Musculoskeletal
825. Cyclobenzaprine is prescribed for a client for muscle spasms and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the health care provider about the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hypothyroidism 4. Diabetes mellitus
1 Rationale: Because cyclobenzaprine has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pres- sure. Cyclobenzaprine should be used only for a short time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication. Test-Taking Strategy: Focus on the subject, a contraindication to cyclobenzaprine. Recalling that this medication has anticho- linergic effects will direct you to the correct option.
16. A patient is experiencing severe lower back pain that radiates down the leg causing weakness. Which diagnostic test should be considered after an MRI? 1) CT scan 2) Bone scan 3) Spinal x-ray 4) Electromyography
1) A CT scan is indicated when the spinal and neurological levels or exam are clear (normal) and bony pathology is suspected such as a disk rupture, spinal stenosis, or damage to vertebrae. 2) A bone scan may be performed to rule out a pathologic condition or infection. 3) An x-ray can help determine the obvious causes of LBP such as fractures, degenerative changes, curves, and deformities. 4) Electromyography assesses the electrical activity in a nerve to detect muscle weakness.
4. A patient has an injury where one side of the bone is bent and the other is fractured. How should the nurse document this fracture? 1) Spiral 2) Oblique 3) Greenstick 4) Comminuted
1) A spiral fracture wraps around the shaft of the bone. 2) An oblique fracture line occurs usually at a 45-degree angle across the cortex of the bone. 3) A greenstick fracture is an incomplete disruption where one side of the bone is bent and the other is fractured. 4) A comminuted fracture has several disruptions producing shattered bone fragments within the fracture site.
25. 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 the 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.
41. 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. TEST-TAKING HINT: The test taker should make sure he or she knows what the question is asking before selecting the option. The question is asking "what will help preserve the thumb?"—which is the key to answering this question.
20. 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 pro- vides 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.
801. The nurse has given instructions to a client return- ing home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? 1. "I can resume regular exercise tomorrow." 2. "I can't eat food for the remainder of the day." 3. "I need to stay off the leg entirely for the rest of the day." 4. "I need to report a fever or swelling to my health care provider."
4 Rationale: After arthroscopy, the client usually can walk care- fully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the health care provider. Test-Taking Strategy: Focus on the subject, teaching points fol- lowing knee arthroscopy. Recalling the general client teaching points related to surgical procedures and that a risk for infection existsafterasurgicalprocedurewilldirectyoutothecorrectoption.
3. The nurse is completing a health screening for a school-age child with rheumatoid arthritis (RA). The parents ask the nurse to recommend activities that will promote exercise for their child. Which recommendation by the nurse is the most appropriate? 1) Running 2) Softball 3) Football 4) Swimming
4) Swimming exercises all the extremities without putting undue stress on joints Running, softball or football could exacerbate joint discomfort.
808. The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? 1. Elevated for 3 hours, then flat for 1 hour 2. Flat for 3 hours, then elevated for 1 hour 3. Flat for 12 hours, then elevated for 12 hours 4. Elevated on pillows continuously for 24 to 48 hours
1 Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry; using the fingertips results in indentations in the cast and skin pressure under the cast. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast because of the risk of altered skin integrity; the client may use a hair dryer on the cool setting to relieve an itch. Test-Taking Strategy: Focus on the subject, client understand- ing about cast care. Knowing that a wet cast can be dented with the fingertips, causing pressure underneath, helps to eliminate option 3 first. Knowing that the cast needs to dry helps to elim- inate option 2 next. Option 4 is dangerous to skin integrity and is also eliminated. Remember that plaster casts, once they have dried after application, should not become wet.
811. The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. Oxygen saturation of 85%4. 4. Arterial oxygen level of 78 mm Hg (10.3 kPa)
1 Rationale: An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80-100 mm Hg (10.6-13.33 kPa). Oxygen saturation should be higher than 95%.Test-Taking Strategy: Note the strategic word, most. Knowing that the arterial oxygen and oxygen saturation levels are below normal helps to eliminate options 3 and 4. Dyspnea, even at a minimal level, is not normal, so eliminate option 2.Review: The expected outcomes in a client being treated for fat embolism
820. Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide? 1. Drink 3000mL of fluid a day. 2. Take the medication on an empty stomach. 3. The effect of the medication will occur immediately. 4. Any swelling of the lips is a normal expected response.
1 Rationale: Clients taking allopurinol are encouraged to drink 3000 mLof fluid a day, unless otherwise contraindicated. Afull therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. Aclient who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the health care provider because this may indicate hypersensitivity.Test-Taking Strategy: Focus on the subject, client instructions for allopurinol. Option 4 can be eliminated easily because it indicates hypersensitivity, which is not a normal expected response. From the remaining options, recalling that this med- ication is used to treat gout and recalling the pathophysiology of this disorder will direct you to the correct option.Review: The client instructions related to allopurinol
816. The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1. Temperature of 101.6°F (38.7°C) orally 2. Complaints of discomfort during repositioning 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep- breathing exercises
1 Rationale: The nursing assessment conducted after spinal sur- geryissimilartothatdoneafterothersurgicalprocedures.Forthis specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watchesforsignsandsymptomsof infection,and inspectsthesurgicalsiteforevidenceofcerebrospi- nal fluid leakage (drainage is clear and tests positive for glucose). Amild temperature is expected after insertion of hardware, but a temperature of 101.6 °F (38.7 °C) should be reported. Test-Taking Strategy: Note the strategic word, most. Deter- mine if an abnormality exists. Thus, you are looking for the option that has the greatest deviation from normal. Options 2 and 4 are expected after surgery and, although the nurse tries to minimize discomfort, the client is likely to have some dis- comfort, even with proper analgesic use. The words old and out- lined in option 3 indicate that this is not a new occurrence. This leaves the temperature of 101.6 °F (38.7 °C), which is excessive and should be reported.
11. During a home visit the nurse suspects that a patient recovering from an amputation is not complying with prescribed postoperative care. What observation caused the nurse to make this clinical determination? 1) Suture line pink and slightly edematous 2) Evidence of a developing hip contracture 3) Stump wrapped with a compression bandage 4) Taking opioid medication every 8 to 10 hours
1) A pink and slightly edematous suture line would indicate healing. 2) A developing hip contracture indicates that the patient is not complying with postoperative exercises and actions to prevent the development of a contracture. 3) Wrapping the stump with a pressure bandage decreases edema and aids in the correct fitting of the prosthesis. 4) Taking pain medication as prescribed indicates adherence to postoperative teaching and care.
6. While playing tennis a patient fell and fractured the right elbow. For which treatment should the nurse prepare this patient? 1) Cast 2) Splint 3) External fixator 4) Pressure dressing
1) An elbow fracture is immobilized with a cast. 2) A fractured forearm or clavicle would be immobilized with a splint. 3) A fractured wrist may need to be immobilized with an external fixator. 4) A fractured wrist may be immobilized with a pressure dressing.
11. A patient with severe hip pain is diagnosed with osteoarthritis (OA). What information should the nurse provide to the patient about this disease process? 1) "OA causes an overgrowth of cartilage in the joints." 2) "OA causes joint fluid to become bluish-white in color." 3) "OA causes a decrease in joint fluid that affects the cartilage." 4) "OA causes a build of fluid in the joints, hindering movement."
1) OA causes a breakdown of the cartilage in the joints. 2) OA causes joint fluid to change to yellow-brown in color. 3) In OA, there is a decrease in the proteoglycans, which are responsible for the management of the fluid within the joints. The result is a loss of cartilage strength and functionality. 4) OA does not affect the volume of joint fluid.
24) A victim of a motor vehicle crash has a partially severed lowered extremity. What emergency care does this patient need? Select all that apply. 1) Administer antibiotics 2) Prepare for blood transfusions 3) Prepare for emergency surgery 4) Assess for active hemorrhaging 5) Monitor effectiveness of tourniquet
1) Antibiotics are not part of emergency care for a traumatic amputation. 2) To prevent hemorrhagic shock after a traumatic amputation, the patient should be prepared for blood transfusions. 3) The patient with a traumatic amputation should be prepared for emergency surgery. 4) The patient with a traumatic amputation should be assessed for active hemorrhaging. 5) The tourniquet or pressure bandage placed over the site of a traumatic amputation should be assessed for effectiveness.
8. A patient recovering from total knee replacement surgery develops osteomyelitis. What teaching should the nurse prepare as a priority for this patient? 1) Antibiotic therapy 2) Pain management 3) Debridement of the wound 4) Removal of the knee prosthesis
1) Antibiotics will be prescribed; however, teaching about this medication can be instructed at any time. 2) The patient will be experiencing pain; however, teaching about pain management would not be a priority. With appropriate surgical and medical therapy, pain should be managed and decrease. 3) Surgical intervention with débridement is required when a patient with osteomyelitis demonstrates failure to respond to antibiotic therapy, evidence of soft tissue abscess or subperiosteal collection, suspected or confirmed joint infection, and/or progressive neurological deficits or spinal instability in the case of vertebral osteomyelitis. Since this patient's osteomyelitis is from orthopedic hardware, the hardware needs to be removed. 4) In the event that a patient has known or suspected infected orthopedic hardware, surgical removal is often warranted.
24. The nurse suspects that a home care patient recovering from hip replacement surgery is developing osteomyelitis. What findings caused the nurse to come to this conclusion? Select all that apply. 1) Fever 2) Bone deformity 3) Pain unrelieved by rest 4) Progressive muscle weakness 5) Tenderness and warmth at the surgical site
1) Clinical manifestations of acute osteomyelitis include fever. 2) Bone deformity is associated with Paget's disease. 3) Clinical manifestations of acute osteomyelitis include pain relieved by rest. 4) Progressive muscle weakness is associated with muscular dystrophy. 5) Clinical manifestations of acute osteomyelitis include tenderness and warmth at the site.
