exam 3 in progress!-unit7

A client is complaining of having the same type of pain that he experienced prior to being diagnosed with cancer. The nurse realizes that which process will influence this clients perception of pain? 1. Transmission 2. Modulation 3. Perception 4. Transduction

ANS 3 Rationale 3: Perception is when the client becomes conscious of the pain. Pain perception is the sum of complex activities in the central nervous system that can shape the character and intensity of pain perceived and ascribes meaning to the pain. The psychosocial context of the situation and the meaning of the pain based on past experiences and future hopes and dreams help to shape the behavioral response that follows.

A client repeatedly asks the nurse How much longer until I can get more pain medication? Once the medication is provided, the client stops asking for it. The nurse identifies the clients behavior as being 1. addiction. 2. tolerance. 3. pseudoaddiction. 4. physical dependence.

ANS 3 Rationale 3: Pseudoaddiction is a condition that results from the under-treatment of pain where the client can become so focused on obtaining medications for pain relief that the client becomes angry and demanding, might clock watch, and might display other inappropriate drug-seeking behaviors. To differentiate between pseudoaddiction and addiction, if the clients negative behavior resolves when the pain is treated effectively, the client is exhibiting pseudoaddiction.

The nurse is providing range-of-motion exercising to the clients elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the clients physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness.

ANS 3 Rationale 3: Range-of-motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued.

A client rates pain as being 7 on a scale from 0 to 10. What should the nurse document as this clients pain intensity? 1. Mild pain 2. Moderate pain 3. Severe pain 4. Physiological pain

ANS 3 Rationale 3: Severe pain is rated as being from 7 to 10 on a scale of 0 to 10.

A client tells the nurse that at home, the dog helps distract the client from chronic hip pain. The nurse realizes that the client is utilizing which form of nonpharmacologic pain control? 1. Body 2. Mind 3. Social interactions 4. Spirit

ANS 3 Rationale 3: Social interactions that are used as nonpharmacologic pain control methods include pet therapy.

The odor from a hospitalized clients draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful? 1. Spray the room routinely with a floral room spray. 2. Instill a vinegar solution into the wound. 3. Keep the wound dressing dry and clean. 4. Burn a candle in the room.

ANS 3 Rationale 3: The best way to keep odors controlled is to keep the wound dressing dry and clean.

When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining a fractured tibia 4. A client who has a severe headache from hypertensive crisis

ANS 3 Rationale 3: The logrolling technique is used in moving any client who may have sustained a spinal injury. Of these clients, the most concern is for the client who fell from a house. Rationale 4: There is no physio

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client

ANS 3 Rationale 3: The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur.

The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes.

ANS 3 Rationale 3: The nurse should measure the calf and compare it to the opposite calf. The client may be developing a deep vein thrombosis or thrombophlebitis.

The nurse is to administer acetaminophen (Tylenol) prn to a client for a headache; however, the client has been vomiting all day. Which route should the nurse use to administer the medication? 1. Oral 2. Vaginal 3. Rectal 4. Intravenous

ANS 3 Rationale 3: The rectal route is often used if the client has nausea or vomiting. The nurse should administer an acetaminophen suppository to the client.

A client has been treated for diabetes mellitus since childhood. Currently, the clients blood glucose reading is 180 mg/dl. For which sensory disturbance should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell

ANS 3 Rationale 3: Uncontrolled diabetes mellitus is a leading cause of blindness in the United States.

The client is taking meperidine (Demerol) and experiencing pruritus. Which medication should the nurse expect the physician to order? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline

ANS 3 Rationale 3: When clients experience pruritus, an antihistamine, such as Benadryl, is ordered.

During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client? 1. Use the clock face as a format for describing the position of food on meal trays. 2. Provide all teaching materials in very large font. 3. Ensure that the client has assistance when ambulating. 4. Use only nonirritating soaps for bathing.

ANS 3 Rationale 3: Kinesthetic sensation refers to the awareness of the position and movement of body parts. The client with impairment of this sensation may be prone to injury by falling and should be assisted when ambulating.

A client is experiencing pain after spraining an ankle. The nurse realizes that the client is most likely experiencing which type of pain? 1. Mild pain 2. Severe pain 3. Somatic pain 4. Visceral pain

ANS 3 Rationale 3: Somatic pain originates in the skin, muscles, bone, or connective tissue. The sharp sensation of a paper cut or aching of a sprained ankle are common examples of somatic pain.

The nurse is admitting a client to the emergency department with complaints of severe abdominal pain. What is the nurses first action? 1. Administer IV pain medication as ordered. 2. Start an IV line of lactated Ringers. 3. Assess pain using a scale of 1 to 10. 4. Place a Foley catheter to bedside drainage.

ANS 3 Rationale 3: Assessment should always occur before implementation.

A client is prescribed a medication that is a blend of an opioid analgesic with an NSAID. The nurse realizes that this medication will have which effects on the client? Standard Text: Select all that apply. 1. Encourage the development of tolerance. 2. Encourage the development of addiction. 3. Maximize pain control while minimizing toxicity. 4. Maximize pain control while minimizing side effects. 5. Reduce the onset of pseudoaddiction.

ANS 3,4 Rationale 3: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing toxicity. Rationale 4: Rational pharmacy is a concept whereby health professionals should be aware of all ingredients of medication that alleviate pain. Combinations reduce the need for high doses of any one medication, maximizing pain control while minimizing side effects.

A client states that a cramping pain started 2 hours ago and is not accompanied by any nausea or vomiting. Which type of pain is this client most likely experiencing? 1. Chronic pain 2. Phantom pain 3. Visceral pain 4. Acute pain

ANS 4 Rationale 4: Acute pain is pain that is directly related to tissue injury and resolves when tissue heals.

The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone. Which diagnosis would be the priority for this client? 1. Social Isolation 2. Risk for Impaired Skin Integrity 3. Disturbed Sensory Perception 4. Risk for Injury

ANS 4 Rationale 4: Because the client lives alone and is recovering from cataract surgery, the clients risk for injury is great.

A client can be aroused only with extreme or repeated stimuli. How should the nurse document this clients behavior? 1. Somnolent 2. Disoriented 3. Comatose 4. Semicomatose

ANS 4 Rationale 4: Because this client can be aroused with extreme stimuli or repeated stimuli, the correct description is semicomatose.

A client tells the nurse that an ice pack works well to reduce the intensity of back pain. The nurse realizes that the client is implementing 1. a placebo. 2. distraction. 3. guided imagery. 4. the gate control theory of pain.

ANS 4 Rationale 4: In the gate control theory, signals of noxious stimuli are carried to the dorsal horn, where they are modified according to the balance of the substantia gelatinosa. By using ice, the substantia gelatinosa is calmed, reducing the pain.

A clients pain level is assessed as being severe. Which intervention would be the most applicable for the client at this time? 1. Provide NSAID medication as prescribed. 2. Coach the client with guided imagery. 3. Suggest the client read or watch television until the pain subsides. 4. Provide opioid analgesic as prescribed.

ANS 4 Rationale 4: The selection of pain relief measures should be aligned with the clients report of the severity of the pain. If a client reports severe pain, a more potent pain relief measure is indicated.

The client who has the medical diagnosis of Alzheimers disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this clients situation? 1. Acute Confusion 2. Altered Role Performance 3. Disturbed Sensory Perception 4. Disturbed Thought Processes

ANS 4 Rationale 4: Because this client has dementia, which interferes with the ability to interpret stimuli, the correct diagnosis problem statement is Disturbed Thought Processes.

The nurse is preparing a client for a back massage. Which positions would be the best for the client to receive this massage? Standard Text: Select all that apply. 1. Supine 2. Fowlers 3. Trendelenburg 4. Prone 5. Side-lying

ANS 4,5 Rationale 4: The prone position is recommended for a back rub. Rationale 5: The side-lying position can be used if a client cannot assume the prone position for a back rub.

