it may be reconnected in surgery. Do not place the amputated part directly on ice because this will cause necrosis of viable tissue.

Which statement by the client diagnosed with a fractured ulna indicates to the nurse the client needs further teaching? 1. "I need to eat a high-protein diet to ensure healing." 2. "I need to wiggle my fingers every hour to increase circulation." 3. "I need to take my pain medication before my pain is too bad." 4. "I need to keep this immobilizer on when lying down only."

1. Protein is necessary for healing. 2. By wiggling the fingers of the affected arm, the client can improve the circulation. 3. Pain medication should be taken prior to perception of severe pain. Pain relief will require more medication if allowed to become severe. **4. The immobilizer should be kept on at all times. This indicates the client does not understand the teaching and needs the nurse to provide more instruction.

The 26-year-old female client is complaining of a low-grade fever, arthralgias, fatigue, and a facial rash. Which laboratory tests should the nurse expect the HCP to order if SLE is suspected? 1. Complete metabolic panel and liver function tests. 2. Complete blood count and antinuclear antibody tests. 3. Cholesterol and lipid profile tests. 4. Blood urea nitrogen and glomerular filtration tests.

1. SLE can affect any organ system, and these tests are used to determine the possibility of the liver being involved, but they are not used to diagnose SLE. **2. No single laboratory test diagnoses SLE, but the client usually presents with moderate to severe anemia, thrombocytopenia, leukopenia, and a positive antinuclear antibody. 3. Female clients with SLE develop atherosclerosis at an earlier age, but cholesterol and lipid profile tests are not used to diagnose the disease. 4. These tests may be done to determine SLE infiltration in the kidneys but not to diagnose the disease itself.

The nurse is developing a care plan for a client diagnosed with SLE. Which goal is priority for this client? 1. The client will maintain reproductive ability. 2. The client will verbalize feelings of body-image changes. 3. The client will have no deterioration of organ function. 4. The client's skin will remain intact and have no irritation.

1. SLE is frequently diagnosed in young women and reproduction is a concern for these clients, but it is not the most important goal. 2. The client's body image is important, but this is not the most important. **3. SLE can invade and destroy any body system or organ. Maintaining organ function is the primary goal of SLE treatment. 4. Measures are taken to prevent breakdown, but skin breakdown is not life threatening

The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit? 1. Severe bone deformity. 2. Joint stiffness. 3. Waddling gait. 4. Swan-neck fingers

1. Severe bone deformity is seen in clients diagnosed with rheumatoid arthritis. **2. Pain, stiffness, and functional impairment are the primary clinical manifestations of OA. Stiffness of the joints is commonly experienced after resting but usually lasts less than 30 minutes and decreases with movement. 3. A waddling gait is usually seen in women in their third trimester of pregnancy or in older children with congenital hip dysplasia. 4. Swan-neck fingers are seen in clients with rheumatoid arthritis.

Which intervention should the nurse implement for a client with a fractured hip in Buck's traction? 1. Assess the insertion sites for signs and symptoms of infection. 2. Monitor for drainage or odor from under the plaster covering the pins. 3. Check the condition of the skin beneath the Velcro boot frequently. 4. Take weights off for one (1) hour every eight (8) hours and as needed

1. Skeletal traction has a pin, screws, tongs, or wires inserted into the bone. There is no insertion site in skin traction. 2. Plaster traction is a combination of skeletal traction using pins and a plaster brace to maintain alignment of any deformities. **3. In Buck's traction, a Velcro boot is used to attach the ropes to weights to maintain alignment. Skin covered by the boot can become irritated and break down. 4. Buck's traction is applied preoperatively to prevent muscle spasms and maintain alignment, and the weights should not be removed unless assessing for skin breakdown.

The client diagnosed with an acute exacerbation of SLE is prescribed high-dose steroids. Which statement best explains the scientific rationale for using high-dose steroids in treating SLE? 1. The steroids will increase the body's ability to fight the infection. 2. The steroids will decrease the chance of the SLE spreading to other organs. 3. The steroids will suppress tissue inflammation, which reduces damage to organs. 4. The steroids will prevent scarring of skin tissues associated with SLE.

