MUSK NCLEX 6/15/20

a nurse is collecting data from a client who reports shoulder pain. which of the following findings should cause the nurse to suspect that the client has a rotator cuff injury?

inability to abduct the arm at the shoulder a client who has a rotator cuff injury has limited ability to abduct the arm at the shoulder.

A nurse in the clinic is collecting data for a client who States she is concerned about developing osteoporosis. Which of the following findings places the client at risk for developing this condition?

Smokes one pack of cigarettes per day Current smoking is a risk factor

A nurse is collecting data from a client who reports wrist pain. Which of the following findings should the nurse expect if the client is experiencing carpal tunnel syndrome?

Positive phalens sign With carpal tunnel syndrome, when a client holds the wrist in flexion, it should produce numbness of the fingers. The nurse should attempt to illicit this finding

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

Prevent hip flexion of the affected extremity The nurse should implement measures to prevent hip flexion of the affected extremity due to the risk of dislocation

An older adult client on an orthopedic unit has an intracapsular fracture of the right hip following a fall. The client is in bucks traction and will have hip prosthesis surgery in the morning. The nurse should reinforce with a client that this type of traction promotes which of the following outcomes?

Relief from muscle spasms-bucks traction immobilizes the fractured bone to relieve muscle spasms at the fracture site and thereby relieves pain. Any movement of the fracture fragments induces severe muscle spasms and triggers pain.

A nurse in an urgent care center is caring for a child who has a forearm fracture. The parents tell the nurse that the provider said it was a green stick fracture and asks what that means. Which of the following description to the nurse provide?

The bone cracked lengthwise but didn't break all the way through This statement describes a greenstick fracture, which is a common fracture in children

Hey nurse is collecting data from an older adult client who is pre-operative for a total hip arthroplasty. For which of the following findings should the nurse notify the provider?

The client has an abscesses tooth The nurse should assess for and report any signs of infection and a pre-operative client as this increase the risk of surgery and pre-operative surgical site infection

A nurse is reinforcing teaching about placement of a prosthesis with a client who is having a below the knee amputation. Which of the following information should the nurse include in the teaching?

This will improve your ability to ambulate sooner-the nurse should explain that the purpose of a prosthesis immediately following surgery is to promote postoperative ambulation

A nurse is collecting data from a client who has a herniated intervertebral cervical disc. Which of the following findings should the nurse expect? Select all that apply.

Tingling in the arms - numbness and tingling in the upper extremities are common findings of a herniated cervical intervertebral disc. Shoulder pain-shoulder pain, particularly on the top of the shoulders, is a common finding of a herniated cervical intervertebral disc. Neck stiffness - stiffness and pain in the neck are common findings of a herniated cervical intervertebral disc.

A nurse is reinforcing teaching with a client who has a new diagnosis of gout. Which of the following information should the nurse include in the teaching?

Avoid consuming shellfish. The client who has gout should avoid Perrine rich foods, such as organ meats and shellfish. These foods increase serum uric acid levels and can promote episodes of acute gout.

A nurse is completing a neurovascular check for a client in madden open reduction internal fixation surgery. Which of the following findings should the nurse identify as possible manifestations of compartment syndrome? Select all that apply.

Cool skin-the nurse should identify Peller as a possible manifestation of compartment syndrome Absence of pulse-the nurse should identify pulselessness as a possible manifestation of compartment syndrome. Altered sensation of the toes-the nurse should identify paresthesias as a possible manifestation of compartment syndrome.

A nurse is assisting with the care if a client who has a femur fracture and is in skeletal traction. Which of the following action should the nurse take?

Ensure the client weights are hanging freely from the bed The nurse should ensure that the clients weights are hanging freely from the bed to maintain the client and proper body alignment and should never be removed without a providers prescription or the development of a life-threatening situation that requires removal

A nurse is reviewing the health history of a client who has osteoporosis. Which of the following medication in the clients history contribute to osteoporosis?

Glucocorticoids Osteoporosis is a complication of long term use of glucocorticoids. These medications suppress bone formation and accelerate bone resorption

A nurse is reinforcing teaching with a client has fibromyalgia about strategies that might help reduce her symptoms. Which of the following interventions should the nurse include?

Limit caffeine consumption-not getting enough deep sleep tends to cause exacerbations of fibromyalgia. Limiting caffeine intake may help the client obtain a more restful sleep.

A nurse is reinforcing teaching with a client who has a new diagnosis of fibromyalgia. Which of the following information should the nurse include in the teaching?