In which order will the nurse take these actions when caring for a patient with left leg fractures after a motor vehicle accident? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis.

ANS: C, D, B, E, A, F The initial actions should be to ensure that airway, breathing, and circulation are intact. This should be followed by checking the neurovascular status of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-rays. The tetanus prophylaxis is the least urgent of the actions.

A 22-year-old man tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. When assessing for possible etiologic factors, which question should the nurse ask first? a. Are you using any recreational drugs or drinking a lot of alcohol? b. Have you been experiencing an unusual amount of anxiety or stress? c. Do you have any history of an erection that lasted for 6 hours or more? d. Do you have any chronic cardiovascular or peripheral vascular disease?

ANS: A A common etiologic factor for erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are not common etiologic factors in younger men.

Anakinra (Kineret) is prescribed for a patient who has rheumatoid arthritis (RA). When teaching the patient about this drug, the nurse will include information about a. self-administration of subcutaneous injections. b. taking the medication with at least 8 oz of fluid. c. avoiding concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). d. symptoms of gastrointestinal (GI) irritation or bleeding.

ANS: A Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with 8 oz of fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or NSAIDs, and these should not be discontinued.

After teaching a patient diagnosed with progressive systemic sclerosis about health maintenance activities, the nurse determines that additional instruction is needed when the patient says, a. I should lie down for an hour after meals. b. Paraffin baths can be used to help my hands. c. Lotions will help if I rub them in for a long time. d. I should perform range-of-motion exercises daily.

ANS: A Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective.

A 53-year-old man tells the nurse he has been having increasing problems with erectile dysfunction (ED) for several years but is now interested in using Viagra (sildenafil). Which action should the nurse take first? a. Ask the patient about any prescription drugs he is taking. b. Tell the patient that Viagra does not always work for ED. c. Discuss the common adverse effects of erectogenic drugs. d. Assure the patient that ED is commonly associated with aging.

ANS: A Because some medications can cause ED and patients using nitrates should not take Viagra, the nurse should first assess for prescription drug use. The nurse may want to teach the patient about realistic expectations and adverse effects of Viagra therapy, but this should not be the first action. Although ED does increase with aging, it may be secondary to medication use or cardiovascular disease in a 53-year-old.

Which of the following actions will the nurse plan to take first when admitting a patient who has a history of neurogenic bladder as a result of a spinal cord injury? a. Ask about the usual urinary pattern and any measures used for bladder control. b. Assist the patient to the toilet at scheduled times to help ensure bladder emptying. c. Check the patient for urinary incontinence every 2 hours to maintain skin integrity. d. Use intermittent catheterization on a regular schedule to avoid the risk of infection.

ANS: A Before planning any interventions, the nurse should complete the assessment and determine the patients normal bladder pattern and the usual measures used by the patient at home. All the other responses may be appropriate, but until the assessment is complete, an individualized plan for the patient cannot be developed.

Which assessment information will the nurse obtain to evaluate the effectiveness of the prescribed calcitonin (Cibacalcin) and ibandronate (Boniva) for a patient with Pagets disease? a. Pain level b. Oral intake c. Daily weight d. Grip strength

ANS: A Bone pain is one of the common early manifestations of Pagets disease, and the nurse should assess the pain level to determine whether the treatment is effective. The other information will also be collected by the nurse, but will not be used in evaluating the effectiveness of the therapy.

A patient with an acute attack of gout is treated with colchicine. The nurse determines that the drug is effective upon finding a. relief of joint pain. b. increased urine output. c. elevated serum uric acid. d. decreased white blood cells (WBC).

ANS: A Colchicine produces pain relief in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day would increase urine output but would not indicate the effectiveness of colchicine. Elevated uric acid levels would result in increased symptoms. The WBC count might decrease with decreased inflammation, but this would not be as useful in determining the effectiveness of colchicine as a decrease in pain.

Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider? a. The patient has dark colored stools. b. The patients pain has not improved. c. The patient is using capsaicin cream (Zostrix). d. The patient has gained 3 pounds over 3 weeks.

ANS: A Dark colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patients ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

A patient whose work involves lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates that the teaching has been effective? a. I plan to start doing exercises to strengthen the muscles of my back. b. I will try to sleep with my hips and knees extended to prevent back strain. c. I can tell my boss that I need to change to a job where I can work at a desk. d. I will keep my back straight when I need to lift anything higher than my waist.

ANS: A Exercises can help to strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back. Modifications in the way the patient lifts boxes are needed, but sitting for prolonged periods can aggravate back pain. The patient should not lift above the level of the elbows.

A patient with an elevated blood urea nitrogen (BUN) and serum creatinine is scheduled for a renal arteriogram. The nurse should question an order from radiology for bowel preparation with the use of a. a Fleet enema. b. a tap-water enema. c. bisacodyl (Dulcolax) tablets. d. senna/docusate (Sennakot-S).

ANS: A High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate.

A patient with an exacerbation of rheumatoid arthritis (RA) is taking prednisone (Deltasone) 40 mg daily. Which of these assessment data obtained by the nurse indicate that the patient is experiencing a side effect of the medication? a. The patients blood glucose is 165 mg/dL. b. The patient has no improvement in symptoms. c. The patient has experienced a recent 5-pound weight loss. d. The patients erythrocyte sedimentation rate (ESR) has increased.

ANS: A Hyperglycemia is a side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR and no improvement in symptoms would indicate that the prednisone was not effective but would not be side effects of the medication.

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. Which of these prescribed collaborative interventions will the nurse implement first? a. Wrap the ankle and apply an ice pack. b. Administer naproxen (Naprosyn) 500 mg PO. c. Give acetaminophen with codeine (Tylenol #3). d. Take the patient to the radiology department for x-rays.

ANS: A Immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

A patient is hospitalized for initiation of regional antibiotic irrigation for acute osteomyelitis of the right femur. Which intervention will be included in the plan of care? a. Immobilization of the right leg b. Frequent weight-bearing exercise c. Avoiding administration of nonsteroidal anti-inflammatory drugs (NSAIDs) d. Support of the right leg in a flexed position

ANS: A Immobilization of the affected leg helps decrease pain and reduce the risk for pathologic fractures. Weight-bearing exercise increases the risk for pathologic fractures. NSAIDs are frequently prescribed to treat pain. Flexion of the affected limb is avoided to prevent contractures.

A patient who is scheduled for an intravenous pyelogram (IVP) gives the nurse the following information. Which information has the most immediate implications for the patients care? a. The patient describes allergies to shellfish and penicillin. b. The patient has not had anything to eat or drink for 8 hours. c. The patient complains of costovertebral angle (CVA) tenderness. d. The patient used a bisacodyl (Dulcolax) tablet the previous night.

ANS: A Iodine-based contrast dye is used during IVP and for many computed tomography (CT) scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. The other information also is important to note and document but does not have immediate implications for the patients care during the procedures.

A patients urine dipstick indicates a small amount of protein in the urine. The next action by the nurse should be to a. check which medications the patient is currently taking. b. obtain a clean-catch urine for culture and sensitivity testing. c. ask the patient about any family history of chronic renal failure. d. send a urine specimen to the laboratory to test for ketones and glucose.

ANS: A Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive readings. The other actions by the nurse may be appropriate, but checking for medications that may affect the dipstick accuracy should be done first.

When caring for a patient who has been diagnosed with orchitis, the nurse will plan to provide teaching about a. pain management. b. emergency surgical repair. c. aspiration of fluid from the scrotal sac. d. application of warm packs to the scrotum.