1. Steroid medications mask the development of infections because steroids suppress the immune system's response. 2. SLE does not metastasize, or "spread"; it does invade other organ systems, but steroids do not prevent this from happening. **3. The main function of steroid medications is to suppress the inflammatory response of the body. 4. Steroid medications can delay the healing process, theoretically making scarring worse.

The client diagnosed with an acute exacerbation of SLE is being discharged with a prescription for an oral steroid which will be discontinued gradually. Which statement is the scientific rationale for this type of medication dosing? 1. Tapering the medication prevents the client from having withdrawal symptoms. 2. So thyroid gland starts working, because this medication stops it from working. 3. Tapering the dose allows the adrenal glands to begin to produce cortisol again. 4. This is the health-care provider's personal choice in prescribing the medication.

1. Steroids are not addicting. 2. The adrenal gland, not the thyroid gland, produces the glucocorticoid cortisol. **3. Tapering steroids is important because the adrenal gland stops producing cortisol, a glucocorticosteroid, when the exogenous administration of steroids exceeds what normally is produced. The functions of cortisol in the body are to regulate glucose metabolism and maintain blood pressure. 4. Tapering the dose is standard medical practice, not a whim of the HCP.

The female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 minutes every day. Which response is most appropriate by the nurse? 1. Praise the client for committing to do this activity. 2. Explain to the client walking 30 minutes a day is a better activity. 3. Encourage the client to swim every other day instead of daily. 4. Discuss with the client how sedentary activities help prevent osteoporosis.

1. Swimming is not as beneficial as walking in maintaining bone density because of the lack of weight-bearing activity. **2. Weight-bearing activity, such as walking, is beneficial in preventing or slowing bone loss. The mechanical force of weight-bearing exercises promotes bone growth. 3. Swimming is not as beneficial in maintaining bone density because of the lack of weight-bearing activity. 4. A sedentary lifestyle is a risk factor for the development of osteoporosis.

The nurse is caring for the client diagnosed with fat embolism syndrome. Which HCP order should the nurse question? 1. Maintain heparin to achieve a therapeutic level. 2. Initiate and monitor intravenous fluids. 3. Keep the O2 saturation higher than 93%. 4. Administer an intravenous loop diuretic

1. The HCP should prescribe heparin to treat a fat embolism. 2. The client should be hydrated to prevent platelet aggregation. 3. The nurse should monitor oxygen levels and administer oxygen as needed to prevent further complications. ***4. The nurse should question this order. This will decrease the client's hydration and may result in further embolism.

The nurse and a female unlicensed assistive personnel (UAP) are caring for a group of clients on a medical floor. Which action by the UAP warrants immediate intervention by the nurse? 1. The UAP washes her hands before and after performing vital signs on a client. 2. The UAP dons sterile gloves prior to removing an indwelling catheter from a client. 3. The UAP raises the head of the bed to a high Fowler's position for a client about to eat. 4. The UAP uses a fresh plastic bag to get ice for a client's water pitcher.

1. The UAP should wash the hands before and after client care. **2. The UAP can remove an indwelling catheter with nonsterile gloves. This is a waste of expensive equipment. The nurse is responsible for teaching UAPs appropriate use of equipment and supplies and cost containment. 3. Raising the head of the bed to a 90-degree angle (high Fowler's position) during meals helps to prevent aspiration. 4. Using a clean plastic bag to access the ice machine indicates the assistant is aware of infection control procedures.

The nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nursing implement postoperatively? 1. Keep an abduction pillow in place between the legs at all times. 2. Cough and deep breathe at least every four (4) to five (5) hours. 3. Turn to both sides every two (2) hours to prevent pressure ulcers. 4. Sit in a high-seated chair for a flexion of less than 90 degrees

1. The abduction pillow should be kept between the legs while in bed to maintain a neutral position and prevent internal rotation. 2. The client should deep breathe and cough at least every two (2) hours to prevent atelectasis and pneumonia. 3. The client will need to turn every two (2) hours but should not turn to the affected side. **4. Using a high-seated toilet and chair will help prevent dislocation by limiting the flexion to less than 90 degrees.

The nurse is providing discharge teaching to the 12-year-old with a fractured humerus and the parents. Which information should the nurse include regarding cast care? 1. Keep the fractured arm at heart level. 2. Use a wire hanger to scratch inside the cast. 3. Apply an ice pack to any itching area. 4. Explain foul smells are expected occurrences.