14. The manager notes that several nurses have been seen in employee health for low back pain over the last month. What type of education should the manager plan to help reduce the incidence of this health problem? 1) Safety 2) Body mechanics 3) Coordinating care 4) Stress management
1) Education about safety will not reduce the risk for low back pain. 2) Risk factors for low back pain include poor body mechanics, which would be helpful for nurses. 3) Coordinating care is not a risk factor for low back pain. 4) Stress is not a risk factor for low back pain even though stress is a part of the diagnosis for low back pain.
3. A 70-year-old patient is diagnosed with a low energy fracture. What most likely caused this injury to occur? 1) A fall 2) Contact sport 3) Bicycle accident 4) Motor vehicle collision
1) Fractures in people 65 or older are generally caused by low-energy trauma such as falls. 2) Contact sports cause high-energy injuries. 3) Bicycle accidents are a type of high-energy trauma. 4) Motor vehicle collisions are a type of high-energy trauma.
12. The blood pressure of a patient recovering from total hip replacement surgery is dropping. What should the nurse suspect is occurring with this patient? 1) Blood loss 2) Pain medication overdose 3) Development of a deep vein thrombosis 4) Development of a postoperative infection
1) Hypotension may signal blood loss. 2) A reduction in respiratory rate would be seen in the patient who is overmedicated for pain. 3) Pain, redness, and edema would indicate a deep vein thrombosis. 4) Increased temperature and purulent drainage would indicate a postoperative infection.
6. A nurse is caring for a pregnant patient who has rheumatoid arthritis (RA). Based on this data, which does the nurse anticipate when providing care to this patient? 1) A higher risk for preterm delivery 2) An increased need for medication 3) An acute exacerbation of symptoms 4) A continued risk for anemia
1) Many pregnant patients with RA may have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. 2) Due to remission, a decrease in medication is often necessitated. 3) Many pregnant patients with RA may have prolonged gestations and often experience a remission during pregnancy and relapse after delivery. 4) The pregnant patient with RA is at a continued risk for anemia.
5. A patient with low back pain asks what aspirin is supposed to do help with the pain. How should the nurse respond to this patient? 1) "It depresses the central nervous system." 2) "It blocks sodium channels and stops the formation of nerve impulses." 3) "It blocks enzymes and chemicals in the body to decrease pain and inflammation." 4) "It blocks the production of substances that trigger allergic and inflammatory reactions."
1) Muscle relaxants depress the central nervous system. 2) Tricyclic antidepressants block the sodium channels and decrease formation of ectopic neuronal pacemakers. 3) NSAIDs block enzymes and prostaglandins throughout the body, thereby decreasing pain and inflammation. 4) Corticosteroids block the production of substances that trigger allergic and inflammatory reactions.
9. A patient with peripheral vascular disease has a non-healing leg wound. Which observation indicates that the patient is at risk for an elective amputation? 1) Mutilation of soft tissue 2) Development of gangrene 3) Crushed lower extremity bone 4) Severed blood vessels and nerves
1) Mutilation of soft tissue occurs with a traumatic amputation. 2) Elective amputations are caused by disease that alters perfusion. Cell death causes necrotic tissue to form. The wound acts as a portal for an infection that can lead to gangrene. 3) A traumatic amputation mutilates bones. 4) A traumatic amputation severed blood vessels and nerves.
4. A patient with low back pain asks why nerve conduction studies are prescribed. What explanation should the nurse provide to the patient relative to this diagnostic test? 1) "It measures damage to nerves." 2) "It shows pressure on nerves from herniated disks." 3) "It measures electrical impulses within muscle tissue." 4) "It shows the structure of the vertebrae and joint outlines."
1) Nerve conduction studies (NCS) measure the electrical nerve impulse that indicates damage to the nerve. 2) A myelogram shows pressure on the spinal cord or nerves from herniated disks. 3) Electromyography (EMG) measures the electrical impulse within muscle tissue. 4) X-rays show the structure of the vertebrae and joint outlines.
7. A patient recovering from surgery to repair a fractured femur is experiencing extreme pain and pulselessness. What should the nurse expect to be prescribed for this patient? 1) Fasciotomy 2) Limb CT scan 3) Intravenous fluids 4) Anticoagulant therapy
1) Once compartment syndrome is suspected, the provider will often remove the cast or perform a fasciotomy to immediately relieve the compartment pressure. 2) A CT scan is not used to relieve the pressure of compartment syndrome. 3) Intravenous fluids would be prescribed to treat rhabdomyolysis. 4) Anticoagulant therapy would be prescribed to treat a deep vein thrombosis.
2. The nurse is collecting a health history for a patient in an outpatient clinic who reports joint pain and swelling for the last two months. The patient is diagnosed with rheumatoid arthritis (RA). When planning care for this patient, which statement supports the nursing diagnosis of Activity Intolerance? 1) "I seem to get tired early in the day and require a nap." 2) "My joints are stiffest at night before I go to sleep." 3) "I find it difficult to move when I first get up in the morning." 4) "I take ibuprofen for the pain as needed."
1) One hallmark symptom of RA is extreme fatigue. The patient's statement regarding the need for a nap supports the inclusion of Activity Intolerance in the plan of care. The nurse would teach the patient about frequent rest periods during the day to conserve energy. 2) Joints of the RA patient are stiffest in the morning. 3) The patient with RA will be stiff early in the morning, but that would not interfere with activities later in the day. 4) Taking ibuprofen for pain does not affect the ability for activity.
1. A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if the disease is caused by ethnicity. Which response by the nurse is the most appropriate? 1) "RA affects all races at the same rate." 2) "RA is most prevalent in Caucasian females." 3) "RA affects those of German descent most often." 4) "RA is most prevalent in men under the age of 20 years."
1) RA affects 12% of the total population across all races. 2) RA is not more prevalent in Caucasian females. 3) RA does not affect those of German descent most often. 4) It affects women three times more than men, and the onset is usually between the ages of 20 and 40 years.
25. The nurse notes that a patient with low back pain is experiencing radiculopathy. What should the nurse expect when assessing this patient? Select all that apply. 1) Pain 2) Edema 3) Weakness 4) Numbness 5) Inability to control motor movement
1) Radiculopathy is nerve root compression and can result in pain in the affected extremity. 2) Edema is not a manifestation of radiculopathy. 3) Radiculopathy is nerve root compression and can result in weakness in the affected extremity. 4) Radiculopathy is nerve root compression and can result in numbness in the affected extremity. 5) Radiculopathy is nerve root compression and can result in the inability to control motor movement in the affected area.
17. A patient is seeking medical treatment for chronic low back pain. Which approach will help speed this patient's recovery? 1) Regular exercise 2) Spinal injections 3) Nonsteroidal anti-inflammatory agents (NSAIDs) 4) Transcutaneous electrical nerve stimulation (TENS)
1) Regular exercise is an effective way to speed recovery and help strengthen the back and core muscles. 2) Spinal injections ease inflammation. 3) NSAIDs are recommended for pain relief. 4) Transcutaneous electrical nerve stimulation (TENS) stimulates the peripheral nerves via skin surface electrodes.
6. The nurse is caring for a patient with unrelenting low back pain caused by a herniated disk. What instruction should the nurse provide to this patient to help with the pain? 1) Sit with the legs elevated 2) Reduce the intake of fluids 3) Limit activity until the pain subsides 4) Bend at the knees with a straight back
1) Sitting with the legs elevated puts pressure on the lower spine. 2) Reducing the intake of fluids can cause constipation, which worsens back pain. 3) Activity should be performed as prescribed to build core muscle strength and stabilize and support the spine. 4) Bending at the knees with the back straight uses the leg muscles to lift and decreases strain on the back muscles.
8. A patient recovering from surgery to repair a fractured hip is placed on skin traction. Which finding indicates that the traction is being effective? 1) Strong peripheral pulses 2) Reduction in muscle spasms 3) Improved mobility of the foot 4) Reduction of lower extremity edema
1) Skin traction is not used to improve blood flow. 2) Skin traction is applied to relieve muscle spasms. 3) Skin traction is not used to improve mobility. 4) Skin traction is not used to reduce edema.
4. A patient with rheumatoid arthritis (RA) is being seen in the outpatient clinic for a progress check-up. The nurse is reviewing the patient's plan of care and determines that the patient has met a goal of treatment when the patient makes which statement? 1) "I sleep for 10 hours at night." 2) "I have increased pain in my joints all the time now." 3) "I have delegated many household chores to my children and spouse." 4) "I do not perform household chores at all anymore."
1) Sleeping for 10 hours at night will not alleviate the need for frequent rest periods during the day. 2) Increased joint pain would indicate that goals have not been met. 3) One technique for reducing stress on the joints is to delegate household tasks to family members. 4) The patient does not need to refrain from all household chores
5. The nurse is caring for a patient who was diagnosed with rheumatoid arthritis (RA) last year. The patient has recently been placed on prednisone for treatment. Which patient statement indicates that the medication teaching was successful? 1) "I will not have to limit my consumption of canned vegetables." 2) "I will take this medication on a full stomach to enhance absorption." 3) "I will not need to monitor my blood sugar more frequently while on this medication." 4) "I will take the ordered dose at the same time every day."
1) Steroids can cause fluid retention, so sodium intake should be limited. A hidden source of sodium is canned vegetables. 2) Steroids are taken with food to minimize GI distress, not to enhance absorption. 3) Steroids also increase blood sugar, so blood sugar may need to be monitored more frequently while on the medication regimen. 4) Steroid therapy is usually done as part of a tapered-dose treatment plan. It is important to take the medication at the same time each day.