ANS: A Orchitis is very painful and effective pain management will be needed. The other therapies will not be used to treat orchitis.

Which statement by a patient who is scheduled for an above-the-knee amputation for treatment of an osteosarcoma of the right tibia indicates that patient teaching is needed? a. I did not have this bone cancer until my leg broke a week ago. b. I wish that I did not have to have chemotherapy after this surgery. c. I know that I will need to participate in physical therapy after surgery. d. I will use the patient-controlled analgesia (PCA) to control postoperative pain.

ANS: A Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other patient statements indicate that patient teaching has been effective.

An assessment finding that alerts the nurse to the presence of osteoporosis in a middle-aged patient is a. measurable loss of height. b. the presence of bowed legs. c. an aversion to dairy products. d. statements about frequent falls.

ANS: A Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate that osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.

A hospitalized patient with a decreased glomerular filtration rate is scheduled to have an intravenous pyelogram (IVP). Which action will be included in the plan of care? a. Monitor the urine output after the procedure. b. Assist with monitored anesthesia care (MAC). c. Give oral contrast solution before the procedure. d. Insert a large size urinary catheter before the IVP.

ANS: A Patients with impaired renal function are at risk for decreased renal function after IVP because the contrast medium used is nephrotoxic, so the nurse should monitor the patients urine output. MAC sedation and retention catheterization are not required for the procedure. The contrast medium is given intravenously, not orally.

A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included? a. You have an appointment with a physical therapist for tomorrow. b. You can still play baseball but you will not be able to return to pitching. c. The doctor will use the drop-arm test to determine the success of surgery. d. Leave the shoulder immobilizer on for the first few days to minimize pain.

ANS: A Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent frozen shoulder. A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion (ROM). The drop-arm test is used to test for rotator cuff injury, but not after surgery. The patient may be able to return to pitching after rehabilitation.

A patient with lower leg fracture has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching? a. You will need to assess and clean the pin insertion sites daily. b. The external fixator can be removed during the bath or shower. c. You will need to remain on bed rest until bone healing is complete. d. Prophylactic antibiotics are used until the external fixator is removed.

ANS: A Pin insertion sites should be cleaned daily to decrease the risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given when an external fixator is used.

Which statement by a 24-year-old woman with systemic lupus erythematosus (SLE) indicates that the patient has understood the nurses teaching about management of the condition? a. I will use a sunscreen whenever I am outside. b. I will try to keep exercising even if I am tired. c. I should take birth control pills to keep from getting pregnant. d. I should not take aspirin or nonsteroidal anti-inflammatory drugs.

ANS: A Severe skin reactions can occur in patients with SLE who are exposed to the sum. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal anti-inflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

A 20-year-old patient with a history of muscular dystrophy is hospitalized with a respiratory tract infection. Which nursing action will be included in the plan of care? a. Assist the patient with ambulation. b. Logroll the patient every 1 to 2 hours. c. Discuss the need for genetic testing with the patient. d. Teach the patient about the muscle biopsy procedure.

ANS: A Since the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing since the patient already knows the diagnosis.

When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with a. a warm bath followed by a short rest. b. a short routine of isometric exercises. c. active range-of-motion (ROM) exercises. d. stretching exercises to relieve joint stiffness.

ANS: A Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

A patient with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the hand. Which patient statement to the nurse indicates realistic expectation for the surgery? a. I will be able to use my fingers to grasp objects better. b. I will not have to do as many hand exercises after the surgery. c. This procedure will prevent further deformity in my hands and fingers. d. My fingers will appear more normal in size and shape after this surgery.

ANS: A The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

A 32-year-old man who is being admitted for a unilateral orchiectomy for testicular cancer does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is best for the nurse to take? a. Ask the patient if he has any questions or concerns about the diagnosis and treatment. b. Document the patients lack of communication on the chart and continue preoperative care. c. Assure the patients wife that concerns about sexual function are common with this diagnosis. d. Teach the patient and the wife that impotence is rarely a problem after unilateral orchiectomy.

ANS: A The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, the nurse should not offer education about complications after orchiectomy. Documentation of the patients lack of interaction is not an adequate nursing action in this situation.

When doing discharge teaching for a patient who has had a repair of a fractured mandible, the nurse will include information about a. when and how to cut the immobilizing wires. b. self-administration of nasogastric tube feedings. c. the use of sterile technique for dressing changes. d. the importance of including high-fiber foods in the diet.

ANS: A The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.

A patient who had arthroscopic surgery of the left knee 5 days ago is admitted with a red, swollen, and hot knee. Which assessment finding by the nurse should be reported to the health care provider immediately? a. The blood pressure is 88/46 mm Hg. b. The white blood cell count is 14,200/L. c. The patient is taking ibuprofen (Motrin). d. The patient says the knee is very painful.

ANS: A The low blood pressure suggests that the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and also should be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

During assessment of a patient with decreased renal function, which of these medications taken by the patient at home will be of most concern to the nurse? a. ibuprofen (Motrin) b. warfarin (Coumadin) c. folic acid (vitamin B9) d. penicillin (Bicillin LA)

ANS: A The nonsteroidal anti-inflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. The nurse also should ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen.

Which statement by a patient who has had an above-the-knee amputation indicates that the nurses discharge teaching has been effective? a. I should lay on my abdomen for 30 minutes 3 or 4 times a day. b. I should elevate my residual limb on a pillow 2 or 3 times a day. c. I should change the limb sock when it becomes soiled or stretched out. d. I should use lotion on the stump to prevent drying and cracking of the skin.

ANS: A The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.

Before assisting a patient with ambulation on the day after a total hip replacement, which action is most important for the nurse to take? a. Administer the ordered oral opioid pain medication. b. Instruct the patient about the benefits of ambulation. c. Ensure that the incisional drain has been discontinued. d. Change the hip dressing and document the wound appearance.

ANS: A The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patients willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

A patient with symptomatic benign prostatic hyperplasia (BPH) is scheduled for photovaporization of the prostate (PVP) at an outpatient surgical center. The nurse will plan to teach the patient a. how to care for an indwelling urinary catheter. b. that the urine will appear bloody for several days. c. about complications associated with urethral stenting. d. that symptom improvement will occur in 2 to 3 weeks.

ANS: A The patient will have an indwelling catheter for 24 to 48 hours and will need teaching about catheter care. There is minimal bleeding with this procedure. Symptom improvement is almost immediate after PVP. Stent placement is not included in the procedure.

A patient who has had an open reduction and internal fixation (ORIF) of left lower leg fractures complains of constant severe pain in the leg, which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which action should the nurse take next? a. Notify the health care provider. b. Assess the incision for redness. c. Reposition the left leg on pillows. d. Check the patients blood pressure.

ANS: A The patients clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

A 46-year-old man who has erectile dysfunction (ED) tells the nurse that he decided to seek treatment because his wife is losing patience with the situation. The most appropriate nursing diagnosis for the patient is a. ineffective role performance related to effects of ED. b. anxiety related to inability to have sexual intercourse. c. situational low self-esteem related to decrease in sexual activity. d. ineffective sexuality patterns related to frequency of intercourse.

ANS: A The patients statement indicates that the relationship with his wife is his primary concern. Although anxiety, low self-esteem, and ineffective sexuality patterns also may be concerns, the patient information suggests that addressing the role performance problem will lead to the best outcome for this patient.

Which information will the nurse plan to include when teaching a 19-year-old to perform testicular self-examination? a. Testicular self-examination should be done in a warm area. b. The only structure normally felt in the scrotal sac is the testis. c. Testicular self-examination should be done at least every week. d. Call the health care provider if one testis is larger than the other.

ANS: A The testes will hang lower in the scrotum when the temperature is warm (e.g., during a shower), and it will be easier to palpate. The epididymis is also normally palpable in the scrotum. One testis is normally larger. The patient should perform testicular self-examination monthly.