1. The arm should be elevated above the heart, not at heart level. 2. The nurse should instruct the child to not insert anything under the cast because it could cause a break in the skin leading to an infection. **3. Applying ice packs to the cast will relieve itching, and nothing should be placed down a cast to scratch. Skin becomes fragile inside the cast and is torn easily. Alteration in the skin's integrity can become infected. 4. Smells indicate infection and should be reported to the HCP.

The client is scheduled for a computed tomography (CT) scan. Which question is most important for the nurse to ask before the procedure? 1. "On a scale of 1 to 10, how do you rate your pain?" 2. "Do you feel uncomfortable in enclosed spaces?" 3. "Are you allergic to seafood or iodine?" 4. "Have you signed a permit for this procedure?"

1. The assessment of the pain is important so the client will be able to tolerate the procedure. Pain is not a life-threatening problem but is a quality-of-care issue. 2. This is an appropriate question for a client having a closed MRI, not a CT scan. **3. This is the most important information the nurse should obtain. Any client who is allergic to seafood cannot be injected with the iodine-based contrast. This contrast could cause an allergic response endangering the client's life. 4. The general consent for admission to the hospital covers this procedure. A separate informed consent is not required.

34. The 84-year-old client is a resident in a long-term care facility. Which intervention should be implemented to help prevent complications secondary to osteoporosis? 1. Keep the bed in the high position. 2. Perform passive range-of-motion exercises. 3. Turn the client every two (2) hours. 4. Provide nighttime lights in the room.

1. The bed should be kept in the low position. Preventing falls is a priority for a client diagnosed with osteoporosis. 2. Range-of-motion (ROM) exercises will help prevent deep vein thrombosis or contractures, but they do not help prevent osteoporosis. 3. Turning the client will help prevent pressure ulcers, but does not help prevent osteoporosis. **4. Nighttime lights will help prevent the client from falling; fractures are the number-one complication of osteoporosis.

The nurse is planning the care for a client diagnosed with RA. Which intervention should be implemented? 1. Plan a strenuous exercise program. 2. Order a mechanical soft diet. 3. Maintain a keep-open IV. 4. Obtain an order for a sedative.

1. The client diagnosed with RA is generally fatigued, and strenuous exercise increases the fatigue, places increased pressure on the joints, and increases pain. 2. The client should be on a balanced diet high in protein, vitamins, and iron for tissue building and repair and should not require a mechanically altered diet. 3. There is no specific reason for the client to be ordered a keep-open IV; the client can swallow needed medications. **4. Sleep deprivation resulting from pain is common in clients diagnosed with RA. A mild sedative can increase the client's ability to sleep, promote rest, and increase the client's tolerance of pain.

The nurse is caring for clients on a medical floor. Which client should the nurse assess first? 1. The client diagnosed with RA complaining of pain at a "3" on a 1-to-10 scale. 2. The client diagnosed with SLE who has a rash across the bridge of the nose. 3. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV. 4. The client diagnosed with scleroderma who has hard, waxlike skin near the eyes.

1. The client in pain should receive medication as soon as possible to keep the pain from becoming worse, but the client is not at risk for a serious complication. 2. A butterfly rash across the bridge of the nose occurs in approximately 50% of the clients diagnosed with SLE. **3. Antineoplastic drugs can be caustic to tissues; therefore, the client's IV site should be assessed. The client should be assessed for any untoward reactions to the medications first. 4. Scleroderma is a disease characterized by waxlike skin covering the entire body. This is expected for this client.

The recovery room nurse is caring for a client who has just had a left BKA. Which intervention should the nurse implement? 1. Assess the client's surgical dressing every two (2) hours. 2. Do not allow the client to see the residual limb. 3. Keep a large tourniquet at the client's bedside. 4. Perform passive range-of-motion exercises to the right leg.

1. The client is in the recovery room, and the dressing must be assessed more frequently than every two (2) hours. 2. The client must come to terms with the amputation; therefore, the nurse should encourage the client to look at the residual limb. **3. The large tourniquet can be used if the residual limb begins to hemorrhage either internally or externally. 4. The nurse should encourage active, not passive, range-of-motion exercises

The client is three (3) hours postoperative left AKA. The client tells the nurse, "My left foot is killing me. Please do something." Which intervention should the nurse implement? 1. Explain to the client his left leg has been amputated. 2. Medicate the client with a narcotic analgesic immediately. 3. Instruct the client on how to perform biofeedback exercises. 4. Place the client's residual limb in the dependent position.