23. The nurse suspects that a patient with an injured ankle is experiencing neurovascular compromise. What did the nurse assess to come to this conclusion? Select all that apply. 1) Pain 2) Pressure 3) Paralysis 4) Peristalsis 5) Pulselessness
1) Symptoms of neurovascular compromise include pain. 2) Symptoms of neurovascular compromise include pressure. 3) Symptoms of neurovascular compromise include paralysis. 4) Peristalsis is not a symptom of neurovascular compromise. 5) Symptoms of neurovascular compromise include pulselessness.
10. A patient recovering from a traumatic amputation is experiencing phantom limb pain. What should the nurse expect to be included in the treatment plan for this patient? 1) Gabapentin 2) Rigid splint 3) Ice compresses 4) Elevate stump on a pillow
1) The administration of antidepressant and anticonvulsant medications such as gabapentin has demonstrated effectiveness in treating phantom limb pain. 2) A rigid splint reduces edema and aids with fitting for a prosthesis. 3) Ice compresses promote vasoconstriction and decrease painful edema. 4) Elevation would encourage the development of contractures and would not help reduce phantom limb pain.
27. The nurse is planning care for a patient with osteoarthritis (OA). On what should the nurse focus when preparing teaching material for this patient? Select all that apply. 1) Weight management 2) Nonsteroidal therapy 3) Activity modification 4) Joint replacement surgery 5) Glucosamine and chondroitin
1) The initial medical management prior to joint replacement is focused on weight management. 2) The initial medical management prior to joint replacement is focused on nonsteroidal therapy. 3) The initial medical management prior to joint replacement is focused on activity modification. 4) The National Institute for Health and Care Excellence states that a total hip replacement (THR) or a total knee replacement (TKR) can be considered once self-management, exercise, and analgesia are no longer effective in relieving pain during activities of daily living. 5) The initial medical management prior to joint replacement is focused on the use of joint supplements such as glucosamine and chondroitin.
15. The nurse is preparing material about back pain for a community health fair. What should be included as a reason why this pain occurs most frequently in the lumbar region of the spine? 1) It contains peripheral nerves. 2) It is the most rigid area of the spine. 3) It is the most flexible area of the spine. 4) It anchors the weight of the lower body.
1) The lumbar region contains nerve roots that are susceptible to injury or disease. 2) The lumbar region is the most flexible area of the spine. 3) The lumbar region is the most flexible area of the spine. 4) The lumbar region supports the weight of the upper body.
7. A nurse is caring for a patient who is newly diagnosed with rheumatoid arthritis (RA). The patient asks the nurse what the difference is between RA and osteoarthritis (OA). Which response by the nurse is most appropriate? 1) "The onset of OA is gradual while the onset of RA may be rapid." 2) "With OA, multiple joints are symmetrically affected; RA affects one joint at a time." 3) "The affected joints in RA feel cold to the touch while the joints affected by OA are warm or hot to the touch." 4) "The pain and stiffness with RA is with activity; OA pain and stiffness is predominant upon arising."
1) The onset of OA is gradual while the onset of RA may be rapid. 2) RA affects multiple joints symmetrically while OA affects one joint at a time. 3) The affected joints in OA feel cold to the touch while the joints affected by RA are warm or hot to the touch. 4) Pain associated with RA is predominant upon arising versus the pain in OA, which is with activity.
1. A patient asks what smoking cigarettes has to do with low back pain. How should the nurse respond to this patient? 1) "Smoking is a sedentary activity." 2) "Smoking is linked to nutritional disorders." 3) "Nicotine in cigarettes interferes with nutrients that supply the disk spaces." 4) "Nicotine hinders the mobility of the vertebral spaces and interferes with nerve function."
1) There is no evidence to link smoking with a sedentary lifestyle. 2) There is no evidence to link smoking with nutritional disorders. 3) Nicotine in cigarettes is thought to interfere with vital nutrients being absorbed by the intervertebral disks. 4) There is no evidence to link nicotine to vertebral space mobility and nerve function.
26. The nurse is providing care to a patient who is receiving nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of rheumatoid arthritis. When providing care to this patient, which actions by the nurse are appropriate? Select all that apply. 1) Assessing for an allergic reaction 2) Monitoring for signs of renal problems 3) Advising against abrupt discontinuation of drugs 4) Assuring the patient that there is no relationship between NSAIDs and heart disease 5) Encouraging the patient to take with water, milk, or small snack to help avoid stomach distress
1) This is correct. When providing care to a patient who is receiving any medication, it is important to monitor the patient for signs of an allergic reaction. 2) This is correct. If you take NSAIDs in high doses, the reduced blood flow can permanently damage the kidneys, and it can eventually lead to kidney failure and require dialysis. 3) This is correct. Abrupt discontinuation can have serious side effects. 4) This is incorrect. NSAIDs have been linked to heart failure; therefore, this action by the nurse is not appropriate when providing care to this patient. 5) This is correct. Taking NSAIDs with food may help reduce irritation of the stomach and prevent an ulcer.
28. A patient recently diagnosed with rheumatoid arthritis (RA) asks the nurse if RA always causes crippling deformities. Which teaching topics will the nurse include as ways to decrease the likelihood of crippling deformities? Select all that apply. 1) Ignore pain as a warning signal 2) Use stronger joints for most activity 3) Avoid stress to any current area of deformity 4) Type instead of handwriting items if possible 5) Stop an activity if it is beyond your ability to perform
1) This is incorrect. Pain is a warning signal, and the patient with RA should stop any activity that causes pain. 2) This is correct. Using a stronger joint or part of the body, such as the palm, to carry items is preferable to grasping. 3) This is correct. When performing a task, the patient should avoid stress in the area of the deformity to help prevent further deformities. 4) This is correct. Writing requires using a strong grip, so typing is preferable. 5) This is correct. The patient with RA should never attempt to push a joint beyond its ability.
30. Which subjective findings should the nurse anticipate when assessing a patient diagnosed with gout? Select all that apply. 1) Presence of tophi 2) Tenderness on palpation 3) Reports of severe pain in the great toe 4) Patient states, "I cannot move my joint." 5) Soft tissue swelling accompanied by warmth
1) This is incorrect. This is an objective, not subjective, assessment finding for a patient diagnosed with gout. 2) This is incorrect. This is an objective, not subjective, assessment finding for a patient diagnosed with gout. 3) This is correct. This is a subjective assessment finding for a patient diagnosed with gout. 4) This is correct. This is a subjective assessment finding for a patient diagnosed with gout. 5) This is incorrect. This is an objective, not subjective, assessment finding for a patient diagnosed with gout.
24. A patient with low back pain asks what nonmedical treatments can be used to help with the discomfort. Which complementary and alternative therapies should the nurse recommend to this patient? Select all that apply. 1) Yoga 2) Qi gong 3) Acupuncture 4) Massage therapy 5) Chiropractic treatments
1) Yoga can be used as part of a general health regimen, to cope with illness, to improve physiological balance, or to increase relaxation; techniques include physical postures and breathing techniques with either a focused attention or an open attitude toward distractions. 2) Qi gong is an ancient Chinese discipline involving physical and mental exercises that focus on specific parts of the body. 3) Acupuncture is the insertion of small needles or exerting pressure on "energy" points in the body; the patient is supposed to experience a feeling of fullness, numbness, tingling, and warmth. 4) Massage therapy consists of alternating levels of concentrated pressure on the areas of spasm; once pressure is applied, it should not vary for 10 to 30 seconds. Massage also leads to increased endorphin levels (chemicals associated with decreased pain and increased euphoria) that are effective in chronic pain management. 5) Chiropractic treatments are not identified as a complementary or alternative therapy for low back pain.
27. A patient, recently diagnosed with rheumatoid arthritis (RA), asks the nurse whether RA will affect her in other ways. When responding to the patient, which systems will the nurse include as possibly being affected by the diagnosis? Select all that apply. 1) Exocrine 2) Respiratory 3) Hematologic 4) Reproductive 5) Cardiovascular
1), 2), 3), 5) This is correct. RA can affect the respiratory system with pleural effusion (collection of fluid in the pleural space); the cardiovascular system with coronary heart disease; the exocrine glands, resulting in dry eyes and mouth; and the hematologic system with a variety of disorders, particularly anemia 4) This is incorrect. If properly managed, RA is not considered to be a danger for pregnant women or their babies.
826. In monitoring a client's response to disease- modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply. 1. Control of symptoms during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show no progression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after the injection is given 6. A low-grade temperature on rising in the morning that remains throughout the day
1, 2, 3, 4 Rationale: Because emotional stress frequently exacerbates the symptoms of rheumatoid arthritis, the absence of symptoms is a positive finding. DMARDs are given to slow the progression of joint degeneration. In addition, an improvement in the range of motion after 3 months of therapy with normal blood work is a positive finding. Temperature elevation and inflam- mation and irritation at the medication injection site could indicate signs of infection.Test-Taking Strategy: Focus on the subject, acceptable responses to therapy. Recalling that signs of an infection can indicate an unexpected and unwanted finding will assist in eliminating options 5 and 6.
45. 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 two (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. 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. TEST-TAKING HINT: Remember, teaching, assessing, and evaluating cannot be delegated.
92. The client asks the nurse, "What are the risk factors for developing multiple sclerosis?" Which statement is a risk factor for multiple sclerosis (MS)? 1. A close relative with MS may indicate a risk for MS. 2. Living in the southern United States predisposes a person to MS. 3. Use of tobacco product is the number-one risk for developing MS. 4. A sedentary lifestyle can cause a person to develop MS.