When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to a. stand rather than sit when performing household chores. b. avoid activities that require continuous use of the same muscles. c. strengthen small hand muscles by wringing sponges or washcloths. d. protect the knee joints by sleeping with a small pillow under the knees.

ANS: B Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion (ROM).

The health care provider prescribes finasteride (Proscar) for a 56-year-old patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that a. he should change position from lying to standing slowly to avoid dizziness. b. his interest in sexual activity may decrease while he is taking the medication. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

ANS: B A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Although orthostatic hypotension may occur if the patient also is taking a medication for erectile dysfunction (ED), it should not occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not cause hypertension.

A patient with a possible urinary tract infection (UTI) gives the nurse in the clinic a urine specimen that is a red-orange color. Which action should the nurse take first? a. Notify the patients health care provider. b. Ask the patient about use of any medications. c. Question the patient about any UTI risk factors. d. Teach about the correct procedure for midstream urine collection.

ANS: B A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine (Pyridium). The color would not be expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen, and does not need to be communicated to the health care provider until further assessment is done.

A patient is seen at the urgent care center after falling on the right arm and shoulder. Which finding is most important for the nurse to communicate to the health care provider? a. There is bruising at the shoulder area. b. The right arm appears shorter than the left. c. There is decreased range of motion of the shoulder. d. The patient is complaining of arm and shoulder pain.

ANS: B A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion also should be reported, but these do not indicate that emergent treatment is needed to preserve function.

When performing discharge teaching for a patient who has undergone a vasectomy in the health care providers office, the nurse instructs the patient that a. he may have temporary erectile dysfunction (ED) because of postoperative swelling. b. he should continue to use other methods of birth control for 6 weeks. c. he should not have sexual intercourse until his 6-week follow-up visit. d. he will notice a decrease in the appearance and volume of his ejaculate.

ANS: B Because it takes about 6 weeks to evacuate sperm that are distal to the vasectomy site, the patient should use contraception for 6 weeks. ED that occurs after vasectomy is psychologic in origin and not related to postoperative swelling. The patient does not need to abstain from intercourse. The appearance and volume of the ejaculate are not changed because sperm are a minor component of the ejaculate.

A patient with benign prostatic hyperplasia (BPH) with mild obstruction tells the nurse, My symptoms have gotten a lot worse this week. Which response by the nurse is most appropriate? a. I will talk to the doctor about ordering a prostate specific antigen (PSA) test. b. Have you been taking any over-the-counter (OTC) medications recently? c. Have you talked to the doctor about surgical procedures such as transurethral resection of the prostate (TURP)? d. The prostate gland changes slightly in size from day to day, and this may be making your symptoms worse.

ANS: B Because the patients increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer.

The health care provider orders a clean-catch urine specimen for culture and sensitivity testing for a patient with a suspected urinary tract infection (UTI). To obtain the specimen, the nurse will plan to a. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. b. have the patient empty the bladder completely, and then obtain the next urine specimen that the patient is able to void. c. insert a short, small mini catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container.

ANS: A This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, insert a short, small, mini catheter attached to a collecting container describes a technique that would result in a sterile specimen, but a health care providers order for a catheterized specimen would be required. Using Betadine before obtaining the specimen is not necessary and might result in suppressing the growth of some bacteria. And the technique described in the answer beginning have the patient empty the bladder completely would not result in a sterile specimen.

During assessment of the patient with fibromyalgia syndrome (FMS), the nurse would expect the patient to report (select all that apply)? a. sleep disturbances. b. multiple tender points. c. cardiac palpitations and dizziness. d. multijoint pain with inflammation and swelling. e. widespread bilateral, burning musculoskeletal pain.

ANS: A, B, C, E These symptoms are commonly described by patients with FMS. Cardiac involvement and joint inflammation are not typical of FMS.

A patient who has a cast in place after fracturing the radius asks when the cast can be removed. The nurse will instruct the patient that the cast will need to remain in place a. for several months. b. for at least 3 weeks. c. until swelling of the wrist has resolved. d. until x-rays show complete bony union.

ANS: B Bone healing starts immediately after the injury, but since ossification does not begin until 3 weeks postinjury, the cast will need to be worn for at least 3 weeks. Complete union may take up to a year. Resolution of swelling does not indicate bone healing.

Which information will the nurse include when teaching range-of-motion exercises to a patient with an exacerbation of rheumatoid arthritis? a. Affected joints should not be exercised when pain is present. b. Application of cold packs before exercise may decrease joint pain. c. Exercises should be performed passively by someone other than the patient. d. Walking may substitute for range-of-motion (ROM) exercises on some days.

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints as well as improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

A patient with dermatomyositis is receiving long-term prednisone (Deltasone) therapy. Which assessment finding by the nurse is most important to report to the health care provider? a. The blood glucose is 112 mg/dL. b. The patient has painful hematuria. c. The patient has an increased appetite. d. Acne is noted on the back and face.

ANS: B Corticosteroid use is associated with increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne also are adverse effects of corticosteroid use, but do not need diagnosis and treatment as rapidly as the probable urinary tract infection.

Which information will the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about the management of the condition? a. Exercise by taking long walks. b. Do daily deep breathing exercises. c. Sleep on the side with hips flexed. d. Take frequent naps during the day.

ANS: B Deep breathing exercises are used to decrease the risk for pulmonary complications that may occur with the reduced chest expansion that can occur with ankylosing spondylitis (AS). Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

A patient has chronic osteomyelitis of the left femur, which is being managed at home with administration of IV antibiotics. The nurse chooses a nursing diagnosis of ineffective health maintenance when the nurse finds that the patient a. takes and records the oral temperature twice a day. b. is unable to plantar flex the foot on the affected side. c. uses crutches to avoid weight bearing on the affected leg. d. is irritable and frustrated with the length of treatment required.

ANS: B Foot drop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis.

Leuprolide (Lupron) is prescribed for a patient with cancer of the prostate. In teaching the patient about this drug, the nurse informs the patient that side effects may include a. dizziness. b. hot flashes. c. urinary incontinence. d. increased infection risk.

ANS: B Hot flashes may occur with decreased testosterone production. Dizziness may occur with the a-blockers used for benign prostatic hyperplasia (BPH). Urinary incontinence may occur after prostate surgery, but it is not an expected medication side effect. Risk for infection is increased in patients receiving chemotherapy.

Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee? a. Heberdens nodules b. Pain upon joint movement c. Redness and swelling of the knee joint d. Stiffness that increases with movement

ANS: B Initial symptoms of OA include pain with joint movement. Heberdens nodules occur on the fingers. Redness of the joint is more strongly associated with rheumatoid arthritis (RA), and stiffness in OA is worse right after the patient rests and decreases with joint movement.

A patient has systemic sclerosis manifested by CREST (calcinosis, Raynauds phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia) syndrome. Which action will the nurse include in the plan of care? a. Avoid use of capsaicin cream on hands. b. Keep patients room warm and draft free. c. Obtain capillary blood glucose before meals. d. Assist to bathroom every 2 hours while awake.

ANS: B Keeping the room warm will decrease the incidence of Raynauds phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose levels or to assist the patient to the bathroom every 2 hours.

A patient has hip replacement surgery using the posterior approach. Which patient action requires rapid intervention by the nurse? a. The patient uses crutches with a swing-to gait. b. The patient leans over to pull shoes and socks on. c. The patient sits straight up on the edge of the bed. d. The patient bends over the sink while brushing the teeth.

ANS: B Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

The health care provider has prescribed the following collaborative interventions for a 49-year-old who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order will the nurse question? a. Draw anti-DNA blood titer. b. Administer varicella vaccine. c. Use naproxen (Aleve) 200 mg BID. d. Take famotidine (Pepcid) 20 mg daily.