Low impact aerobics can help reduce episodes of pain The nurse should recommend that the client who has fibromyalgia engage in regular aerobic exercise to improve overall quality of life

A nurse is assisting with discharge teaching for a client who is postoperative from a mastectomy including the removal of axillary lymph nodes. Which of the following instructions should the nurse include? Select all that apply

Perform range of motion exercises of the affected arm - The client should perform range of motion exercises on the affected arm to improve circulation and reduce the risk of lymphedema. Elevated the affected arm on a pillow when resting in bed -The client should elevate affected arm to increase circulation and reduce the risk of lymphedema

a nurse is discharging a client who came to the outpatient clinic with an ankle sprain. which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

ill apply ice to my ankle for 20 min every hour the client should apply ice for 20 min every hr for the first 24 to 48 hr.

a nurse is checking a client who has a new short leg cast to treat an ankle fracture. which of the following findings should the nurse report to the provider.

inability to flex the toes of the casted foot. the application of a cast can result in compromise of the vascular and nerve function of the extremity. the lack of movement of an extremity can indicate neurovascular compromise or compartment syndrome and warrants immediate notifications of the provider.

while collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. which of the following finding should the nurse identify as a complication to clients condition?

infection an area of warmth on a cast is an indication of an infection; therefore, the nurse should report this finding to the provider.

a nurse is assisting with the plan of care for a client who is 1 day postoperative following spinal fusion. which of the following interventions should the nurse include in the plan?

log roll the client every 2 hours. the nurse should log roll the client from side to back or back to side every 2 hours to keep his spinal column in alignment, prevent pressure sores and to monitor the incision site.

a nurse is contributing to the plan of care for an older adult client who is postoperative following a right hip arthroplasty. which of the following interventions should the nurse include in the plan?

maintain abduction of the right hip. the nurse should use an abductor pillow or other devices to maintain abduction of the affected hip to prevent dislocation.

a nurse in a providers office is reinforcing teaching with a female client about risk factors for osteoporosis. which of the following factors should the nurse include in the teaching? select all that apply

obesity - women who are obese have a greater capacity for storing estrogen to help maintain acceptable levels of calcium. aging - women lose bone due to estrogen depletion after menopause caffeine intake - excessive caffeine intake causes calcium loss in the urine.

a nurse is reinforcing discharge teaching with a client who has osteoarthritis. which of the following statements by the client indicates an understanding of the teaching?

osteoarthritis occurs due to the aging process and results in disintegration of cartilage in a joint. aging and obesity are the leading factors that cause osteoarthritis, a disease of progressive loss of cartilage.

a nurse is caring for a client who has balanced skeletal traction with a thomas splint for the treatment of a fracture of the femur. which of the following actions should the nurse take to prevent skin breakdown.

pad the top of the splint with protective dressing. the nurse should pad the top of the splint with protective dressing or soft cotton padding to prevent skin breakdown at the splint edge.

a nurse is monitoring a client who has a cast on her right ankle following an open reduction and internal fixation. procedure. the nurse should monitor for which of the following findings to identify compartment syndrome?

pain unrelieved by routine medications clients who have a fracture and a new cast can have swelling, which can cause the cast to be tight, obstructing circulation and damaging nerves. the nurse should monitory for pain unrelieved by routine medications, numbness and tingling, and skin that is cold to touch and pale to identify compartment syndrome.

a client who has a lower- leg cast reports skin irritation around the upper edge of the cast. which of the following actions should nurse take?

petal the edges of the cast. petaling the edges of the cast is a procedure that involved cutting strips of tape and applying them in an overlapping fashion around the edges of cast. this reduces skin irritation from rough edges.

a client who is postoperative returns to the unit in skeletal traction. when collecting data from the client, the nurse should expect which of the following findings? (select all that apply)

redness at the pin site - the nurse should expect the client to have redness at the pin site, as it is a manifestation of the expected reaction after insertion warmth at the pin sites - the nurse should expect the client to have warmth at the pin sites, as it is a manifestation of the expected reaction after insertion.

a nurse is caring for a client who has a new below the knee amputation. which of the following actions should the nurse take?

rewrap the stump 3 times a day the nurse should rewrap the stump 3 times each day and when it becomes loose, to control edema.

a nurse is reinforcing teaching about russell's traction with a newly licensed nurse. which of the following statements should the nurse make?

russells traction uses a sling under the knee to treat a fracture of the femur russells traction is a type of skin traction which incorporates a sling under the knee that is connected by a rope to an overhead bar pulley.

a nurse is caring for a client who has a skeletal traction for treatment of a femur fracture. which of the following actions should the nurse take?

the nurse should adminsiter pain medications to the client 30 min prior to performing pin car to reduce clients discomfort.

a client returns to the surgical unit from the PACU in skeletal traction. the nurse should take action to correct which of the following problems with the traction setup?

the weights rest against the foot of the bed. weights that rest against the foot of the bed or on the floor do not apply the traction essential for reducing the fracture and immobilizing the bone.