1. The client is three (3) hours postoperative and needs medical intervention. **2. Phantom pain is caused by severing the peripheral nerves. The pain is real to the client, and the nurse needs to medicate the client immediately. 3. Biofeedback exercises will not help address the client's postoperative surgical pain. 4. Placing the residual limb below the heart (dependent) will not help address the client's pain and could actually increase the pain

The nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify? 1. Risk for ineffective coping related to the inability to perform ADLs. 2. Risk for compartment syndrome-related injured muscle tissue. 3. Risk for infection related to exposed bone and tissue. 4. Risk for complications related to compromised neurovascular status.

1. The client may experience difficulty coping depending on how much mobility the client has after medical treatment, but it is not the most appropriate nursing diagnosis at this time. 2. Compartment syndrome (edema within a muscle compartment) may occur, but there are multiple complications the nurse should be assessing for, so this is not the most appropriate nursing intervention. 3. The client has a closed fracture, so there is no exposed bone or tissue. **4. Assessing and preventing complications related to the neurovascular compromise is the most appropriate intervention because, if there are no complications, a closed fracture should heal without problems

The client diagnosed with RA is being seen in the outpatient clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits? 1. Perform joint x-rays to determine progression of the disease. 2. Send blood to the lab for an erythrocyte sedimentation rate. 3. Recommend the flu and pneumonia vaccines. 4. Assess the client for increasing joint involvement.

1. This is done, but it will not prevent any disease from occurring. 2. This will follow the progression of the disease of RA, but it is not preventive. **3. RA is a disease with many immunological abnormalities. The clients have increased susceptibility to infectious disease, such as the flu or pneumonia, and therefore vaccines, which are preventive, should be recommended. 4. Assessing the client does not address preventive care.

Which psychosocial problem should the nurse identify for a client with an external fixator device? 1. Ineffective coping. 2. Alteration in body image. 3. Grieving. 4. Impaired communication.

1. The client problem of ineffective coping is usually not indicated for a client with an external fixator device, unless the stem provides more information about the client. **2. Many clients with an external fixator have alterations in body image because the large, bulky frame makes dressing difficult and because of scarring which occurs from the trauma and treatment. The length of healing is prolonged, so returning to the client's normal routine is delayed. 3. The client problem of grieving is usually not indicated for a client with an external fixator device, unless the stem of the question provides more information about the client. 4. The client problem of impaired communication is usually not indicated for a client with an external fixator device, unless the stem provides more information about the client.

A client sustained a fractured femur in a motor-vehicle accident. Which data require immediate intervention by the nurse? Select all that apply. 1. The client requests pain medication to sleep. 2. The client has eupnea and normal sinus rhythm. 3. The client has petechiae over the neck and chest. 4. The client has a high arterial oxygen level. 5. The client has yellow globules floating in the urine

1. The client requesting something for sleep is expected and does not require notifying the HCP. 2. Normal respirations and heart rate do not require notifying the HCP. **3. Petechiae are macular, red-purple pinpoint bleeding under the skin. The appearance of petechiae is a classic sign of fat embolism syndrome. 4. The arterial oxygen level would be low, not elevated. This sign does not warrant immediate intervention. ***5. Yellow globules in the urine are fat globules released from the bone as it breaks. This should be reported immediately.

The nurse is caring for a client in a hip spica cast. Which intervention should the nurse include in the plan of care? 1. Assess the client's popliteal pulses every shift. 2. Elevate the leg on pillows and apply ice packs. 3. Teach the client how to ambulate with a tripod walker. 4. Assess the client for distention and vomiting.

1. The client's popliteal pulse will be under the cast and cannot be assessed by the nurse; circulation is assessed by the 6 Ps of the neurovascular assessment. 2. Elevation should be used with an arm cast or leg cast, but this is not possible with a spica cast. 3. Clients with spica casts will not be able to ambulate because the cast covers the entire lower half of the body. **4. The nurse should assess the client for signs and symptoms of cast syndrome—vomiting after meals, epigastric pain, and abdominal distention. This is caused by a partial bowel obstruction from compression and can lead to complete obstruction. The client may still have bowel sounds present with this syndrome.