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

A patient with gout tells the nurse that he takes losartan (Cozaar) for control of the condition. The nurse will plan to monitor a. blood glucose. b. blood pressure. c. erythrocyte count. d. lymphocyte count.

ANS: B Losartan, an angiotensin II receptor antagonist, will lower blood pressure. It does not affect blood glucose, red blood cell count (RBC), or lymphocytes.

After obtaining the health history from a 28-year-old woman who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information about the patient is most important for the nurse to report to the health care provider? a. The patient had a history of infectious mononucleosis as a teenager. b. The patient is trying to have a baby before her disease becomes more severe. c. The patient has a family history of age-related macular degeneration of the retina. d. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

A 22-year-old patient hospitalized with a fever and red, hot, and painful knees is suspected of having septic arthritis. Information obtained during the nursing history that indicates a risk factor for septic arthritis is that the patient a. has a parent who has reactive arthritis. b. is sexually active and has multiple partners. c. recently returned from a trip to South America. d. had several sports-related knee injuries as a teenager.

ANS: B Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

After the nurse has finished teaching a patient with osteoarthritis (OA) of the left hip and knee about how to manage the OA, which patient statement indicates a need for more education? a. I can take glucosamine to help decrease my knee pain. b. I will take 1 g of acetaminophen (Tylenol) every 4 hours. c. I will take a shower in the morning to help relieve stiffness. d. I can use a cane to decrease the pressure and pain in my hip.

ANS: B No more than 4 g of acetaminophen should be taken daily to avoid liver damage. The other patient statements are correct and indicate good understanding of OA management.

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema.

ANS 2 Rationale 2: The nurse should palpate for bladder fullness that could cause this discomfort.

The nurse is caring for a postpartum client receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician? 1. Pulse rate: 80 2. Respiratory rate: 8 3. Blood pressure: 120/80 4. Pain rating of 4 on scale of 1 to 10

ANS 2 Rationale 2: A respiratory rate below 8 should be reported immediately.

A client has been taking medication for back pain for several months, and has seen several different health care providers in efforts to receive pain medication. The nurse is concerned that the client is exhibiting 1. tolerance. 2. addiction. 3. physical dependence. 4. pseudoaddiction.

ANS 2 Rationale 2: Addiction is characterized by the behaviors of compulsive use of pain medication, continued use despite harm, and craving.

The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurses most important action? 1. Ensure the clients modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding.

ANS 2 Rationale 2: All of these actions are important, but the priority is ensuring the client does not strike her head on anything when falling. The nurse should ease the client down while supporting her body against the nurse, protecting the head and laying it gently on the floor.

A client diagnosed with congestive heart failure has been treated for many years with intravenous furosemide (Lasix). What sensory impairment should the nurse assess in this client? 1. Loss of ability to taste 2. Hearing loss 3. Vision loss 4. Loss of ability to smell

ANS 2 Rationale 2: Furosemide (Lasix) can be ototoxic if taken over long periods of time. The nurse would monitor for hearing loss.

The nurse is providing discharge instructions to a client prescribed an opioid medication. What should the nurse suggest to decrease the risk of constipation with this medication? 1. Take an antihistamine three times per day. 2. Drink 6 to 8 glasses of water per day. 3. Assess respiratory rate before taking medication. 4. Assess heart rate before taking medication

ANS 2 Rationale 2: Increasing fluid intake can help prevent constipation.

A client experiencing chronic pain is not getting relief with pain medication. What should the nurse do to help this client? 1. Ask the physician to change the prescribed pain medication. 2. Reassess the pain and consider another pain relief measure. 3. Limit interaction with the client. 4. Stop using alternative pain relief measures, if not effective.

ANS 2 Rationale 2: Keep trying. Do not ignore a client because pain persists despite failed attempts to alleviate the discomfort. In these circumstances, reassess the pain and consider other relief measures.

A client recovering from hip surgery is reluctant to ambulate because of the amount of pain that occurred with walking prior to the surgery. What can the nurse do to help this client with pain control? 1. Provide pain medication before every ambulation session. 2. Address the clients fear of pain with walking. 3. Tell the client that the pain is now gone. 4. Explain that the client is confusing postoperative pain with the pain before the surgery.

ANS 2 Rationale 2: Nurses can use the gate control theory to stop nociceptor firing by applying topical therapies and addressing the clients mood to reduce fear and anxiety.

A client is surprised to learn of the diagnosis of a heart attack when there was no chest pain experienced but only some left shoulder pain. The nurse should explain that the client experienced which type of pain? 1. Phantom pain 2. Referred pain 3. Visceral pain 4. Chronic pain

ANS 2 Rationale 2: Referred pain appears to arise in different areas of the body, as may occur with cardiac pain.

The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse consider for this planning? 1. Background noise such as music will keep this client calm. 2. Activities should be scheduled at the same time each day. 3. Pain mediation will increase dementia. 4. It is important to talk with the client throughout procedures.

ANS 2 Rationale 2: The client with dementia benefits from a routine schedule of activities.

A client is hospitalized for treatment of a new disorder. While admitted, the client receives no telephone calls or visitors. The nurse should assess which aspect of the clients sensory-perception function? 1. Risk for sensory overload 2. Social support network 3. Mental status 4. Environment

ANS 2 Rationale 2: The degree of isolation a person feels is significantly influenced by the quality and quantity of support from family members and friends. The nurse should assess the clients living arrangements, visitors, and any signs indicating social deprivation, such as withdrawal from contact with others to avoid embarrassment or dependence on others, negative self-image, reports of lack of meaningful communication with others, and absence of opportunities to discuss fears or concerns that facilitate coping mechanisms.

The nurse provides an oral opiate to a client with pain. In how many hours should the nurse expect the client to need another dose of the medication? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours

ANS 2 Rationale 2: The duration of action for most opiates is 4 hours.

The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ? 1. Schedule a Weber and Rinne test. 2. Observe the clients interaction with significant others. 3. Use an otoscope to visualize the inner ear. 4. Confront the client with the nurses suspicion.

ANS 2 Rationale 2: The most telling of these options would be to observe the clients interactions with significant others. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip-reading.

A client with a long leg cast is complaining of knee discomfort. Which nonpharmacologic intervention can the nurse use to help this client? 1. Apply ice to the knee over the cast. 2. Rub the knee of the non-casted leg. 3. Apply heat to the knee over the cast. 4. Rub the foot of the casted extremity.

ANS 2 Rationale 2: The nurse can use contralateral stimulation, which is accomplished by stimulating the skin in an area opposite to the painful area, such as stimulating the left knee if the pain is in the right knee. The nurse should explain the rationale to the client in that nerves are crossed in the spinal cord, and that is why this technique works contralaterally.

The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention? 1. Walk slightly behind the client. 2. Walk 1 foot in front of the client. 3. Walk on the right side of the client. 4. Walk on the left side of the client.

ANS 2 Rationale 2: The nurse should walk about 1 foot in front of the client, offering the client an arm.

What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client.

ANS 3 Rationale 3: Although all of these activities address important safety issues, the most important is to lock the wheels on the bed. If the wheels are not locked and the bed moves out from under the client, none of the other safety actions will likely prevent a fall or near fall.

The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference

ANS 3 Rationale 3: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. The registered nurse must assess and evaluate the clients response to the ambulation. Once the client has successfully ambulated, any nursing staff member can assist. The registered nurse should make assistive personnel aware of potential untoward effects of ambulation and of what to report to the nurse.

While assisting the client with a bath, the nurse encourages full range of motion in all the clients joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the clients hand and arm joints through passive range of motion.

ANS 3 Rationale 3: Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face.