A nurse is collecting data on a client who has manifestations of osteoporosis. The nurse anticipates the provider will prescribe which of the following diagnostic tests?

Dual energy absorptiometry It's all energy absorptiometry Scan is the most commonly use screening and diagnostic tool for measuring bone mineral density

A nurse is reinforcing teaching with a client prescribed celecoxib to treat osteoarthritis symptoms. The nurse should remind the client to monitor for and report which of the following findings?

Black, tarry stools-the nurse should instruct the client to monitor and report black, dark colored, or bloody stools, abdominal pain, or coffee-ground emesis. One of the side effects of celecoxib is gastrointestinal bleeding. The nurse should also instruct the client to take celecoxib with food to reduce gastric irritation.

a nurse is caring for a client who has a fracture of the right hip. which of the following types of traction should the nurse expect the client to have prior to hip surgery?

Bucks traction Bucks traction prior to hip surgery help to maintain alignment and prevent muscle spasms prior to surgical fixation.

A nurse is contribution to the plan of care for a client who is 12 hour postoperative following a right radical mastectomy which closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm?

Combing her hair-the nurse should recognize that combing the hair requires abduction of the arm. This movement is avoided for the client who is in the immediate postoperative period until the drains have been removed. Activities requiring abduction and rotation of the shoulder may resume following healing of the surgical site.

a nurse is reinforcing teaching with a client who has a new dx of fibromyalgia. which of the following client statements indicates the needs for further teaching?

fibromyalgia causes joint inflammation clients who have fibromyalgia may report joint discomfort; however, fibromyalgia is a non inflammatory disorder and does not cause joint inflammation.

a nurse is collecting data from a client who is postoperative from a below- the - knee amputation and whose residual limb is wrapped with a an elastic bandage to shrink the stump. Which of the following findings should alert the nurse to a possible complication?

pitting edema above the bandage. if the elastic bandage is properly applied, it should prevent edema. the nurse should remove the bandage and rewrap the stump.

a nurse is caring for a client who is postoperative following a foot surgery and is not to bear weight on the operative foot. the nurse enters the room to discover the client hopped on one foot to the bathroom, using an IV pole for support. which of the following actions should the nurse take?

tell the client to remain in the bathroom after toileting and obtain a wheelchair. the greatest risk to the client is falling. since the client is already in the bathroom, the nurse should allow the client to void and then return the client to bed safely in a wheelchair to prevent a fall.

s nurse is collecting data from a client who has multiple fractures in his left leg and reports severe pain and tingling in the extremity. the nurse should suspect which of the following complications?

acute compartment syndrome in compartment syndrome, increased pressure within fascia leads to reduced circulation to the area. the nurse should check for other manifestation of compartment syndrome and report them to the provider immediately.

a nurse is reinforcing discharge teaching to a client following arthroscopic surgery. to prevent postoperative complications which of the following actions should be reinforced during the teaching?

administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.

a nurse in a providers is reinforcing teaching with a client about the risk factors for osteoarthritis. which of the following information should the nurse include? select all that apply.

aging - aging is a risk factor for osteoarthritis, as the joints bear the load of the body's weight over time. obesity - obesity is a risk factor for osteoarthritis, as it increases the load of the body's weight over time heredity - there is a genetic component to the development of osteoarthritis

a nurse is instructing coworkers about how to minimize lower back pain and avoid repeated episodes of back pain. which of the following strategies should the nurse include? select all that apply.

avoid prolonged sitting - staying in any one position for too long, even lying down can worsen back pain. changing positions frequently is essential. do partial sit ups with the knees bent - exercises that strengthen back muscles and help prevent pain include partial sit ups with the knees bent, knees chest exercises and pelvic tilts. ask for help when moving clients - the nurse should remind coworkers to use good body mechanics when handling clients and never to attempt lifting or moving clients by themselves.

a nurse is reinforcing teaching with a client who has rheumatoid arthritis (RA) about self care techniques. Which of the following strategies should the nurse include in the teaching?

avoiding exercising joints that are swollen exercise are an important part of maintaining joint mobility and should be competed daily. however, joints that are inflamed, red, and hot to touch should not be exercised to prevent excess strain and possible injury to the joint.

a nurse is assisting with the plan of care for an older adult client who is 4 hr postoperative following an open reduction and internal fixation of a fractured femur. which of the following interventions should the nurse include in the plan of care?

check capillary refill in the affected extremity every 4 hr. the client is at rish for neurovascular compromise. for a client who is 4 hr postoperative, the nurse should check the capillary refill in the affected extremity every 2-4 hr.