1. A close relation (parent or sibling) who has MS may indicate a risk for the client also to develop MS. Other common risk factors are age, race, gender, environment, immune factors, and smoking. 2. There is a higher incidence of MS in people who live in the northeastern United States and Canada, but there is no known reason for this occurrence. 3. Tobacco use is a risk factor but not the primary risk factor for MS. 4. A sedentary lifestyle does not predispose a person to develop MS.
24. 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. TEST-TAKING HINT: The test taker must take a systematic approach when answering pri- oritizing questions. First, the test taker must determine if any client is experiencing a life-threatening or life-altering complication such as loss of a limb. The test taker must determine if the sign/symptom is expected for the disease or condition.
27. The emergency department nurse is caring for a 6-year-old child with a fractured forearm and suspects the injury is the result of abuse. Which x-ray would confirm the suspicions for the nurse? (Pic on other side)
1. A compound fracture is a fracture where the bone protrudes through the skin; it is also called an open fracture, and the nurse would not suspect child abuse based on only the type of fracture. 2. A spiral fracture is a fracture that involves twisting around the shaft of the bone, such as when an adult twists the arm of a child. The nurse should suspect child abuse. 3. An oblique fracture is a fracture that remains contained and does not break the skin. There are many reasons the child could have this type of fracture other than child abuse. 4. A greenstick fracture is a fracture in which one side of the bone is broken and the other side is bent. There are many reasons other than child abuse that could account for this type of fracture.
78. The nurse identifies a concept of impaired mobility for a male client with degenerative disk disease. Which assessment data best support this concept? 1. The client reports a history of chronic back pain and multiple back surgeries. 2. The client reports that taking NSAIDs caused the development of peptic ulcers. 3. The client reports a three (3)-year history of difficulty initiating a urinary stream. 4. The client states he fell a year ago and had to have a cast on the right arm for a month.
1. A history of low back pain and multiple back surgeries indicates a history of disk and back issues. 2. The use of NSAIDS could have happened for reasons other than degenerative disk disease. 3. Difficulty initiating a urinary stream usually indicates a male client has benign prostatic hypertrophy. The prostate is blocking the urethra. 4. A fall and wearing a cast on the arm do not indicate degenerative disk (vertebra of the back) disease. TEST-TAKING HINT: The test taker could eliminate option "4" if familiar with medical terminology; disks refer to the back, not the arm. Option "2" is nonspecific as to the reason for taking the NSAIDs and could be eliminated.
46. The nurse writes the problem "high risk for impaired skin integrity" for the client with an L5-6 spinal cord injury. Which intervention should the nurse include in the plan of care? 1. Perform active range-of-motion exercise. 2. Massage the legs and trochanters every shift. 3. Arrange for a Roho cushion in the wheelchair. 4. Apply petroleum-based lotion to the extremities.
1. A patient with an L5-6 spinal cord injury is paralyzed and cannot perform active ROM exercises. 2. Massaging bony prominences can cause trauma to the underlying blood vessels and will increase the risk for skin breakdown. 3. The nurse must realize that the clientis at risk for skin breakdown even when sitting in the chair. A Roho cushion is an air-filled cushion that provides reduced pressure on the ischium. 4. Lotion will not prevent skin breakdown and should be water based, not petroleum based.
19. 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 per- son 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. TEST-TAKING HINT: The nurse must know the roles of all the health-care team members.
81. The nurse writes a concept of "impaired mobility" for a client diagnosed with a fractured right hip. Which would the nurse include in the plan of care? Select all that apply. 1. Request a physical therapy referral. 2. Administer enoxaparin (Lovenox) subcutaneously. 3. Utilize a gait belt when ambulating the client. 4. Assess the client's pain levels on a 1-to-10 scale. 5. Provide a high-carbohydrate, high-fat, high-sodium diet.
1. A physical therapist will assist the client to ambulate safely while protecting the hip from being displaced. 2. The client's mobility is compromised, placing the client at risk for developing a deep vein thrombosis (DVT). Lovenox will assist in preventing a DVT. 3. Health-care workers should use gait belts to provide support and stability when ambulating clients. 4. Fractures of any bone are painful; pain scales are useful in qualifying the amount and type of pain being experienced by the client. 5. The client's diet should be a well-balanced diet with an emphasis on protein for wound healing. TEST-TAKING HINT: Knowledge of basic nursing care is required when answering this question. The use of a gait belt for ambulating and assessing pain are basic nursing skills.
95. Which psychosocial problem should the nurse identify as priority for a client diagnosed with rheumatoid arthritis? 1. Alteration in comfort. 2. Ineffective coping. 3. Anxiety. 4. Altered body image.
1. Alteration in comfort is a client problem, but it not a psychosocial problem. 2. Ineffective coping is a problem that is not applicable to all clients with rheumatoid arthritis and is a very individualized problem; the test taker would need more information before selecting this as a correct answer. 3. Anxiety is a problem that is not applicable to all clients with rheumatoid arthritis and is a very individualized problem; the test taker would need more information before select- ing this as a correct answer. 4. Altered body image is an expected psychosocial problem for all clients with rheumatoid arthritis because of the joint deformities.
16. 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. A therapeutic 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 pre- scribed areas, the "love handles," ensures safety and decreases the risk of abdominal trauma.
60. 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 the 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. TEST-TAKING HINT: When prioritizing two equal options, usually, assessing is the answer.
51. 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 thetissues. 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.An x-ray should be done before the immobilizer is in place, not after. 4. Anytime trauma occurs, tetanus should be considered. In an open fracture, this is an appropriate treatment.TEST- TAKING HINT: This is an alternative- type question. When selecting all that apply, it is important to consider the descriptive words which make the options incorrect. Read adjectives and adverbs carefully. The terms "snugly," "dependent," and "after" make options "1," "3," and "4" incorrect.
73. The nurse identifies the concept of impaired functional ability for a client diagnosed with rheumatoid arthritis. Which intervention should the nurse implement? 1. Teach the client to apply antiembolism (TED) hose. 2. Administer the nonsteroidal medication before the morning meal. 3. Encourage the client to perform low-impact exercises daily. 4. Refer the client to occupational therapy for gait training.
1. Antiembolism hose are to prevent venous stasis, a circulatory issue, not for functional ability. 2. Nonsteroidal medications (NSAIDs) are given with meals or food to prevent gastric distress and risk of bleeding ulcers. They are not administered on empty stomachs. 3. Low-impact exercises improve the client's range of motion in the joints and help to maintain functional ability. They should be performed on a daily basis. 4. Occupational therapists work on upper body activities and activities of daily living. Physical therapists work on the lower body and gait training as well as large muscle functioning. TEST-TAKING HINT: The test taker could eliminate option "4" by knowing the function of the different therapies, "1" can be eliminated by knowing the purpose of antiembolism hose, and "2" can be eliminated by knowing basic nursing interventions for classifications of medications.
46. 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 re- sidual 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 first24 hours. TEST-TAKING HINT: The stem of the question asks the test taker to choose a method of toughening the residual limb. Demonstrating how to apply an elastic bandage or elevating the limb would not accomplish this, so options "2" and "4" could be eliminated from consideration.
9. 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.
62. The client one (1) day postoperative total hip replacement complains of hearing a "popping sound" when turning. Which assessment data should the nurse report immediately to the surgeon? 1. Dark red-purple discoloration. 2. Equal length of lower extremities. 3. Groin pain in the affected leg. 4. Edema at the incision site.
1. Bruising is common after a total hip replacement. 3. When a dislocation occurs, the affected extremity will be shorter. 3. Groin pain or increasing discomfort in the affected leg and the "popping sound" indicate the leg has dislocated, which should be reported immediately to the HCP for a possible closed reduction. 4. Edema at the incision site is common, but an increase in edema or redness should be reported. TEST-TAKING HINT: The nurse should notify the surgeon of abnormal, unexpected, or life-threatening assessment data; if the test taker did not have an idea of the answer, pain is always a good choice because pain means something is wrong—it may be expected pain, but it may mean a complication.
77. Which medication should the nurse question administering to a client diagnosed with rheumatoid arthritis who has a comorbid condition of non-Hodgkin's lymphoma? 1. Celecoxib. 2. Filgrastim. 3. Adalimumab. 4. Acetaminophen.
1. Celebrex is approved for the routine treatment of arthritis and bone and joint dis- eases. The nurse would not question this medication. 2. Clients undergoing treatment for cancer frequently require filgrastim to promote the production of WBCs due to the suppression of the bone marrow. The nurse would not question this medication. 3. An adverse effect of adalimumab is the development of lymphoma. Because this client has a lymphoma, suppressing the immune system even further could have disastrous results for the client. The nurse would question administering this medication. 4. Acetaminophen would not be questioned; the client has pain and the dose is a recommended dose. TEST TAKING HINT: The test taker must know basic medication guidelines.
1. The 50-year-old female client is being evaluated 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.
65. Which interventions should be included in the discharge teaching for a client who had a total hip replacement? Select all that apply. 1. Discuss the client's weight-bearing limits. 2. Request the client demonstrate use of assistive devices. 3. Explain the importance of increasing activity gradually. 4. Instruct the client not to take medication prior to ambulating. 5. Tell the client to ambulate with open-toed house shoes.