The client diagnosed with RA who has been prescribed etanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach? 1. Explain the medication loses its efficacy after a few months. 2. Continue to have checkups and lab work while taking the medication. 3. Have yearly magnetic resonance imaging to follow the progress. 4. Discuss the drug is taken for three (3) weeks and then stopped for a week.

1. The drug does not lose efficacy, and clients are removed from the drug when the body cannot tolerate the side effects. **2. The drug requires close monitoring to prevent organ damage. 3. MRI scans are not used to determine the progress of RA. 4. There is no "off" period for the drug.

The client admitted with a diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? 1. Adjust the patient-controlled analgesia (PCA) machine for a lower dose. 2. Ensure the weights of the Buck's traction are off the floor and hang freely. 3. Raise the head of the bed to 45 degrees and the foot to 15 degrees. 4. Turn the client on the affected leg using pillows to support the other leg.

1. The health-care provider orders the dosage on a PCA. Unless a range of dosages or a new order is obtained, a lower dose will not help pain. **2. Weights from traction should be off the floor and hanging freely. Buck's traction is used to reduce muscle spasms preoperatively in clients who have fractured hips. 3. Raising the head of the bed or the foot will alter the traction. 4. Turning the client to the affected side could increase pain rather than relieve it.

The client recently diagnosed with SLE asks the nurse, "What is SLE and how did I get it?" Which statement best explains the scientific rationale for the nurse's response? 1. SLE occurs because the kidneys do not filter antibodies from the blood. 2. SLE occurs after a viral illness as a result of damage to the endocrine system. 3. There is no known identifiable reason for a client to develop SLE. 4. This is an autoimmune disease that may have a genetic or hormonal component.

1. The kidneys filter wastes, not antibodies, from the blood. 2. The problem is an overactive immune system, not damage to the endocrine system. There is no research supporting a virus as an initiating factor. 3. SLE is an autoimmune disease characterized by exacerbations and remission. There is empirical evidence indicating hormones may cause the development of the disease, and some drugs can initiate the process. **4. There is evidence for familial and hormonal components to the development SLE. SLE is an autoimmune disease process in which there is an exaggerated production of autoantibodies.

Which priority intervention should the day surgery nurse implement for a client who has had right knee arthroscopy? 1. Encourage the client to perform range-of-motion exercises. 2. Monitor the amount and color of the urine. 3. Check the client's pulses distally and assess the toes. 4. Monitor the client's vital signs.

1. The nurse should not encourage range of motion until the surgeon gives permission for flexion of the knee. 2. Urinary output is important postoperatively, but monitoring it is not priority over a neurovascular assessment. ***3. Neurovascular assessment is priority because this surgery has two to three small incisions in the knee area. The nurse needs to make sure circulation is getting past the surgical site. 4. Vital signs should be assessed, but the priority is to maintain the neurovascular status of the limb.

The nurse is caring for an 80-year-old client admitted with a fractured right femoral neck who is oriented × 1. Which intervention should the nurse implement first? 1. Check for a positive Homans' sign. 2. Encourage the client to take deep breaths and cough. 3. Determine the client's normal orientation status. 4. Monitor the client's Buck's traction.

1. There is controversy over assessing for a positive Homans' sign, but it is not the first intervention for a client who is oriented to person only. 2. Encouraging the client to take deep breaths and cough aids in the exchange of gases. Mental changes are early signs of hypoxia in the elderly client, but the nurse must first determine if mental changes have occurred. **3. The nurse is not aware of the client's usual mental status so, before taking any further action, the nurse should determine what is normal or usual for this client. 4. Checking the client's Buck's traction will not address the problem of confusion. This will not address taking care of the orientation of the client

The client is taking calcium carbonate (Tums) to help prevent further development of osteoporosis. Which teaching should the nurse implement? 1. Encourage the client to take Tums with at least eight (8) ounces of water. 2. Teach the client to take Tums with the breakfast meal only. 3. Instruct the client to take Tums 30 to 60 minutes before a meal. 4. Discuss the need to get a monthly serum calcium level.