a nurse is caring for a client who has a new cast in place for a fractured tibia. the nurse should recognize that which of the following interventions is a priority?

check for capillary refill distal to the clients cast. the priority action the nurse should take when using the airway, breathing and circulation (ABC) approach to client care is to check capillary refill. reduce capillary refill can indicate a change in the neurovascular status due to the injury or pressure from the cast. the nurse should monitor color, movement, temperature, sensation and capillary refill of the toes on the affect extremity.

a nurse is caring for a client who has a fractured tibia as a result of a fall. the xray shows that the bone is splintered into several pieces around the shaft. the nuse should recognize this is a finding for which of the following types of fractures?

comminuted a comminuted fracture is a injury which the bone is broken and splintered into several pieces.

a nurse is caring for a client who has Parkinson's disease and is taking selegilline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with client who is taking this medication?

decreased tremors selegilline, an MAO-B inhibitor, improves motor function by decreasing tremors, rigidity, and bradykinesia in the client who has Parkinson's disease.

a nurse is collecting data on a client who has a femur fracture. which of the following findings is a manifestation of fat embolism syndrome?

petechiae over the client's chest. a client who has fat embolism syndrome can develope petechiae over the chest arms, neck, and abdomen. Other manifestations include chasge in mental status, dyspnea, tachypnea and tachycardia. This develops due to inadequate arterial oxygen from fat globules blocking small arteries that provide oxygen to various organs.

a nurse is assisting a client who is postoperative following a total hip arthroplasty into a supine position. which of the following actions is appropriate to prevent hip dislocation?

place a wedge pillow between the legs. the nurse should place a wedge pillow or a different abduction device between the legs to prevent adduction, which can lead to possible dislocation.

a client who has undergone a right below the knee amputation now has a prosthetic limb. when reinforcing teaching with client about prosthesis and residual limb care, the nurse should include which of following instructions?

dry the prosthesis socket completely before applying it to the limb. the client should dry the prosthesis socket thoroughly with a clean cloth. Moisture between the socket and the residual limb can put the client at risk for fungal or bacterial infection and skin breakdown.

a nurse is talking with a client who has a new dx of acute bursitis in her right shoulder. which of the following self-care strategies should the nurse recommend?

intermittent ice and heat. bursitis is an inflammation of the fluid-filled portion of a joint and is common in the shoulder. intermittent ice and heat are part of the traditional conservation management of acute bursitis.

a nurse is collecting data from a client who has systemic lupus erythematosus. which of the following findings is the highest priority to report to the provider.

presense of peripheral edema the client who has systemic lupus erythematosus is at greatest risk for death from lupus nephritis; therefore, according to the safety and risk of reduction priority-setting framework, finding that indicate an impairment of renal function are the highest priority to repot.

a nurse is contributing to the plan of care for a client who has spinal cord injury at level C8 who is admitted for comprehensive rehabilitation. which of the following term goal is appropriate with regard to the client's mobility.

propel a wheelchair equipped with knobs on the wheels. a client who as an injury at C8 has full use of the shoulders and arms but will likely experience hand weakness. the addition of knobs on the wheels will help the client use the wheelchair more effectively.

a charge nurse is observing a nurse who is caring for a client who has continuous skeletal traction of a lower extremity. For which of the following actions should the charge nurse intervene?

removes the traction weights for a brief period each day traction applies a pulling force to an injured extremity and helps immobilize and reduce the fracture. the nurse should not remove the weights because doing so can further injure the client.

a client who has a compound fracture of the right tibia has a long-leg fiberglass cast. to reinforce teaching for the client about how to observe and manage his fracture at home, the nurse should include which of the following instructions?

report any worsening or unrelieved pain. pain can be sign of complications such as compartment syndrome or skin breakdown. the client should report it to the provider.

a nurse is caring for a client who 1 day postoperative right total hip arthroscopy. the nurse should monitor for which of the following findings to identify deep-vein thrombosis.

report of pain in lower extremity a client who is postoperative from a major surgery is a risk deep vein thrombosis due to immobility. the nurse should monitor for swelling, redness, aching, and cramping pain and tenderness of a lower extremity.

a nurse is assisting with the care of a newly- admitted client who has acute osteomyslitis. which of the following interventions is the priority for the nurse to implement?

antibiotic therapy osteomyelitis is a bone infection. antibiotic therapy is the priority treatment

A nurse is caring for a client who has an acute ankle sprain. Which of the following actions should the nurse take? Select all that apply

Rest- rest helps limit the movement of the extremity and prevents further injury Compression - compression reduces edema, Hoping to relieve pain. Elevation-elevation reduces edema, helping to relieve pain

a nurse is talking with a client who has gout. the nurse should remind the client to avoid the use of which of the following medications?

aspirin the nurse should warn the client that taking aspirin can block uric acid excretion and tripper a gout attack.