1. Clients need to understand the amount of weight bearing to prevent injury. 2. Teaching the safe use of assistive devices is necessary prior to discharge. 3. Increases in activity should occur slowly to prevent complications. 4. Using medication therapy, including analgesics, anti-inflammatory agents, or muscle relaxants, should be taught so the client is comfortable while ambulating. 5. The client should ambulate with well-fitted, supported, closed-toed shoes such as a tennis shoe or walking shoe. TEST-TAKING HINT: The test taker should apply basic concepts to all surgeries. Many times the test taker may not be familiar with the specific surgery, but by using discharge teaching applicable to all clients, a choice can be made.
63. The nurse is discharging a client who had a total hip replacement. Which statement indicates further teaching is needed?1. 1. "I should not cross my legs because my hip may come out of the socket." 2. "I will call my HCP if I have a sudden increase in pain." 3. "I will sit on a chair with arms and a firm seat." 4. "After three (3) weeks, I don't have to worry about infection."
1. Clients should not cross their legs because the position increases the risk for dislocation. 2. If the client experiences a sudden increase in pain, redness, edema, or stiffness in the joint or surrounding area, the client should notify the HCP. 3. Clients should sleep on firm mattresses and sit on chairs with firm seats and high arms. These will decrease the risk of dislocating the hip joint. 4. Infections are possible months after surgery. Clients should monitor temperatures and report any signs of infection. TEST-TAKING HINT: Note the stem is asking about the need for "further teaching." This means the test taker is looking for an unex- pected option. This is an "except" question. Sometimes, if the test taker will change the question and say "the client understands the teaching," then the option with an incorrect statement is the answer.
15. 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 walk- ing 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 re- fuse a bath, but the nursing staff must explain why moving and bathing will help decrease the pain. TEST-TAKING HINT: Allowing clients to stay in bed only increases complications of immobility and will increase the client's pain secondary to OA. Clients with chronic illnesses should be encouraged to be as independent as possible. The family should only be notified if a significant situation has occurred.
67. The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon? 1. A total of 100 mL of red drainage in the autotransfusion drainage system. 2. Pain relief after using the patient-controlled analgesia (PCA) pump. 3. Cool toes, distal pulses palpable, and pale nail beds bilaterally. 4. Urinary output of 60 mL of clear yellow urine in three (3) hours.
1. Drainage in the first 24 hours can be expected to be 200 to 400 mL. When using an auto- transfusion drainage system, the client's blood will be filtered and returned to the client. 2. Pain relief with the PCA does not require notifying the surgeon. 3. Bilateral coolness of toes is not concerning because both feet are cool. Circulation is not restricted if pulses are present. Seeing pale pink nailbeds indicates blood loss during surgery. 4. The urinary output is not adequate; therefore, the surgeon needs to be notified. This is only 20 mL/hr. The minimum should be 30 mL/hr. TEST-TAKING HINT: A concept the test taker will see throughout testing and throughout the nurse's practice is 30 mL of urine output per hour is necessary to maintain kidney function.
39. 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 ad- ministered through an 18-gauge catheter. TEST-TAKING HINT: The nurse must take into account all the client's comorbid conditions (diabetes type 2) when selecting the correct answer.
44. 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 levels.
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: de- creased 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. TEST-TAKING HINT: Remember, when the stem asks the test taker to identify the first intervention, all four options will be probable interventions but only one is the first intervention. Also, the nurse should always assess first. Remember the nursing process.
52. 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 tender- ness 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 healthcare provider. These are signs of neurovascular compromise. 4. Pain management is a desired outcome demonstrated by pain relieved after medication administration. TEST-TAKING HINT: The nurse should notify the health-care provider of abnormal or un- expected assessment data; no pulse indicates a neurovascular complication. All the other options contain normal or expected data.
23. 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. TEST-TAKING HINT: If the test taker is guess- ing which answer is correct and knows os- teo- means "bone," the only option with any specific connection to bones is an x-ray. This selection is an educated guess.
22. 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 cli- ents with OA. 3. Alternative forms of treatment have not been proved efficacious in the treatment of a disease. The nurse should be non- judgmental 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. TEST-TAKING HINT: The test taker needs to read the stem carefully to be able to determine what the question is asking. There is only one option with alternative-type treatment, which is option "3"; options "1," "2," and "4" are accepted treatment options listed in a textbook.
66. The nurse is caring for the client who has hada total hip replacement. Which data indicate the surgical treatment is effective? 1. The client states the pain is at a "3" on a 1-to- 10 scale. 2. The client has a limited ability to ambulate. 3. The client's left leg is shorter than the right leg. 4. The client ambulates to the bathroom.
1. Minimal pain is expected in a postoperative client but it does indicate surgical treatment is effective. 2. The client should be able to ambulate with almost full mobility. 3. A shorter leg indicates a dislocation of the hip. 4. The hip should have functional motion and the client should be able to ambulate to the bathroom. This indicates surgical treatment has been effective. TEST-TAKING HINT: With musculoskeletal problems, functional movement is priority. Also note option "2" has the word "limited" and "3" has "one leg shorter than the other," both of which are negative outcomes, so the test taker could eliminate these options.
21. 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 de- crease 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. TEST-TAKING HINT: There are some questions requiring the test taker to have the knowl- edge, and there are no test-taking hints to help with selecting the right answer.
13. 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 can- not 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. TEST-TAKING HINT: The adjective "modifiable" is the key to selecting the correct answer. Only option "1" contains anything the client has control over changing or modifying.
14. 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. TEST-TAKING HINT: The test taker can have difficulty distinguishing clinical manifestations of two similar sounding diseases, os- teoarthritis and rheumatoid arthritis. Both diseases involve the joints and cause pain and stiffness. Remember, rheumatoid arthritis can permanently disfigure the client, leading to "bone deformity" and "swan-neck fingers."
83. The client who has sustained a left-sided cerebrovascular accident (stroke) has residual right-sided paralysis. The nurse identifies a concept of impaired functional ability. Which should be included in the care map? Select all that apply. 1. Refer to the occupational therapist. 2. Assess the client for neglect of the right side. 3. Place the client in a room where the door is on the left side. 4. Teach the client to call for assistance prior to getting out of bed. 5. Encourage the client to participate in physical therapy daily.
1. Occupational therapists work on upper body ability and activities of daily living as well as increasing cognitive ability. This is an excellent referral. 2. Clients who no longer have the use of a side of the body will not realize when the arm or leg moves and this can be a safety issue. 3. The client may not realize that one-half of the visual field has been impaired as a result of the stroke. If this has happened the client will not see things in the left visual fields. Remember that the nerve pathways cross over at the base of the skull, so a left- sided stroke produces issues for the body below the neck on the opposite side of the stroke, but in the brain (visual fields) it would be on the side of the stroke. 4. For safety this should be done for all clients. 5. The nurse should encourage the client to participate in activity that increases the client's functional ability. TEST-TAKING HINT: When answering "Select all that apply" questions, each option is read independently of the others. Each option be- comes a true/false question.
16. 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. TEST-TAKING HINT: The adjective "psycho- social" should help the test taker rule out option "1." The test taker needs to read the stem carefully. This client has had a problem for years, and, therefore, option "3" could be ruled out as a correct answer.
48. 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 ad- just 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. TEST-TAKING HINT: The test taker needs to select all appropriate options.
80. The client who underwent a left above-the- knee amputation as a result of uncontrolled diabetes questions the nurse, asking, "Why did this happen to me? I have always been a good person." Which is the nurse's most therapeutic response? 1. "Tell me about how it feels to have caused this to happen to you." 2. "I know how you feel; having your leg cut off is sad." 3. "Why do you think that you had to have your leg amputated?" 4. "I can see you are hurting. Would you like to talk?"
1. Placing blame is not therapeutic. 2. Unless the nurse has had exactly the same situation happen to him/her, the nurse cannot make this statement. It is not therapeutic. 3. Asking why is not therapeutic; the nurse is requesting the client to defend his/her feeling. 4. This is a broad opening statement and offering self. Both are therapeutic techniques. The client needs an opportunity to verbalize the feeling associated with loss. TEST-TAKING HINT: When a question asks for a therapeutic response by the nurse, the nurse must give a response that does NOT lay blame or advise in any way and MUST encourage the client to discuss feelings.
57. 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. TEST-TAKING HINT: When selecting an answer for questions such as this, the test taker should remember to look for an untrue statement. This indicates teaching is needed
20. 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. Osteoarthritis occurs most often in weight- bearing 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. TEST-TAKING HINT: The test taker can rule out option "3" as an answer because the stem says "pain control"; option "1" is correct for any exercise program.
17. 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.
4. The occupational health nurse is planning health promotion activities for a group of factory workers. Which activity is an example of primary prevention for clients at risk for low back pain? 1. Teach back exercises to workers after returning from an injury. 2. Place signs in the work area about how to perform first aid. 3. Start a weight-reduction group to meet at lunchtime. 4. Administer a nonnarcotic analgesic to a client complaining of back pain.
1. Teaching back exercises to a client who has al- ready experienced a problem is tertiary care. 2. Placing signs with instructions about how to render first aid is a secondary intervention, not primary prevention. 3. Excess weight increases the workload on the vertebrae. Weight-loss activities help to prevent back injury. 4. Administering a nonnarcotic analgesic to a cli- ent with back pain is an example of secondary or tertiary care, depending on whether the cli- ent has a one-time problem or a chronic problem with back pain. TEST-TAKING HINT: Primary care is any activity which will prevent an illness or injury.
69. The nurse is caring for a client with a right total knee repair. Which intervention should the nurse implement?1. 1. Monitor the continuous passive motion machine. 2. Apply thigh-high TED hose bilaterally. 3. Place the abductor pillow between the legs. 4. Encourage the family to perform ADLs for the client.