1. There is no reason to take Tums with eight (8) ounces of water. Tums are usually chewed. 2. Tums should not be taken with meals. **3. Free hydrochloric acid is needed for calcium absorption; therefore, Tums should be taken on an empty stomach. 4. To determine the effectiveness of calcium supplements, the client must have a bone density test, not a serum calcium level measurement.

The school nurse is completing spinal screenings. Which data require a referral to an HCP? 1. Bilateral arm lengthening while bending over at the waist. 2. A deformity which resolves when the head is raised. 3. Equal spacing of the arms and body at the waist. 4. A right arm lower than the left while bending over at the waist.

1. These are normal data and do not require intervention. 2. If the screener suspects the client has scoliosis while the client is bending over, the screener asks the client to raise the head. An abnormality caused by scoliosis will not resolve. 3. This indicates a normal occurrence and does not need to be referred. *** 4. Unequal arm length may indicate scoliosis, and further assessment is needed by an HCP.

The client with a long arm cast is complaining of unrelenting severe pain and feeling as if the fingers are asleep. Which complication should the nurse suspect the client is experiencing? 1. Fat embolism. 2. Compartment syndrome. 3. Pressure ulcer under cast. 4. Surgical incision infection.

1. These are not signs/symptoms of a fat embolism. **2. These are the classic signs/symptoms of compartment syndrome. 3. Clients in casts rarely develop pressure ulcers and usually they are not painful. 4. Hot spots on the cast usually indicate an infection of the surgical incision under the

The nurse is caring for a client with a left fractured humerus. Which data warrant intervention by the nurse? 1. Capillary refill time is less than three (3) seconds. 2. Pain is not relieved by the patient-controlled analgesia. 3. Left fingers are edematous and the left hand is purple. 4. Warm and dry skin on left fingers distal to the elastic bandage.

1. This is a normal assessment finding and does not require immediate action. ***2. Unrelieved pain should warrant intervention by the nurse. Pain may indicate a complication or the need for pain medication, but either way it warrants intervention. 3. Edema and a hematoma as a result of the injury are expected and do not warrant intervention by the nurse. 4. The fingers distal to the Ace bandage indicate adequate circulation and require no intervention.

The elderly client is admitted to the hospital for severe back pain. Which data should the nurse assess first during the admission assessment? 1. The client's use of herbs. ***2. The client's current pain level. 3. The client's sexual orientation. 4. The client's ability to care for self.

1. This is a question the admitting nurse asks all clients, but it is not the most important. 2. Pain assessment and management are the most important issues if the client is breathing and has circulation. Lack of pain management decreases the attention of the client during the admission process. Pain is called the fifth vital sign. 3. Sexual practices are included in the admission forms, but they are not as important as pain management. 4. Assessing the client's ability to perform activities of daily living and self-care is important to prepare this client f

The client diagnosed with rule-out osteosarcoma asks the nurse, "Why am I having a bone scan?" Which statement is the nurse's best response? 1. "You seem anxious. Tell me about your anxieties." 2. "Why are you concerned? Your HCP ordered it." 3. "I'll have the radiologist come back to explain it again." 4. "A bone scan looks for cancer or infection inside the bones."

1. This is a therapeutic technique, but the client is asking for information. When a client seeks information, the nurse should give information first. Discussion of feelings should follow. 2. This nontherapeutic technique blocks communication between the client and the nurse. The nurse should avoid a response with the word "why," which asks the client to explain or justify feelings to the nurse. 3. When the client requests information, the nurse needs to provide accurate information, not pass the buck. **4. This statement answers the client's question.

Which client goal is most appropriate for a client diagnosed with OA? 1. Perform passive range-of-motion exercises. 2. Maintain optimal functional ability. 3. Client will walk three (3) miles every day. 4. Client will join a health club.

1. This is an intervention, not a goal, and "passive" means the nurse performs the range of motion, which should not be encouraged. **2. The two main goals of treatment for OA are pain management and optimizing functional ability of the joints to ensure movement of the joints. 3. Most clients with OA are elderly, are overweight, and have a sedentary lifestyle, so walking three (3) miles every day is not a realistic or safe goal. 4. Joining a health club is an intervention, and the fact the client joins the health club doesn't mean the client will exercise.