A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following position she's a nurse place the clients right leg?

Abduction When caring for a client following a total hip arthroplasty, the nurse should abduct the affected extremity to prevent dislocation

A nurse is reviewing the medical record of a client who has gout. Which of the following factors places the client at risk for osteoporosis?

History of bulimia-the nurse should identify history of an eating disorder as a risk factor for osteoporosis.

A nurse is reinforcing teaching with a client who is postoperative following the insertion of a femoral head prosthesis. Which of the following client statements should indicate to the nurse the need for further instructions?

I will bend from my hip to time I shoes-the client should not bent over from the hip. This can cause the hip to flex greater than 90°, which increases the risk of discoloration of the prosthesis

A nurse is contributing to the plan of care for a client who achieve the outcome of functional healing of a fracture. Which of the following nursing intervention is the highest priority to assist in meeting this outcome?

Maintain and mobilization and alignment for the clients The nurse should maintain the prescribed immobilization and body alignment to keep the fracture fragments in close anatomical proximity, thereby promoting functional fractures healing; therefore, this intervention is the highest priority.

A nurse is reinforcing teaching with a client who has gout. Which of the following dietary restrictions should the nurse include in the teaching?

Milk Alcohol Alcohol can trigger painful gout attacks and should be avoided by the client who has gout

A nurse is collecting data from a client following the application of a leg cast for the treatment of a fracture. Which of the following findings should the nurse expect to find first if the cast is too tight?

Pallor of the toes The client who has a cast that is too tight may have pallor of the toes cost from inflammation and edema that puts pressure on the vascular system, tissue and nerves, which decreases blood flow and can lead to compartment syndrome. When this occurs, pallor of toes is the initial finding. The nurse should immediately report this finding to the provider

A nurse is assisting with the care of a client who has multiple facial injuries. Which of the following equipment should the nurse place at the clients bedside?

Suction catheter-establishment and maintenance of a patient airway is the primary nursing goal for client who has facial injuries. Because official injuries can make it difficult for the client to manage secretions or emesis safely, the nurse must be prepared to suction the clients airway.

A nurse is reinforcing teaching with a client who has diabetes Mellitus about foot care. which of the following instructions should the nurse include?

Wear a cotton socks The client should wear socks made from cotton or wool material that allows perspiration to dry

And occupational health nurse is instructing workers at an industrial facility about emergency procedures to follow in the event of a traumatic amputation. Which of the following guidelines should the nurse include about preserving the amputated part for possible surgical reattachment?

Wrap the part and sterile gauze- The person at the scene should wrap the served part in sterile gauze or a clean cloth and soak it with saline solution if available Put the serve part in a plastic bag-The person at the scene should place the surf part in a sealed waterproof plastic bag and then put the bag in ice water. Prevent the served part from coming in contact with water-The person at the scene should not allow the served part to become wet but should keep it dry

a nurse is discussing cast applications with a newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of the information?

a synthetic cast is light weight the nurse should recognize that a synthetic cast is less restrictive, is lighter in weight and requires less drying time than plaster cast. therefore, this statement indicates an understanding of the information.

a nurse in a clinic is talking with an older adult client newly diagnosed with osteoarthritis. the nurse should reinforcing that which of the following medications is usually prescribed first to treat osteoarthritis?

acetaminophen according to evidence - based practice, the nurse should expect the provider to first prescribed acetaminophen to the older adult client. most osteoarthritis pain is manageable with an OTC medication, and acetaminophen is a safer choice for the older adult client than an NSAID.

a nurse in a clinic a collecting data from an older adult client who has a new dx of osteoarthritis. which of the following medications should the nurse anticipate the provider will initially prescribed to the client?

acetaminophen the nurse should anticipate a prescription for acetaminophen. the discomfort of osteoarthritis can be managed with the use of mild analgesics such as acetaminophen or NSAIDs. Acetaminophen is preferred over NSAIDs for the older adult client because it has fewer toxic side effects.

a nurse is reinforcing teaching with a client about risk factors for osteoarthritis. Which of the following risk factors should the nurse identify as contributing to this diagnosis?

aging - aging is risk factor for osteoarthritis, as the joints bear the load of the body's weight over time. obesity - obesity is a risk factor for osteoarthritis, as it increase the load of the body's weight over time.

a nurse is caring for a client who has a new dx of paget's disease. the nurse should anticipate the provider will prescribed which of the following medications for this client?

alendronate the nurse should recognize that paget's disease is a chronic bone disorder characterized by a fragile, misshapen bone growth. alendronate, a bisphosphonate, is prescribed for the client who has paget's disease to prevent bone loss and increased bone density.