1. The CPM machine is used to ensure the client has adequate range of motion in the knee postoperatively. 2. The TED hose are only applied to the unaffected leg, not the leg with the incision. 3. Adductor pillows are used in clients with total hip replacements to maintain function hip alignment. 4. The client should perform as many ADLs as possible. The client should maintain independence as much as possible. TEST-TAKING HINT: The test taker should remember to think about basic concepts of surgical care: Would an elastic hose be placed over a new incision? Sometimes trying to imagine what is actually occurring at the bedside helps to eliminate some options.
14. 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.
42. 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. TEST-TAKING HINT: The nurse must always address the cultural needs of the client, and when the test taker sees a specific culture in the stem of a question, it is a prompt indicating this will be important when selecting the answer.
61. 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. TEST-TAKING HINT: Option "1" has the word "all"; an absolute word such as this usually eliminates the option as a possible correct answer. Nursing usually does not have situa- tions involving absolutes.
56. 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. TEST-TAKING HINT: A concept for any injury is elevating it above the heart to decrease edema. Many times the test taker must apply basic concepts to a variety of client conditions. Any foul smell is not expected in any disease or condition.
4. 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, endanger- ing the client's life. 4. The general consent for admission to the hospital covers this procedure. A separate in- formed consent is not required.
14. The nurse identifies the problem "high risk for complications" for the client with a right total hip replacement who is being discharged from the hospital. Which problem would have the highest priority? 1. Self-care deficit. 2. Impaired skin integrity. 3. Abnormal bleeding. 4. Prosthetic infection.
1. The client is being discharged, so a self-care deficit would not be a potential complication. 2. The client is being discharged and is ambulating; therefore, impaired skin integrity should not be a problem. 3. The client would have been taking a prophylactic anticoagulant but would not be at risk for abnormal bleeding. 4. The client must inform all HCPs, especially the dentist, of the hip prosthesis because the client should be taking prophylactic antibiotics prior to any invasive procedure. Any bacteria invading the body may cause an infection in the joint, and this may result in the client having the prosthesis removed.
38. 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. TEST-TAKING HINT: Remember to look at the phrases describing the intervention, such as "every two (2) hours" and "passive."
43. 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. TEST-TAKING HINT: The test taker needs to be aware of adjectives such as "dependent." The nurse must know medical terms for position- ing a client.
50. 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. TEST-TAKING HINT: Physiological problems are priority over psychosocial problems, so the test taker could rule out option "1."
13. 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.
84. The 35-year-old client who sustained a crushing injury to the left hand and forearm is being discharged. Which referral should the nurse implement? 1. Refer the client to physical therapy at home. 2. Refer the client to an assistive living facility. 3. Refer the client to a workforce commission for job training. 4. Refer the client to the dietitian.
1. The client should be able at age 35 to per- form exercises on his/her own. 2. The client is 35 and should prepare to live life with the new limitations, not go into an assistive living facility. 3. The client needs to gain new skills to be- come a productive member of society with the new limitations. All states have opportunities for clients who have issues to be able to access training and assistance. 4. The client has a functional disability, not a dietary need. TEST-TAKING HINT: The test taker must read the words in the question and options. Ages matter. This is a 35-year-old client who should be in Erikson's stage of Generativity vs. Stagnation.
57. The client reports a twisting motion of the knee during a basketball game. The client is scheduled for arthroscopic surgery to repair the injury. Which information should the nurse teach the client about postoperative care? 1. The client should begin strengthening the surgical leg. 2. The client should take pain medication routinely. 3. The client should remain on bedrest for two (2) weeks. 4. The client should return to the doctor in six (6) months.
1. The client should begin exercises that will strengthen the surgical leg as soon as the surgery is completed. 2. Pain medication should be taken as needed, not routinely. 3. The client may ambulate with the restrictions ordered by the surgeon. 4. The client will return to see the surgeon prior to six (6) months. The surgeon will need to monitor for healing and complications.
70. The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention? 1. The client's hemoglobin is 8.1 g/dL. 2. The client's white blood cell count is 9,000/mm . 3. The client's creatinine level is 0.8 mg/dL. 4. The client's potassium level is 4.2 mEq/L.
1. The client's hemoglobin is near 8 g/dL, which indicates the client requires a blood transfusion. This information warrants intervention by the nurse. 2. This white blood cell count is within normal limits, so it does not warrant immediate intervention. 3. The creatinine level is within normal limits and does not warrant intervention. 4. The potassium level is within normal limits and does not require intervention by the nurse. TEST-TAKING HINT: The test taker must be knowledgeable of laboratory values. There is no test-taking hint except memorize the values.
18. 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 a 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.
58. 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. TEST-TAKING HINT: The test taker must note the words "most appropriate" and look at the client as a whole entity. With musculoskeletal problems, maintaining normal function or anatomical function is the desired outcome. Remember, independence is priority for the client.
55. 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. TEST-TAKING HINT: This intervention is a form of assessment, assessing the equipment being used for the client's condition. Re- member to apply the nursing process.
82. The nurse is admitting a female client who is complaining of severe back pain radiating down the left leg whenever she tries to ambulate. The concepts of impaired mobility and comfort are implemented on the care map. Which nursing interventions should the nurse implement? 1. Assist the client when ambulating to the bathroom and administer medications based on the pain scale. 2. Place the client on strict bedrest and have the client use a regular bedpan for elimination of urine and feces. 3. Ambulate the client in the hallway at least four (4) times per day and discourage the use of pharmacological pain relief. 4. Request the health-care provider (HCP) to assist the client in ambulating in the hallway so the HCP can observe the client's pain.
1. The nurse or nursing staff should assist the client to ambulate to the bathroom, and pain medication should be administered using the pain scale to quantify and qualify the pain level. 2. The client should have bathroom privileges; strict bedrest will place the client at risk for pneumonia and DVT development. Movement should be encouraged within safe guidelines. A regular bedpan would place the client's back in an awkward position and in- crease the pain. 3. Pain is whatever the client says it is and occurs whenever the client says it does. The nurse should not discourage the use of pain medications in the light of "severe" pain. 4. The HCP does not need to assist the client to ambulate in the hallway to observe the effect of ambulation on the client's pain. The HCP can ask the client to ambulate in the room with the assistance of the UAP, nurse, or PT. TEST-TAKING HINT: The test taker should read words in the stem of a question and in the options—words matter. In option "2" "strict" and "regular" make this an incorrect option; in option "3" "discourage" makes it incorrect. In option "4" HCPs do not do the nurse's job of ambulating.
13. The client has a fractured right tibia. Which assessment data warrant immediate intervention? 1. The client complains of right calf pain. 2. The nurse cannot palpate the radial pulse. 3. The client's right foot is cold to touch. 4. The nurse notes ecchymosis on the right leg.
1. The nurse would expect the client with a fractured right leg to have pain but it would not warrant immediate intervention. 2. The nurse would assess the client's pedal or posterior tibial pulse for a client with a fractured right tibia. 3. Any abnormal neurovascular assessment data, such as coldness, paralysis, or paresthesia, warrant immediate intervention by the nurse. 4. Ecchymosis is bruising and would be expected in the client who has a fractured tibia.
59. 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. TEST-TAKING HINT: This is an alternate-type question in which the test taker must select all options that apply. The test taker should remember the neuromuscular assessment, which includes the 6 Ps—pulse, pain, pares- thesia, paralysis, pallor, polar (cold).
53. The unlicensed assistive personnel (UAP) reports a client with a fractured femur has "fatty globules" 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 "fatty globules" 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 is 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. TEST-TAKING HINT: If the test taker is unsure of the correct answer, always apply the nursing process. Assessment is the first part of the nursing process.
49. 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 nail beds 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. TEST-TAKING HINT: When the question asks to prioritize nursing care, usually assessment is first. Assessment is an independent nursing intervention.
9. The client in the long-term care facility has severe osteoarthritis. Which nursing task should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Feed the client the breakfast meal. 2. Give the client Maalox, an antacid. 3. Monitor the client's INR results. 4. Assist the client to the shower room.
1. The nurse should encourage the client to maintain independent functioning, and delegating the UAP to feed the client would be encouraging dependence. 2. Although this is an over-the-counter medication, a UAP cannot administer any medication to a client. 3. The UAP cannot assess or evaluate any of the client's diagnostic information. 4. The UAP could assist the client to ambulate to the shower room and assist with morning care.
75. The client in the rehabilitation hospital refuses to participate in physical therapy following surgery for repair of a fractured right femur sustained in a motor-vehicle accident (MVA). The client also fractured the left forearm. Which should the nurse implement first when encouraging the client to participate in therapy? 1. Medicate the client for pain 30 minutes prior to the therapy. 2. Have the health-care provider make the client go to therapy. 3. Explain that insurance will not pay if the client does not participate in therapy daily. 4. Determine why the client refuses to participate in therapy sessions.
1. The nurse should medicate the client for pain prior to therapy if that is determined to be the cause for the client refusing to participate in therapy. 2. The client can make his/her own decisions. The HCP cannot make the client do anything. 3. The nurse should explain the rules of rehabilitation coverage, but this is not first. 4. The nurse should first assess the situation to determine the reason the cli- ent does not wish to participate in therapy. TEST-TAKING HINT: The test taker should re- member the first step of the nursing process is assessment. There are many words that can be used to indicate an assessment step.
6. 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 is not priority over a neurovascular assessment. 3. Neurovascular assessment is priority be- cause this surgery has two (2) to three (3) 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.
11. The 54-year-old female client is diagnosed with osteoporosis. Which interventions should the nurse discuss with the client? Select all that apply. 1. Instruct the client to swim 30 minutes every day. 2. Encourage drinking milk with added vitamin D. 3. Determine if the client smokes cigarettes. 4. Recommend the client not go outside. 5. Teach about safety and fall precautions.