The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instruction should the nurse teach regarding the use of nonsteroidal antiinflammatory drugs (NSAIDs)? 1. Take with an over-the-counter medication for the stomach. 2. Drink a full glass of water with each pill. 3. If a dose is missed, double the medication at the next dosing time. 4. Avoid taking the NSAID on an empty stomach.

1. This is prescribing, and the nurse is not licensed to do this unless the nurse has become a nurse practitioner. 2. NSAIDs do not require a specific amount of water to be effective, unlike bulk laxatives. 3. The medication should be taken in the usual dose when the client realizes a dose has been missed. **4. NSAID medications decrease prostaglandin production in the stomach, resulting in less mucus production, which creates a risk for the development of ulcers. The client should take the NSAID with food.

The client diagnosed with osteoporosis asks the nurse, "Why does smoking cigarettes cause my bones to be brittle?" Which response by the nurse is most appropriate? 1. "Smoking causes nutritional deficiencies which contribute to osteoporosis." 2. "Tobacco causes an increase in blood supply to the bones, causing osteoporosis." 3. "Smoking low-tar cigarettes will not cause your bones to become brittle." 4. "Nicotine impairs the absorption of calcium, causing decreased bone strength."

1. This is the rationale for heavy alcohol use leading to the development of osteoporosis. 2. Smoking decreases, not increases, blood supply to the bone. 3. Cigarette smoking has long been identified as a risk factor for osteoporosis, and it doesn't matter if the cigarettes are low tar. **4. Nicotine slows the production of osteoblasts and impairs the absorption of calcium, contributing to decreased bone density.

The client diagnosed with OA is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which instruction should the nurse teach the client? 1. Take the medication on an empty stomach. 2. Make sure to taper the medication when discontinuing. 3. Apply the medication topically over the affected joints. 4. Notify the health-care provider if vomiting blood.

1. This medication should be taken with food to prevent gastrointestinal distress. 2. Glucocorticoids, not NSAIDs, must be tapered when discontinuing. 3. Topical analgesics are applied to the skin; NSAIDs are oral or intravenous medications. **4. NSAIDs are well known for causing gastric upset and increasing the risk for peptic ulcer disease, which could cause the client to vomit blood

The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day. The client asks the nurse, "Why do I need to lie on my stomach?" Which statement is the most appropriate statement by the nurse? 1. "This position will help your lungs expand better." 2. "Lying on your stomach will help prevent contractures." 3. "Many times this will help decrease pain in the limb." 4. "The position will take pressure off your backside

1. This position will decrease lung expansion. **2. The prone position will help stretch the hamstring muscles, which will help prevent flexion contractures leading to problems when fitting the client for a prosthesis. 3. Lying on the back will not help decrease actual or phantom pain. 4. This will help take pressure off the client's buttocks area, but it is not why it is recommended for a client with a lower extremity amputation.

The 27-year-old client has a right above-the-elbow amputation secondary to a boating accident. Which statement to the rehabilitation nurse indicates the client has accepted the amputation? 1. "I am going to sue the guy who hit my boat." 2. "The therapist is going to help me get retrained for another job." 3. "I decided not to get a prosthesis. I don't think I need it." 4. "My wife is so worried about me and I wish she weren't."

1. This statement does not indicate acceptance; the client is still in the anger stage of grieving. **2. Looking toward the future and problem-solving indicate the client is accepting the loss. 3. At this young age, a client with an upper extremity prosthesis needs to be thinking about obtaining employment and living a full life. Getting a prosthesis is important to pursue this goal. 4. This statement does not indicate acceptance; his wife will worry about the client's life, which has been changed dramatically.

Which intervention should the nurse include for a client diagnosed with carpal tunnel syndrome? 1. Teach hyperextension exercises to increase flexibility. 2. Monitor safety during occupational hazards. 3. Prepare for the insertions of pins or screws. 4. Monitor dressing and drain after the fasciotomy

1. Treatment for carpal tunnel syndrome does not include hyperextension of the wrist. **2. The nurse should monitor for potential injuries resulting from the alterations in motor, sensory, and autonomic function of the first three digits of the hand and palmar surface of the fourth. 3. Surgery may be needed to release the compression of the medial nerve, but pins and screws are used to hold the position. 4. Fasciotomy refers to the surgical excision of strips of connective tissue. This is not applicable in clients with carpal tunnel syndrome.