A client recovering from back surgery is refusing pain medication for fear of becoming addicted. What should the nurse say to the client? 1. I understand. 2. There are ways to treat addictions to pain medications. 3. If the medication is taken to treat pain, you will not become addicted to it. 4. All pain medication causes addiction. There is nothing that can be done to prevent it.

ANS 3 Rationale 3: Clients are unlikely to become addicted to an analgesic provided to treat pain.

An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How should the nurse document this mental state? 1. As reversible confusion 2. As sundown syndrome 3. As delirium 4. As dementia

ANS 3 Rationale 3: Delirium is acute confusion caused by illness, medication, or a change in environment and is the appropriate documentation for this client.

After receiving medication for mild pain, the client states that the pain is getting worse. What should the nurse plan to do for this client? 1. Administer another dose of a nonopioid medication. 2. Administer an opioid for severe pain. 3. Administer an opioid for moderate pain. 4. Administer two doses of an opioid for moderate pain.

ANS 3 Rationale 3: If the client has mild pain that persists or increases despite using full doses of step 1 medications, or if the pain is moderate, then a step 2 regimen is appropriate. At the second step, an opioid for moderate pain or a combination of opioid and nonopioid medicine is provided with or without coanalgesic medications.

The family of a client in the hospital is concerned about the constant noise in the care area. Which health care professionals have the greatest control over the level of sensory input in the hospital? 1. Physicians 2. Administrators 3. Nurses 4. Planners

ANS 3 Rationale 3: Nurses have the greatest amount of control over the level of sensory input in the hospital. Nurses can decrease sensory overload by controlling lights, noise, odors, and pain. Nurse

Which of the following objective assessment data will the nurse obtain before administering a prescribed opioid medication to a client? 1. Pain level as stated by client 2. Any nausea the client may be feeling 3. Respiratory rate 4. Color of skin

ANS 3 Rationale 3: Opioids may depress the respiratory system, so the nurse should assess the respiratory rate before administering opioids.

The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful? 1. Client places hearing aid on beside table when not in use. 2. Client does not respond appropriately to questions. 3. Client demonstrates use and care of hearing aid. 4. Client demonstrates difficulty with problem solving.

ANS 3 Rationale 3: Outcome criteria that indicate interventions to address Disturbed Sensory Perception, Auditory have been successful would include the clients demonstrating use and care of the hearing aid.

A patient has muscle spasms and acute low back pain. An appropriate nursing intervention for this problem is to teach the patient to a. avoid the use of cold because it will exacerbate the muscle spasms. b. keep both feet flat on the floor when prolonged standing is required. c. keep the head elevated slightly and flex the knees when resting in bed. d. twist gently from side to side to maintain range of motion in the spine.

ANS: C Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. A pillow placed under the upper back will cause strain on the lumbar spine. Alternate application of cold and heat should be used to decrease pain.

A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patients elbows. Which action will the nurse take? a. Draw blood for rheumatoid factor analysis. b. Teach the patient about injection of the nodule. c. Assess the nodules for skin breakdown or infection. d. Discuss the need for surgical removal of the nodule.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

When caring for a patient with gout and a red and painful left great toe, which nursing action will be included in the plan of care? a. Gently palpate the toe to assess swelling. b. Use pillows to keep the left foot elevated. c. Use a footboard to hold bedding away from the toe. d. Teach patient to avoid use of acetaminophen (Tylenol).

ANS: C Since any touch on the area of inflammation may increase pain, bedding should be held away from the toe and touching the toe will be avoided. Elevation of the foot will not reduce the pain, which is caused by the urate crystals. Acetaminophen can be used for pain relief.

To determine whether a patient with joint swelling and pain has systemic lupus erythematosus, which test will be most useful for the nurse to review? a. Rheumatoid factor (RF) b. Antinuclear antibody (ANA) c. Anti-Smith antibody (Anti-Sm) d. Lupus erythematosus (LE) cell prep

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests also are used in screening but are not as specific to SLE.

A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care? a. Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers on the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. The nurse will plan to teach the patient a. to restrict oral fluid intake. b. pelvic floor muscle exercises. c. the use of belladonna and opium suppositories. d. how to perform intermittent self-catheterization.

ANS: B Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent self-catheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L.

A couple is seen at the infertility clinic because they have not been able to conceive. When performing a focused examination to determine any possible causes for infertility, the nurse will check the man for the presence of a. hydrocele. b. varicocele. c. epididymitis. d. paraphimosis.

ANS: B Persistent varicoceles are commonly associated with infertility. Hydrocele, epididymitis, and paraphimosis are not risk factors for infertility.

On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take? a. Explain the reasons for the phantom limb pain. b. Administer prescribed analgesics to relieve the pain. c. Loosen the compression bandage to decrease incisional pressure. d. Remind the patient that this phantom pain will diminish over time.

ANS: B Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.

The nurse obtains this information when assessing a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis. Which symptom is most important to report to the health care provider? a. Abdominal cramping b. Complaint of blurry vision c. Phalangeal joint tenderness d. Blood pressure 170/84 mm Hg

ANS: B Plaquenil can cause retinopathy; the medication should be stopped. The other findings are not related to the medication, although they also will be reported.

The nurse working in a health clinic receives calls from all these patients. Which patient should be seen by the health care provider first? a. A 44-year-old man who has perineal pain and a temperature of 100.4 F b. A 66-year-old man who has a painful erection that has lasted over 7 hours c. A 62-year-old man who has light pink urine after having a transurethral resection of the prostate (TURP) 3 days ago d. A 23-year-old man who states he had difficulty maintaining an erection last night

ANS: B Priapism can cause complications such as necrosis or hydronephrosis, and this patient should be treated immediately. The other patients do not require immediate action to prevent serious complications.

When planning care for a patient who has had hip replacement surgery, which nursing action can the nurse delegate to experienced nursing assistive personnel (NAP)? a. Teach quadriceps-setting exercises. b. Reposition the patient every 1 to 2 hours. c. Assess for skin irritation on the patients back. d. Determine the patients pain level and tolerance.

ANS: B Repositioning of patients is within the scope of practice of NAP (after they have been trained and evaluated in this skill). The other actions should be done by licensed nursing staff members.

A creatinine clearance test is ordered for a hospitalized patient with possible renal insufficiency. Which equipment will the nurse need to obtain? a. Sterile specimen cup b. Large container for urine c. Foley catheter and drainage bag d. Towelettes for perineal cleaning

ANS: B Since creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test.

Following discharge teaching for a patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH), the nurse determines that additional instruction is needed when the patient says, a. I will avoid driving until I get approval from my doctor. b. I should call the doctor if I have any incontinence at home. c. I will increase fiber and fluids in my diet to prevent constipation. d. I should continue to schedule yearly appointments for prostate exams.

ANS: B Since incontinence is common for several weeks after a TURP, the patient does not need to call the health care provider if this occurs. The other patient statements indicate that the patient has a good understanding of post-TURP instructions.

When the nurse is caring for a patient who is on bed rest after having a complex pelvic fracture, which assessment finding is most important to report to the health care provider? a. The patient states that the pelvis feels unstable. b. Abdominal distention is present and bowel tones are absent. c. There are ecchymoses on the abdomen and hips. d. The patient complains of pelvic pain with palpation.

ANS: B The abdominal distention and absent bowel tones may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

The result of a patients creatinine clearance test is 60 mL/min. The nurse equates this finding to a glomerular filtration rate (GFR) of _____ mL/min. a. 30 b. 60 c. 120 d. 240

ANS: B The creatinine clearance approximates the GFR. The other responses are not accurate.