1. The nurse should suggest walking daily be- cause bones need stress to maintain strength. 2. Vitamin D helps the body absorb calcium. 3. Smoking interferes with estrogen's protective effects on bones, promoting bone loss. 4. Lack of exposure to sunlight results in decreased vitamin D, which is necessary for calcium absorption and normal bone mineralization. The client should go outside. 5. The client is at risk for fractures; therefore, a fall could result in serious complications.
68. The client who had a total knee replacement is being discharged home. To which multidisciplinary team member should the nurse refer the client? 1. The occupational therapist. 2. The physiatrist. 3. The recreational therapist. 4. The home health nurse.
1. The occupational therapist addresses upper extremity activities of daily living, swallowing issues, and cognition. This is not an appropriate referral. 2. The physiatrist is a physician specializing in rehabilitation medicine who practices in a re- habilitation setting. 3. The recreational therapist is used in psychiatric settings, rehabilitation hospitals, and long- term care facilities. The discipline is not seen in the home. 4. The home health-care nurse will be able to assess the client in the home and make further referrals if necessary. TEST-TAKING HINT: The nurse should always think about safety; therefore, the test taker should select options addressing safety issues.
12. The 33-year-old client had a traumatic amputation of the right forearm as a result of a work-related injury. Which referral by the rehabilitation nurse is most appropriate? 1. Physical therapist. 2. Occupational therapist. 3. Workers' compensation. 4. State rehabilitation commission.
1. The physical therapist focuses on evaluating, diagnosing movement dysfunctions (injured tissues and structures), and treating these issues. The PT helps restore movement and mobility. 2. The occupational therapist focuses on evaluating and improving functional abilities to optimize independence and address activities of daily living, which would be an appropriate referral. 3. Workers' compensation is an insurance provider for the employer and employee to cover medical expenses and loss of wages. This is not an appropriate referral by the rehabilitation nurse. 4. The client may need this referral but after the occupational therapist has worked with the client and determined the ability to perform skills.
74. The client diagnosed with osteomyelitis ofthe left foot and ankle is being prepared for a below-the-knee amputation. Which intervention to improve the client's functional ability is a priority after rehabilitation? 1. Keep a large tourniquet at the bedside to stop potential bleeding from the amputation site. 2. Place a pillow in the bed for the client to push the stump against many times per day. 4. Take and document the client's vital signs every four (4) hours. 5. Have the dietary department send high- protein, high-carbohydrate meals six (6) times a day.
1. The tourniquet is used to prevent hemorrhage from the residual limb. It does not improve functional ability. 2. The client should push against a pillow to toughen the stump and prepare it fora prosthesis. This will assist the client in regaining functional ability and mobility. 3. Taking and documenting vital signs provides the nurse with data to determine the stability of the client but does not improve functional ability. 4. A diet high in protein improves wound heal- ing. The client's diet should have sufficient calories for wound healing but not particularly high carbohydrates. These interventions help with tissue integrity and would healing, not functional ability. TEST-TAKING HINT: The test taker should read the question carefully; the question is asking about what helps with functional ability. In this question, the test taker can eliminate the other three (3) options based on the fact that they do not address functional ability. Even if the test taker does not "like" option "2," it is the odd man out so it should be the one chosen.
54. The nurse is caring for an 80-year-old client admitted with a fractured right femoral neck who is oriented 3 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. TEST-TAKING HINT: The test taker needs to understand what the question is asking. Although the client has a fractured hip, the orientation status is the unexpected symp- tom which requires assessment.
64. The nurse finds small, fluid-filled lesions on the margins of the client's surgical dressing. Which statement is the most appropriate scientific rationale for this occurrence? 1. These were caused by the cautery unit in the operating room. 2. These are papular wheals from herpes zoster. 3. These are blisters from the tape used to anchor the dressing. 4. These macular lesions are from a latex allergy.
1. These are not burns from the cautery unit. Such burns are located in or near the incision site and are usually black. 2. Herpes simplex lesions occur in a linear pattern along a dermatome. 3. Fluid-filled blisters are from a reaction to the tape and usually occur along themargins of the dressing where the tape was applied. 4. Skin reactions to latex are local irritations or generalized dermatitis, not blisters. TEST-TAKING HINT: If the test taker does not know the answer, the test taker might think about the dressing because the lesions are on the side of the dressing. How is a dressing anchored to the skin? Answer: with tape. The test taker should choose the option having the word "tape."
23. 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 the 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 cast.
71. The nurse is assessing the client who is postoperative total knee replacement. Which assessment data warrant immediate intervention? 1. T 99 ̊F, HR 80, RR 20, and BP 128/76. 2. Pain in the unaffected leg during dorsiflexion of the ankle. 3. Bowel sounds heard intermittently in four quadrants. 4. Diffuse, crampy abdominal pain.
1. These vital signs are within normal limits. 2. Pain with dorsiflexion of the ankle indicates deep vein thrombosis. This can be from immobility or surgery; therefore, pain should be assessed in both legs. 3. Bowel sounds are normally intermittent. 4. This type of pain should make the nurse suspect the client has flatus, which is not a life-threatening complication and does not warrant immediate intervention. TEST-TAKING HINT: "Warrant immediate intervention" means life threatening, abnor- mal, or unexpected for the client's condi- tion. Pain with dorsiflexion of the ankle, the Homans' sign, may be life threatening if not treated immediately.
19. The nurse is discharge teaching for a client with a short leg cast. Which statement indicates the client understands the dischargeteaching? 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 first24 hours. If edema is present, the client needs to keep it elevated longer. 2. Sequential compression devices work to pre- vent 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.
22. 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.
24. 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 for discharge, which begins on admission, but this is not the most important at this time.
18. 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 over- weight, 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. TEST-TAKING HINT: The test taker must re- member a goal is the measurable outcome of nursing interventions based on the client problem/diagnosis. Interventions are not goals; therefore, the test taker could eliminate options "1" and "4" as possible answers.
17. 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. TEST-TAKING HINT: The worst-scenario option is "4," which has blood in the answer. If the test taker did not know the answer, then selecting an option with blood in it is most appropriate.
76. The nurse is admitting a client with rheumatoid arthritis (RA) and the hands have the appearance shown next. Which concept would the nurse identify as priority? 1. Mobility. 2. Functional ability. 3. Coping. 4. Rehabilitation.
1. This picture does not indicate any deformity except the hands. 2. This is a picture of swan neck fingers associated with rheumatoid arthritis. The function of the client's hands is priority. 3. The client may have an issue with coping with the RA, but a psychosocial need is not priority over an actual physiological need. 4. Rehabilitation would be an interrelated concept needed for this client, but determining the extent of functional impairment is priority first. TEST-TAKING HINT: The test taker should not read into the question; in option "1" mobility refers to the ability of the client to move the body, not just the hands. The hands are the only body parts pictured. If an option exists that is more specific to the picture (functional ability) then the test taker should choose the one that is most closely related to the issue.
37. 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. TEST-TAKING HINT: The test taker can eliminate option "1" if visualizing the client in a prone position. This position will limit expansion of the lung more than increase it. When trying to allow for expansion of the lungs, clients are placed with the head elevated, a position the client in a prone position cannot achieve.
47. 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. TEST-TAKING HINT: Always notice when the age is given for the client. This will help guide the test taker to the correct answer.
10. The primary nurse is applying antiembolism hose to the client who had a total hip replacement. Which situation warrants immediate intervention by the charge nurse? 1. Two fingers can be placed under the top of the band. 2. The peripheral capillary refill time is less than three (3) seconds. 3. There are wrinkles in the hose behind the knees. 4. The nurse does not place a hose on the foot with a venous ulcer.
1. This would not warrant intervention because this indicates the hose are not too tight. 2. This indicates the hose are not too tight. 3. There should be no wrinkles in the hose after application. Wrinkles could cause constriction in the area, resulting in clot formation or skin breakdown; therefore, this would warrant immediate intervention by the charge nurse. 4. Antiembolism hose should not be put over a wound; they would restrict the circulation to the wound and cause a decrease in wound healing.
40. 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 de- crease 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. TEST-TAKING HINT: Remember, when the stem asks the test taker to identify the first intervention, all four options will be prob- able interventions, but only one is the first intervention.
72. The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report? 1. The 84-year-old female with a fractured right femoral neck in Buck's traction. 2. The 64-year-old female with a left total knee replacement who has confusion. 3. The 88-year-old male post-right total hip replacement with an abduction pillow. 4. The 50-year-old postop client with a continuous passive motion (CPM) device.
1.This is a normal treatment of a fractured femoral neck. 2. This is an abnormal occurrence from this information. This client should be seen first because confusion is a symptom of hypoxia. 3. This is a common treatment of a total hip replacement. 4. This is a treatment used for total knee replacement.
823. The nurse is preparing discharge instructions for a client receiving baclofen. Which instruction should be included in the teaching plan? 1. Restrict fluid intake. 2. Avoid the use of alcohol. 3. Stop the medication if diarrhea occurs. 4. Notify the health care provider (HCP) if fatigue occurs.
2 Rationale: Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other cen- tral nervous system depressants because baclofen potentiates the depressant activity of these agents. Constipation rather than diarrhea is a side effect. Restriction of fluids is not neces- sary, but the client should be warned that urinary retention can occur. Fatigue is related to a central nervous system effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the HCP about fatigue.Test-Taking Strategy: Focus on the subject, teaching points for baclofen. Recalling that baclofen is a skeletal muscle relaxant will direct you easily to the correct option. If you were unsure of the correct option, use general principles related to medica- tion administration. Alcohol should be avoided with the use of medications.
821. Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder? 1. Myxedema 2. Kidney disease 3. Hypothyroidism 4. Diabetes mellitus
2 Rationale: Colchicine is used with caution in older clients, debilitated clients, and clients with cardiac, kidney, or gastro- intestinal disease. The disorders in options 1, 3, and 4 are not concerns with administration of this medication. Test-Taking Strategy: Focus on the subject, the cautions asso- ciated with colchicine. Note that options 1, 3, and 4 are com- parable or alike and are endocrine-related disorders. The correct option is different from the others.Review: The cautions associated with colchicine
817. The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? 1. Calcium level of 9.0 mg/dL (2.25 mmol/L) 2. Uric acid level of 9.0 mg/dL (0.54 mmol/L) 3. Potassium level of 4.1 mEq/L (4.1 mmol/L) 4. Phosphorus level of 3.1 mg/dL (1.0 mmol/L)
2 Rationale: In addition to the presence of clinical manifesta- tions, gout is diagnosed by the presence of persistent hyperuri- cemia, with a uric acid level higher than 8 mg/dL(0.48 mmol/ L); a normal value for a male ranges from 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L) and for a female, from 2.7 to 7.3 mg/ dL(0.16to0.43mmol/L).Options1,3,and4indicatenormal laboratory values. In addition, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis. Test-Taking Strategy: Focus on the subject, manifestation of gout. Use knowledge of normal laboratory values. Recalling that increased uric acid levels occur in gout and noting that the correct option has the only abnormal value will assist you in answering the question.
819. A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess? 1. The injection site for itching and edema 2. The white blood cell counts and platelet counts 3. Whether the client is experiencing fatigue and joint pain 4. Whether the client is experiencing a metallic taste in the mouth, and a loss of appetite
2 Rationale: Infection and pancytopenia are adverse effects of etanercept. Laboratory studies are performed prior to and dur- ing medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste and loss of appetite are not common signs of adverse effects of this medication.Test-Taking Strategy: Note the strategic words, most impor- tant. Option 4 can be eliminated, because this is not a common adverse effect. In early treatment, residual fatigue and joint pain may still be apparent. For the remaining options, the cor- rect option monitors for a hematological disorder, which could indicate a reason for discontinuing this medication and should be reported.
812. The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of com- partment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture
2 Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of propor- tion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation. Test-Taking Strategy: Note the strategic word, early. Knowing that compartment syndrome is characterized by insufficient circulation and ischemia caused by pressure will direct you to the correct option.
13. A patient recovering from total hip replacement surgery is having difficulty with position changes and ambulation. Which member of the interdisciplinary team should be consulted to address this patient's issues? 1) Orthopedic nurse 2) Physical therapist 3) Orthopedic surgeon 4) Occupational therapist
2) Assistive walking devices such as a walker or crutches are recommended by physical therapy. 1), 3), 4) Devices to assist with position changes and ambulation would not be recommended by the orthopedic surgeon, orthopedic nurse, or occupational therapist.
814. The nurse is caring for a client who had an above- knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1.Apply ice to the site. 2. Call the health care provider (HCP). 3. Rewrap the residual limb with an elastic compression bandage. 4. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.
3 Rationale: If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the HCP so that a new one could be applied. Elevation on 1 pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the HCP were called, the prescriptionlikelywouldbetoreapplythecompressiondressing anyway.Test-Taking Strategy: Note the strategic word, immediate, and focus on the data in the question. Recalling that excessive edema can form rapidly in the residual limb will direct you to the correct option.
827. The nurse is administering an intravenous dose of methocarbamol to a client with multiple sclerosis. For which adverse effect should the nurse monitor? 1. Tachycardia 2. Rapid pulse 3. Bradycardia 4. Hypertension
3 Rationale: Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to mon- itor for these adverse effects. Options 1, 2, and 4 are not effects with administration of this medication.Test-Taking Strategy: Eliminate options 1 and 2 first because they are comparable or alike. Knowledge about the specific adverse effects related to the intravenous use of this medication will direct you to the correct option. Remember that hypoten- sion and bradycardia can occur with intravenous administra- tion of methocarbamol.
815. A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1.Bedrest 2. Ibuprofen 3. Bending or lifting 4.Application of heat
3 Rationale: Low back pain that radiates into 1 leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the cli- ent to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raisingtest).Bedrest,heat(orsometimesice),andnonsteroi- dal antiinflammatory drugs (NSAIDs) usually relieve back pain. Test-Taking Strategy: Focus on the subject, factors that aggra- vate back pain. Think about how each item in the options would relieve or exacerbate back pain. Recall that bed rest, heat (or sometimes ice), and NSAIDs usually relieve back pain, whereas bending, lifting, and straining aggravate it.
806. Aclient has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture
3 Rationale: Most pain associated with fractures can be mini- mized with rest, elevation, application of cold, and administra- tion of analgesics. Pain that is not relieved by these measures should be reported to the health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the frac- ture should assist in relieving the pain associated with the injury. Test-Taking Strategy: Focus on the subject, intense pain, and focus on the data in the question. Use of the ABCs—airway- breathing-circulation—will direct you to the correct option. Review: Care of the client with a fracture and new cast
805. The nurse is assessing the casted extremity of a cli- ent. Which sign is indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity
3 Rationale:Signsofinfection underacasted areaincludeodoror purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema. Test-Taking Strategy: Focus on the subject, signs of infection. Think about what you would expect to note with infection—red- ness, swelling, heat, and purulent drainage. With this in mind, you can eliminate options 2 and 4 easily. From the remaining options, remember that "dependent edema" is not necessarily indicative of infection. Swelling would be continuous. The hot spot on the cast could signify infection underneath that area. Review: Signs of infection in an extremity with a cast
804. The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1. Redness around the pin sites 2. Pain on palpation at the pin sites 3. Thick, yellow drainage from the pin sites 4. Clear, watery drainage from the pin sites
3 Rationale:Thenurseshouldmonitorforsignsofinfectionsuch as inflammation, purulent drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes. Test-Taking Strategy: Note the strategic word, most. Deter- mine if an abnormality exists. Recall that purulent drainage is indicative of infection, and that some degree of pain, inflam- mation, and serous drainage should be expected.
9. The nurse is evaluating dietary teaching provided to a patient recovering from osteomyelitis. Which meal choice indicates that additional teaching is required? 1) Green salad, meat loaf, brown rice, and broccoli 2) Caesar's salad, pork loin slices, sauerkraut, baked potato, and sautéed carrots 3) Tossed salad, spaghetti with marinara sauce, Italian bread, and creamed spinach 4) Iceberg lettuce wedge, baked chicken breast, parsley red potatoes, and green beans
3) This meal choice has no protein. It may have adequate zinc and folic acid; however, protein is missing, which is required for wound healing. Adequate ingestion of vitamin C, zinc, iron, thiamine, folic acid, and protein can help with wound healing and eliminating infection. This meal choice would be adequate.
21. 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
824. The nurse is analyzing the laboratory studies on a client receiving dantrolene. Which laboratory test would identify an adverse effect associated with the administration of this medication? 1. Platelet count 2. Creatinine level 3. Liver function tests 4. Blood urea nitrogen level
3Rationale: Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and throughout the treatment interval. Dantrolene is administered at the lowest effective dosage for the shortest time necessary. Test-Taking Strategy: Eliminate options 2 and 4 because these tests assess kidney function and are comparable or alike. From the remaining options, you must recall that this medication affects liver function.
818. A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1. Allows bony healing to begin before surgery and involves pins and screws 2. Provides rigid immobilization of the fracture site and involves pulleys and wheels 3. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels
4 Rationale: Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobi- lize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel sev- erance. This type of traction involves pulleys and wheels, not pins and screws.Test-Taking Strategy: Focus on the subject, use of traction fol- lowing a hip fracture. Read each option carefully and note that each option has more than one part. All parts of the option need to be correct in order for the answer to be correct. Noting the words provides comfort and fracture immobilization will direct you to the correct option.
813. A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the cli- ent at most risk for after surgery? 1. Hemorrhage 2. Edema of the residual limb 3. Slight redness of the incision 4. Separation of the wound edges
4 Rationale: Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative hemorrhage and edema of the residual limb are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as the incision is dry and intact. Test-Taking Strategy: Note the strategic word, most, and focus on the subject, complications following surgery for the client with diabetes mellitus. Recalling that diabetes mellitus increases the client's chances of developing infection and delayed wound healing will direct you to the correct option. Review: The complications associated with an amputation
822. Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide? 1. Take the medication at bedtime. 2. Take the medication in the morning with breakfast. 3. Lie down for 30 minutes after taking the medication. 4. Take the medication with a full glass of water after rising in the morning.
4 Rationale: Precautions need to be taken with the administra- tion of alendronate to prevent gastrointestinal adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication. Focus on the subject, the administration of alendronate. Recalling that this medication can cause esoph- ageal irritation will direct you to the correct option.
800. The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of develop- ing this disorder? 1. A25-year-old woman who runs 2. A 36-year-old man who has asthma 3. A70-year-old man who consumes excess alcohol 4. A sedentary 65-year-old woman who smokes cigarettes
4 Rationale: Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.Test-Taking Strategy: Focus on the subject, risk factors for osteoporosis. The 25-year-old woman who runs (exercises using the long bones) has negligible risk. The 36-year-old man with asthma is eliminated next because his only risk factor might be long-term corticosteroid use (if prescribed) to treat the asthma. Of the remaining options, the 65-year-old woman has higher risk (age, gender, postmenopausal, sedentary, smoking) than the 70-year-old man (age, alcohol consumption).
26. 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.