a nurse is collecting data from a client who has rheumatoid arthritis. which of the following is an expected finding for this client?

boutonniere deformity. rheumatoid arthritis is a chronic, inflammatory autoimmune disorder which primarily affects the synovia (linging of the joints). boutonniere deformity is a manifestation of rheumatoid arthritis in which a finger is flexed or bent inward towards the palm at the lowest (most proximal) joint and then extended outward away from the palm at the furtherst (most distal) joint. this deformity arises due to the loss of collagen ( connective tissue) in the joints

a nurse is reinforcing dietary teaching to a client who is at risk for osteoporosis about increasing her calcium intake. which of the following foods should the nurse recommend the client consume frequently?

collards one cup of cooked collards contains 268 mg of calcium.

a nurse is collecting data from a client who has an exacerbation of gout. which of the following findings should the nurse expect? select all that apply.

edema - swelling over the affected joints is a classic manifestation of gout. erythema - redness over the affected joints is a classic manifestation of gout. tophi - tophi are a classic manifestation of gout. they are nodules that form in subcutaneous tissue due to the accumulation of urate crystals. tight skin - tight skin over the affected joints is a classic manifestation of gout

the nurse is reinforcing teaching with a client who has an ankle sprain. which of the following instructions should the nurse include?

elevate the affected ankle to the level of the heart. the client who has an ankle sprain should be instructed to elevate the extremity to the level of the heart to minimize swelling and to increase venous return.

a nurse is caring for a client who has been placed in halo traction to immobilize his cervical spine. which of the following actions should the nurse take?

elevate the head of the bed. to keep the client from migrating toward the head of the bed while using cervical halter traction, the nurse should elevate the head of the bed.

a nurse in an urgent care clinic is checking a client who was brought in by a relative following a motor-vehicle crash. the client is not breathing, and the nurse suspects a cervical vertebrae fracture. which of the following actions should the nurse take first?

open the airway using the jaw-thrust maneuver. using the airway, breathing circulation approach to client care, the first action the nurse should take is to open the client's airway. for a client who is not breathing and might have cervical spine injury, the nurse should use the jaw-thrust maneuver ( not the head tilt chin life maneuver) to open the airway. The jaw thrust maneuver prevents hyperextension of the neck and reduces the risk for further spinal injury.

a nurse is assisting in planning care for a client who has advanced multiple myeloma. when planning care the nurse should recognize that the client is at risk for which of the following complications?

pathologic fracture thinning of the bone and bone loss place the client who has multiple myeloma at risk for fractures.

a nurse is reinforcing teaching with a client who has osteoarthritis. which of the following information should the nurse include in the teaching?

the client should take acetaminophen as the primary medication to treat osteoarthritis because this condition is not primary anti-inflammatory disorder.

A nurse in the clinic is reinforcing teaching to a client who is postmenopausal About the prevention of osteoporosis. Which of the following statements by the client requires clarification of the teaching?

I will include vitamin E rich foods in my diet This statement requires clarification because vitamin C rich foods do not prevent osteoporosis. The nurse should instruct the client that calcium, vitamin D, phosphorus, and vitamin K are required for proper bone health

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. Which of the following actions should the nurse take?

Ensure the affected extremity is rusting at 20 degree angle The nurse should ensure the affected extremity is resting above the bed at a minimum of a20° angle while in balanced suspension traction. This position maintains traction while allowing the client some degree of movement and independence.

The nurse is collecting data from a client who is 24 hour postoperative for my hip open reduction with internal fixation of the tibia. Which of the following findings should the nurse report to the provider?

The clients affect extremity is cool to the touch Call skin is an indication of decrease artial perfusion

a nurse is collecting data from a client who has paget's disease. which of the following findings should the nurse expect? select all that apply.

cranial enlargement - when the skull is involved, paget's disease causes thickening and enlargment of the skull bones and enlargement of the cranium. skeletal pain - paget's disease causes pain and tenderness over the affected bones. waddling gait - when the legs are involved, paget's disease causes bowling of the legs and waddling gait.

a nurse is caring for a client who 2 days postoperative following an above the knee amputation. which of the following is an approriate nursing intervention for the client at this time?

have the client lie prone several times each day. the nurse should encourage the client to lie prone for 20 30 min every 3-4 hr to help prevent hip flexion contractures.

a nursing is caring for a client who is postoperative following a below the knee amputation and will soon undergo fitting for a leg prosthesis. which of the following is an appropriate nursing intervention for this client at this time?

wrap the stump with an elastic bandage in a figure- eight configuration. the figure eight style of wrapping helps prevent blood flow restriction and also helps shape and shrink the limp to prepare it for the prosthesis.

a nurse is reinforcing teaching with client who has osteoarthritis about a total hip replacement. which of the following instructions should the nurse include in the teaching?

you should not cross your legs after this procedure. the clients should not cross his legs after this procedure to prevent adduction of the hip that can cause hip dislocation.

