41,42,43
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals? A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day
a
A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient? A) Keep the patient's hips in abduction at all times. B) Keep hips flexed at no less than 90 degrees. C) Elevate the head of the bed to high Fowler's. D) Seat the patient in a low chair as soon as possible.
a
A nurse is caring for an adult patient diagnosed with a back strain. What health education should the nurse provide to this patient? A) Avoid lifting more than one-third of body weight without assistance. B) Focus on using back muscles efficiently when lifting heavy objects. C) Lift objects while holding the object a safe distance from the body. D) Tighten the abdominal muscles and lock the knees when lifting of an object.
a
A patient has returned to the postsurgical unit from the PACU after an above-the-knee amputation of the right leg. Results of the nurse's initial postsurgical assessment were unremarkable but the patient has called out. The nurse enters the room and observes copious quantities of blood at the surgical site. What should be the nurse's initial action? A) Apply a tourniquet. B) Elevate the residual limb. C) Apply sterile gauze. D) Call the surgeon.
a
A rehabilitation nurse is working with a patient who has had a below-the-knee amputation. The nurse knows the importance of the patient's active participation in self-care. In order to determine the patient's ability to be an active participant in self-care, the nurse should prioritize assessment of what variable? A) The patient's attitude B) The patient's learning style C) The patient's nutritional status D) The patient's presurgical level of function
a
An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? A) Bone fracture B) Loss of estrogen C) Negative calcium balance D) Dowager's hump
a
The patient scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the patient's concern? A) "You will eventually be able to withstand full weight-bearing after the amputation." B) "You will have minimal weight-bearing on this extremity but you'll be taught how to use an assistive device." C) "You likely will not be able to use this extremity but you will receive teaching on use of a wheelchair." D) "You will be fitted for a prosthesis which may or may not allow you to walk."
a
The surgical nurse is admitting a patient from postanesthetic recovery following the patient's below-the-knee amputation. The nurse recognizes the patient's high risk for postoperative hemorrhage and should keep which of the following at the bedside? A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate
a
A nurse is caring for a patient who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention? A) Maintenance of high Fowler's positioning whenever possible B) Intermittent application of heat to the patient's back C) Use of a pressure-reducing mattress D) Passive range of motion exercises
b
A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge? A) Patient is able to perform ADLs independently. B) Patient is able to perform transfers safely. C) Patient is able to weight-bear equally on both legs. D) Patient is able to demonstrate full ROM of the affected hip.
b
A nurse is reviewing a patient's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation? A) Straining during a bowel movement B) Bending down to put on socks C) Lifting items above shoulder level D) Transferring from a sitting to standing position
b
A patient has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery? A) Deficient fluid volume B) Delayed wound healing C) Hypocalcemia D) Pathologic fractures
b
A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A) "Actually, patients are only on bed rest for 2 to 3 days before they begin walking with assistance." B) "The physical therapist will likely help you get up using a walker the day after your surgery." C) "Our goal will actually be to have you walking normally within 5 days of your surgery." D) "For the first two weeks after the surgery, you can use a wheelchair to meet your mobility needs."
b
A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action? A) Administer pain medication as ordered. B) Assess the surgical site and the affected extremity. C) Reassure the patient that pain is a direct result of increased activity. D) Assess the patient for signs and symptoms of systemic infection.
b
A nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. What should the nurse teach the patient? A) Strive to achieve maximum weight-bearing capabilities. B) Gradually strengthen the affected muscles through weight training. C) Support the affected extremity with external supports such as splints. D) Limit reliance on assistive devices in order to build strength.
c
A nurse is planning the care of a patient with osteomyelitis that resulted from a diabetic foot ulcer. The patient requires a transmetatarsal amputation. When planning the patient's postoperative care, which of the following nursing diagnoses should the nurse most likely include in the plan of care? A) Ineffective Thermoregulation B) Risk-Prone Health Behavior C) Disturbed Body Image D) Deficient Diversion Activity
c
A patient presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain? A) Bursitis B) Radiculopathy C) Sciatica D) Tendonitis
c
An elderly patient's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? A) The presence of leg shortening B) The patient's complaints of pain C) Signs of neurovascular compromise D) The presence of internal or external rotation
c
The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Have the patient reposition himself independently. C) Protect the affected leg from internal rotation. D) Keep the hip flexed by placing pillows under the patient's knee.
c
A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient's statements would indicate to the nurse that the patient requires further teaching? A) "I'll need to keep several pillows between my legs at night." B) "I need to remember not to cross my legs. It's such a habit." C) "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D) "I will need my husband to assist me in getting off the low toilet seat at home."
d
A patient who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A) Maximize the efficiency of care B) Ensure that the patient's health care is holistic C) Facilitate the patient's adjustment to a new body image D) Promote the patient's highest possible level of function
d
n older adult patient sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize which of the following aspects of care? A) Administration of oral and IV corticosteroids as ordered B) Prevention of falls and pathologic fractures C) Maintenance of adequate serum levels of vitamin D D) Intravenous administration of antibiotics
d