The nurse enters the room of a female client diagnosed with SLE and finds the client crying. Which statement is the most therapeutic response? 1. "I know you are upset, but stress makes the SLE worse." 2. "Please explain to me why you are crying." 3. "I recommend going to an SLE support group." 4. "I see you are crying. We can talk if you would like."

1. Unless the nurse has SLE and has been through the exact same type of tissue involvement, then the nurse should not tell a client "I know." This does not address the client's feelings. 2. The nurse should never ask the client "why." The client does not owe the nurse an explanation of his or her feelings. 3. Support groups should be recommended, but this is not the best response when the client is crying. **4. The nurse stated a fact, "You are crying," and then offered self by saying "Would you like to talk? ?" This addresses the nonverbal cue, crying, and is a therapeutic response.

The client is postoperative open reduction and internal fixation (ORIF) of a fractured femoral neck. Which long-term goal should the nurse identify for the client? 1. The client will maintain vital signs within normal limits. 2. The client will have a decrease in muscle spasms in the affected leg. 3. The client will have no signs or symptoms of infection. 4. The client will be able to ambulate down to the nurse's station.

1. Vital signs remaining stable is a short-term goal, not a long-term goal. 2. This is an expected short-term outcome for a preoperative client with a fractured femoral neck. 3. No signs/symptoms of infection is a short-term goal for the nurse to identify in the hospital. **4. The discharge goal or long-term goal for this client is to return the client to ambulatory status.

The male nurse is helping his friend cut wood with an electric saw. His friend cuts two fingers of his left hand off with the saw. Which action should the nurse implement first? 1. Wrap the left hand with towels and apply pressure. 2. Instruct the friend to hold his hand above his head. 3. Apply pressure to the radial artery of the left hand. 4. Go into the friend's house and call 911.

1. Wrapping the hand with towels is appropriate, but it is not the first intervention. 2. Holding the arm above the head will help decrease the bleeding, but it is not the first intervention. **3. Applying direct pressure to the artery above the amputated parts will help decrease the bleeding immediately and is the first intervention the nurse should implement. Then the nurse should instruct the client to hold the hand above the head, apply towels, and call 911. 4. Calling 911 should be done, but it is not the first intervention.

A client recovering from a total hip replacement has developed a deep vein thrombosis. The health-care provider has ordered a continuous infusion of heparin, an anticoagulant, to infuse at 1,200 units per hour. The bag comes with 20,000 units of heparin in 500 mL of 0.9% normal saline. At what rate should the nurse set the pump? ______

30 mL/hr. Divide the amount of heparin by the volume of fluid to get the concentration: 20,000 units ÷ 500 mL = 40 units of heparin per 1 mL Divide the dose ordered by the concentration for the amount of milliliters per hour to set the pump: 1,200 units/hr ÷ 40 units/mL = 30 mL/hr

The client must take three (3) grams of calcium supplement a day. The medication comes in 500-mg tablets. How many tablets will the client need to take daily? _______

Six (6) tablets. 1,000 mg is equal to one (1) gram. Therefore, three (3) grams is equal to 3,000 mg. If one (1) tablet is 500 mg, the client will need six (6) tablets to get the total amount of calcium needed daily: 3,000 ÷ 500 = 6

The emergency department nurse is caring for a client with a compound fracture of the right ulna. Which interventions should the nurse implement? List in order of priority. 1. Apply a sterile, normal saline-soaked gauze to the arm. 2. Send the client to radiology for an x-ray of the arm. 3. Assess the fingers of the client's right hand. 4. Stabilize the arm at the wrist and the elbow. 5. Administer a tetanus toxoid injection.

The order should be 4, 1, 3, 2, 5. 4. The nurse first should stabilize the arm to prevent further injury. 1. A compound fracture is one in which the bone protrudes through the skin. The nurse should apply sterile, saline-soaked gauze to protect the area from the intrusion of bacteria. 3. The nurse should assess the client's circulation to the part distal to the injury. This is done after the first two interventions because life-threatening complications could occur if stabilization and protection from infection are not addressed first 2. An x-ray will be needed to determine the extent of the injury. 5. A tetanus toxoid injection should be administered, but this can be done last.