A nurse is caring for a client who is today's postoperative following an above the knee amputation. Which of the following is an appropriate nursing intervention for this client at this time?

Have the client lie prone several times each day The nurse should encourage the client to lie prone for 20 to 30 minutes every 3 to 4 hours to help prevent hip flexion contractures

A nurse is reinforcing discharge instructions to a client who is postoperative from a hip arthroplasty. Which of the following statements by the client indicates a correct understanding of the teaching?

I will avoid crossing my legs for the first three months after surgery The client should avoid crossing his or her legs for three months after surgery to prevent dislocation of the hip

A nurse is reinforcing teaching with a client who has a new diagnosis of gout. The client asked the nurse how she got the disorder. Which of the following information should the nurse include in the teaching?

Intro articular urate crystal deposits causes inflammation Gout or gouty arthritis, develops when urate crystals deposits in joints and tissues, leading to inflammation and pain

A nurse in the clinic is collecting data from a client who reports wrist pain caused by carpal tunnel syndrome. the nurse should expect which of the following findings?

Positive phalens sign A client who has a positive Phalens test, has carpal tunnel syndrome. The test is performed by having the client hold the rest in a 90° flexion for 60 seconds. Tingling and numbness over the median nerve, the Palmer surface of the thumb, the index finger, the middle finger, and part of the ring finger will occur indicating a positive phalens test

A nurse is reinforcing teaching with a female client about risk factors for osteoporosis. which of the following factors should the nurse include? Select all that apply.

Sedentary lifestyle - immobility depletes bone aging - women lose bone density due to estrogen depletion after menopause. caffeine- excessive caffeine intake causes calcium loss in the urine. smoking - smoking is a risk factor for osteoporosis, both active and passive (secondhand) smoking.

A nurse is teaching an assistive personnel about attaching a footboard to the bed of a client who is immobile. Which of the following information should the nurse include in the teaching?

The footboard will help to prevent plantar flexion The nurse should teach that the purpose of a footboard is to prevent plantar flexion contracture or foot drop.

A nurse in a providers office is reinforcing teaching with a client who is scheduled for an arthroplasty. When the client asked the nurse what this procedure went to for him, which of the following responses should the nurse make?

The purpose of this procedure is to replace the joints and improve function Arthroplasty is the reconstruction or replacement of a joint. The surgeon performs this procedure to relieve pain, improve or maintain range of motion, and correct the present deformity

a nurse is reinforcing teaching for a client who is to have a myelogram. which of the following statements indicates the client understands the teaching.

i will not eat or drink anything for 8 hours before the procedure. the client should remain NPO for 4 or 8 hours before the procedure to prevents any movement that could occur from the client being nauseated or vomiting during the procedure.

a nurse is talking with a client who has osteoporosis and needs to increase her vitamin D intake as part of her treatment plan. which of the following recommendation should the nurse reinforce with the client to help ensure an adequate intake of vitamin D.

increase her daily amount of sunlight exposure. there are two source of vitamin D: sunlight and diet. increasing the clients daily exposure to the sunlight is essential for calcium absorption and metabolism.

a nurse in reinforcing teaching with a client who has osteoarthritis. To slow the degenerate process, which of following interventions should the nurse recommend?

maintaining a BMI 18.5 and 24.9 a BMI between 18.5 and 24.9 is classified as a health weight. osteoarthritis is the degeneration of the cartilage in the joints caused by prolonged wear and tear of the joint surfaces. Osteoarthritis most commonly affects weight- bearing joint of the hip, knees, spine. Maintaining a healthy, appropriate weight for height or participating in a weight reduction program if the client is overweight, reduces the stress on the involved joints and slows the disease process.

a nurse is reinforcing teaching with a client who has a new rx for methotrexate for the treatment of rheumatoid arthritis. the nurse should instruct the client to notify the provider of which of the following manifestation?

malaise the nurse should instruct the client to report manifestation of infection, such a fever and malaise, to the provider. Disease modifying antirheumatic drugs (DMARDs) such as methotrexate can suppress the client's natural immune response, increasing the risk for infection.

a nurse is collecting data from a client who has hip fracture. which of the following findings should the nurse expect when checking the extremity?

muscle spasms the nurse should expect muscle spasms following a hip fracture.

a nurse is collecting data from a client who has short arm cast for a fractured wrist. which of the following findings indicates impaired venous return in the affected arm?