When the nurse is reviewing laboratory results for a patient with systemic lupus erythematosus (SLE), which result is most important to communicate to the health care provider? a. Decreased C-reactive protein (CRP) b. Elevated blood urea nitrogen (BUN) c. Positive antinuclear antibodies (ANA) d. Positive lupus erythematosus cell prep

ANS: B The elevated BUN and creatinine levels indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus (LE) cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows an improvement in the inflammatory process.

Following an intravenous pyelogram (IVP), all of the following assessment data are obtained. Which one requires immediate action by the nurse? a. The heart rate is 58 beats/minute. b. The respiratory rate is 38 breaths/minute. c. The patient complains of a dry mouth. d. The urine output is 400 mL in the first 2 hours.

ANS: B The increased respiratory rate indicates that the patient may be experiencing an allergic reaction to the contrast medium used during the procedure. The nurse should immediately assess the patients oxygen saturation and breath sounds. The other data are not unusual findings following an IVP.

A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate? a. You may need to see a family therapist for some help. b. Tell me more about the situations that are causing stress. c. Perhaps it would be helpful for you and your family to get involved in a support group. d. Your family may need some help to understand the impact of your rheumatoid arthritis.

ANS: B The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

While assessing a patients urinary system, the nurse cannot palpate either kidney. Which action should the nurse take next? a. Obtain a urine specimen to check for hematuria. b. Document the information on the assessment form. c. Ask the patient about any history of recent sore throat. d. Ask the health care provider about scheduling a renal ultrasound.

ANS: B The kidneys are protected by the abdominal organs, ribs, and muscles of the back and may not be palpable under normal circumstances, so no action except to document the assessment information is needed. Asking about a recent sore throat, checking for hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal problems for some patients, but there is nothing in the question stem to indicate that they are appropriate for this patient.

The nurse is preparing to assist a patient who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which action should the nurse take? a. Use a mechanical lift to transfer the patient from the bed to the chair. b. Check the postoperative orders for the patients weight-bearing status. c. Avoid administration of pain medications before getting the patient up. d. Delegate the transfer of the patient out of bed to nursing assistive personnel (NAP).

ANS: B The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given, since the movement is likely to be painful for the patient. The RN should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish this skill.

A patient undergoes a right above-the-knee amputation with an immediate prosthetic fitting. When the patient first arrives on the orthopedic unit after surgery, the nurse should a. place the patient in a prone position. b. check the surgical site for hemorrhage. c. remove the prosthesis and wrap the site. d. keep the residual leg elevated on a pillow.

ANS: B The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.

A patient with benign prostatic hyperplasia (BPH) is admitted to the hospital with urinary retention and new onset elevations in the blood urea nitrogen (BUN) and creatinine. Which of these prescribed therapies should the nurse implement first? a. Schedule an abdominal computed tomography (CT) scan. b. Insert a urinary retention catheter. c. Draw blood for a complete blood count. d. Infuse normal saline at 50 mL/hr.

ANS: B The patient data indicate that the patient may have acute renal failure caused by the BPH. The initial therapy will be to insert a catheter. The other actions also are appropriate, but they can be implemented after the acute urinary retention is resolved.

A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching? a. How to apply warm packs safely to the leg to reduce pain b. How to monitor and care for the long-term IV catheter site c. The need for daily aerobic exercise to help maintain muscle strength d. The reason for taking oral antibiotics for 7 to 10 days after discharge

ANS: B The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.

An 82-year-old man has been admitted with benign prostatic hyperplasia. Which of the following is most appropriate to include in the nursing plan of care? a. Limit fluid intake to no more than 1500 mL/day. b. Leave a light on in the bathroom during the night. c. Pad the patients bed to accommodate overflow incontinence. d. Ask the patient to use a urinal so that all urine can be measured.

ANS: B The patients age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patients output is necessary or that the patient has overflow incontinence.

A patient who has been hospitalized for 3 days with a hip fracture has sudden onset shortness of breath and tachypnea. The patient tells the nurse, I feel like I am going to die! Which action should the nurse take first? a. Stay with the patient and offer reassurance. b. Administer the prescribed PRN oxygen at 4 L/min. c. Check the patients legs for swelling or tenderness. d. Notify the health care provider about the symptoms.

ANS: B The patients clinical manifestations and history are consistent with a pulmonary embolus, and the nurses first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for fat embolus or venous thromboembolism (VTE) are obtained.

A patient hospitalized with polymyositis has joint pain, an erythematosus facial rash with eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is a. acute pain related to inflammation. b. risk for aspiration related to dysphagia. c. risk for impaired skin integrity related to scratching. d. disturbed visual perception related to eyelid swelling.

ANS: B The patients vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other nursing diagnoses also are appropriate but are not as high a priority as the maintenance of the patients airway.

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a. keep the left arm in a dependent position. b. handle the cast with the palms of the hands. c. place gauze around the cast edge to pad any roughness. d. cover the cast with a small blanket to absorb the dampness.

ANS: B Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.

Which of the following observations made by the nurse who is evaluating the crutch-walking technique of a patient who is to have no weight bearing on the right leg indicates that the patient can safely ambulate independently? a. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating. b. The patient advances the right leg and both crutches together and then advances the left leg. c. The patient moves the left crutch with the left leg and then the right crutch with the right leg. d. The patient uses the bedside chair to assist in balance as needed when ambulating in the room.

ANS: B When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.

When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse include in the plan of care? a. Instruct the patient to purchase a soft mattress. b. Teach patient to use lukewarm water when bathing. c. Suggest that the patient take a nap in the afternoon. d. Suggest exercise with light weights several times daily.

ANS: C Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to avoid stressing joints, to use warm baths to relieve stiffness, and to use a firm mattress.

Which nursing action will the nurse include in the plan of care for a patient who has had a total knee arthroplasty? a. Avoid extension of the knee beyond 120 degrees. b. Use a compression bandage to keep the knee flexed. c. Start progressive knee exercises to obtain 90-degree flexion. d. Teach about the need to avoid weight bearing for 4 weeks.

ANS: C After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Full weight bearing is expected before discharge.

A 51-year-old man is scheduled for an annual physical exam at the outpatient clinic. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS).

ANS: C An annual digital rectal exam (DRE) and PSA are recommended starting at age 50 for men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA are abnormal.

After a patient with a left femur fracture has a hip spica cast applied, which nursing intervention will be included in the plan of care? a. Avoid placing the patient in the prone position. b. Use the cast support bar to reposition the patient. c. Ask the patient about any abdominal discomfort or nausea. d. Discuss the reasons for remaining on bed rest for several weeks.

ANS: C Assessment of bowel tones, abdominal pain, and nausea and vomiting will detect the development of cast syndrome. To avoid breakage, the support bar should not be used for repositioning. After the cast dries, the patient can begin ambulating with the assistance of physical therapy personnel and may be turned to the prone position.

When the nurse is reviewing laboratory data for a patient who is taking methotrexate (Rheumatrex) to treat rheumatoid arthritis, which information is most important to communicate to the health care provider? a. The blood glucose is 75 mg/dL. b. The rheumatoid factor is positive. c. The white blood cell (WBC) count is 1500/mL. d. The erythrocyte sedimentation rate is elevated.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patients low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in rheumatoid arthritis. The blood glucose is normal.

Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. Which laboratory result will the nurse monitor to determine whether the medication has been effective? a. Blood glucose test b. Liver function tests c. C-reactive protein level d. Serum electrolyte levels

ANS: C C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels also will be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids.

When caring for a patient who has osteoarthritis, the nurse will anticipate the need to teach the patient about which of these medications? a. Adalimumab (Humira) b. Prednisone (Deltasone) c. Capsaicin cream (Zostrix) d. Sulfasalazine (Azulfidine)

ANS: C Capsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with RA.