pain unrelieved by opioid analgesic

a nurse is reinforcing teaching with a client who is about to undergo electromyography. the nurse should explain to the client that this diagnostic test involves which of the following actions?

placement of thin needles into muscles to record responses to stimuli. thin needs are placed into certain muscles to record responses to stimuli during an electromyography. this procedure gives the provider data about muscle weakness and helps distinguish muscles disorders from nerve disorders.

a nurse is reinforcing teaching with a client who has gout. which of the following medications classes should the nurse instruct the client to avoid.

salicylates salicylates, such as aspirin, can trigger gout attacks and should be avoided. Additionally, clients who have gout and are prescribed probenecid or sulfinpyrazone, uricosuric drugs, should not take aspirin.

a nurse is discussing skeletal and skin traction with a newly licensed nurse. which of the following statements should the nurse identify as an induction that the newly licensed nurse understands these therapies.?

skeletal traction is better than skin traction for reducing a fracture. skeletal traction allows for reduction and alignment of fracture. skin traction decreases muscle spasms common with a fracture.

a nurse is reinforcing teaching about self care- techniques with a client who has rheumatoid arthritis. which of the following strategies should the nurse include to illustrate the concept of the joint protection?

turn doorknobs in a counterclockwise motion to open them. the nurse should instruct the client to turn the wrist in a counterclockwise motion to open doors because this motion causes less stress on the elbow joint.

a nurse is reinforcing teaching with a client who has fibromyalgia about strategies to help reduce her manifestation. which of the following interventions should the nurse include?

establish a regular sleep pattern. improving sleep patterns can be beneficial for reducing manifestation of fibromyalgia.

a nursing is collecting data from an older adult client who has a femoral head fracture 24 hr ago and is in Buck's traction. Which of the following findings is an indication of fat embolism syndrome?

petechiae on the chest a red rash on the clients abdomen, chest, neck, or upper arms is a manifestation of fat embolism.

a nurse is caring for a client who has a fractured right femur and is in skeletal traction. the nurse should monitor for which of the following findings to identify a fat embolus?

petechiae over the chest and the neck. clients who have a fracture of a large bone are at risk for globules of fat entering the blood stream and occluding circulation. the nurse should monitor for petechiae over the chest, neck, upper arms or abdomen, dyspnea, tachypnea and decreased oxygen saturation to identify a fat embolus. the nurse should report these findings immediately to the provider.

a nurse is reinforcing teaching about ergonomic principle with a group of assistive personnel. Which of the following strategies should the nurse include in the teaching?

tighten the abdominal muscles when lifting objects - the abdominal muscle can provide balance and support to the back when lifting if they are tightened and the pelvis is tucked uder. flex knees and hips periodically when standing for period of time - the nurse should emphasize that occasionally flexing the knees and hips when standing for a long periods of time helps relieve the strain on the lower back prevents back injuries. enlarges the distance between the front foot and the back foot when pulling a client towards you - the nurse should emphasize the when pulling or pushing an object, increasing the base of support by widening the stance increase balance and limits the risk of musculoskeletal injury.

a nurse at an urgent care center is reinforcing information with a new employee about the difference between sprains and strains. which of the following examples should the nurse include as cause of sprain injury.

twisting a ligament while walking a sprain is caused by a stretching injury to ligaments around a joint. ligaments being moved or twisted beyond their typical range of motion is a potential cause of a sprain.

a nurse is collecting data from a client who reports having stiffness in her joints. which of the following finds should indicate to the nurse that the client may have rheumatoid arthrisits?

ulnar deviation the client who has rheumatoid arthritis develops inflammation and deformity of the metacarpophalangeal joints. the fingers deviate toward the ulnar bone while the wrist deviates toward the radial side.

a nurse is talking with a client who reports acute lower back pain after moving heavy boxes. which of the following information should the nurse reinforce.

use ice packs intermittently for 48hr. the nurse should instruct client to use ice for the first 2 days following an injury to reduce back spasms, then apply intermittently heat for several days to promote muscle relaxation.

a nurse is reinforcing teaching to a client who has a new dx of a grade ll ankle sprain. which of the following instructions should the nurse include in the teaching?

wrap the ankle snugly with an elastic bandage. the client should wrap the the ankle snugly with an elastic bandage to reduce swelling and pain.

a nurse is caring for a client who is postoperative following a below the knee amputation and will soon undergo a fitting for leg prosthesis. which of the following is an appropriate nursing intervention for the client at this time?

wrap the stump with an elastic bandage in a figure eight configuration. the nurse should use the figure eight style of wrapping to help prevent blood flow restriction and to shape and shrink the limn to prepare it for the prosthesis.