How will the nurse assess the flank area of a patient with pyelonephritis for tenderness? a. Push gently into the two lowest intercostal spaces. b. Palpate along both sides of the lumbar vertebral column. c. Position one hand flat at the costovertebral angle (CVA) and strike it with the other fist. d. Use two fingers to percuss the area between the iliac crest and ribs along the midaxillary line.

ANS: C Checking for flank pain is best performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain

. When counseling an older patient about ways to prevent fractures, which information will the nurse include? a. Tack down scatter rugs in the home. b. Most falls happen outside the home. c. Buy shoes that provide good support and are comfortable to wear. d. Range-of-motion exercises should be taught by a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range of motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

A patient with rheumatoid arthritis refuses to take the prescribed methotrexate (Rheumatrex), telling the nurse That drug has too many side effects. My arthritis isnt that bad yet. The most appropriate response by the nurse is a. You have the right to refuse to take the methotrexate. b. Methotrexate is less expensive than some of the newer drugs. c. It is important to start methotrexate early to decrease the extent of joint damage. d. Methotrexate is effective and has fewer side effects than some of the other drugs.

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

When reading a patients chart, the nurse notes that the patient has dysuria. To assess whether there is any improvement, which question will the nurse ask? a. Do you have any blood in your urine? b. Do you have to urinate very frequently? c. Do you have any pain when you urinate? d. Do you have to get up at night to urinate?

ANS: C Dysuria is painful urination. The alternate responses are used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.

Which information will the nurse include when teaching a patient who has a diagnosis of chronic prostatitis? a. Ibuprofen (Motrin) should provide good pain control. b. Prescribed antibiotics should be taken for 7 to 10 days. c. Sexual intercourse and masturbation will help relieve symptoms. d. Cold packs should be used every 4 hours to reduce inflammation.

ANS: C Ejaculation helps drain the prostate and relieve pain. Warm baths are recommended to reduce pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed but usually do not offer adequate pain relief. Antibiotics for chronic prostatitis are taken for 4 to 12 weeks.

Which information will the nurse include when discharging a patient with a sprained wrist from the emergency department? a. Keep the wrist loosely wrapped with gauze. b. Apply a heating pad to reduce muscle spasms. c. Use pillows to elevate the arm above the heart. d. Gently move the wrist through the range of motion.

ANS: C Elevation of the arm will reduce the amount of swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The wrist should be rested and kept immobile to prevent further swelling or injury.

After a patient has a short-arm plaster cast applied in the emergency department, which statement by the patient indicates a good understanding of the nurses discharge teaching? a. I can get the cast wet as long as I dry it right away with a hair dryer. b. I should avoid moving my fingers and elbow until the cast is removed. c. I will apply an ice pack to the cast over the fracture site for the next 24 hours. d. I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. Plaster casts should not get wet. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

Which of these patients seen by the nurse in the outpatient clinic is most likely to require teaching about ways to reduce risk for osteoarthritis (OA)? a. A 56-year-old man who is a member of a construction crew b. A 24-year-old man who participates in a summer softball team c. A 49-year-old woman who works on an automotive assembly line d. A 36-year-old woman who is newly diagnosed with diabetes mellitus

ANS: C OA is more likely to occur in women as a result of estrogen reduction at menopause and in individuals whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces risk for OA. Diabetes is not a risk factor for OA. Working on a construction crew would involve nonrepetitive work and thus would not be as risky.

A 26-year-old patient with urethritis and knee pain is diagnosed with reactive arthritis. The nurse will plan to teach the patient about the need for several months of therapy with a. anakinra (Kineret). b. etanercept (Enbrel). c. doxycycline (Vibramycin). d. methotrexate (Rheumatrex).

ANS: C Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

A patient with a herniated intravertebral disk undergoes a laminectomy and discectomy. Following the surgery, the nurse should position the patient on the side by a. instructing the patient to move the legs before turning the rest of the body. b. having the patient turn by grasping the side rails and pulling the shoulders over. c. placing a pillow between the patients legs and turning the entire body as a unit. d. turning the patients head and shoulders first, followed by the hips, legs, and feet.

ANS: C The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.

When administering alendronate (Fosamax) to a patient, the nurse will first a. be sure the patient has recently eaten. b. ask about any leg cramps or hot flashes. c. assist the patient to sit up at the bedside. d. administer the ordered calcium carbonate.

ANS: C To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.

In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is a. activity intolerance related to deconditioning. b. risk for constipation related to prolonged bed rest. c. risk for impaired skin integrity related to immobility. d. risk for infection related to disruption of skin integrity.

ANS: D A patient having an ORIF is at risk for problems such as wound infection and osteomyelitis. After an ORIF, patients typically are mobilized starting the first postoperative day, so problems caused by immobility are not as likely.

A patient with diabetic nephropathy is admitted for a right renal biopsy. Immediately after the biopsy, which of these is an essential nursing action? a. Monitor the blood urea nitrogen (BUN) and creatinine to assess renal function. b. Check blood glucose to assess for hyperglycemia or hypoglycemia. c. Insert a straight catheter to check for gross or microscopic hematuria. d. Apply a pressure dressing and keep the patient on the affected side for 30 to 60 minutes.

ANS: D A pressure dressing is applied and the patient is kept on the affected side for 30 to 60 minutes to put pressure on the biopsy side and decrease the risk for bleeding. The blood glucose and BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is needed, there is no need for catheterization.

The nurse is caring for a patient who has had a surgical reduction of an open fracture of the left tibia. Which assessment finding is most important to report to the health care provider? a. Left leg muscle spasms b. Serous wound drainage c. Left leg pain with movement d. Temperature 101.4 F (38.6 C)

ANS: D An elevated temperature is suggestive of possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.

A patient with an acute attack of gout in the left great toe has a new prescription for probenecid (Benemid). Which information about the patients home routine indicates a need for teaching regarding gout management? a. The patient sleeps about 8 to 10 hours every night. b. The patient usually eats beef once or twice a week. c. The patient generally drinks about 3 quarts of juice and water daily. d. The patient takes one aspirin a day prophylactically to prevent angina.

ANS: D Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patients sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

Which action will the nurse take in order to evaluate the effectiveness of Bucks traction for a patient who has an intracapsular fracture of the left femur? a. Assess for hip contractures. b. Monitor for hip dislocation. c. Check the peripheral pulses. d. Ask about left hip pain level.

ANS: D Bucks traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Bucks traction.

When obtaining a focused health history for a patient with possible testicular cancer, the nurse will ask the patient about any history of a. sexually transmitted disease (STD) infection. b. testicular trauma. c. testicular torsion. d. undescended testicles.

ANS: D Cryptorchidism is a risk factor for testicular cancer if it is not corrected before puberty. STD infection, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer.

A long-term care patient who takes multiple medications develops acute gouty arthritis. The nurse will consult with the health care provider before giving the prescribed dose of a. sertraline (Zoloft). b. famotidine (Pepcid). c. oxycodone (Roxycodone). d. hydrochlorothiazide (HydroDiuril).

ANS: D Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because he is afraid it might affect his ability to have intercourse. Which action should the nurse take? a. Offer reassurance that sperm production is not affected by TURP. b. Discuss alternative methods of sexual expression besides intercourse. c. Provide education about the use of medications for erectile dysfunction (ED) occurring after TURP. d. Teach that ED is not a common complication following a TURP.

ANS: D ED is not a concern with TURP, although retrograde ejaculation is likely and the nurse should discuss this with the patient. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns.

A 26-year-old patient who is employed as a hairdresser and has a 10 pack-year history of cigarette smoking is scheduled for an annual physical examination. The nurse will plan to teach the patient about the increased risk for a. renal failure. b. kidney stones. c. pyelonephritis. d. bladder cancer.

ANS: D Exposure to the chemicals involved with working as a hairdresser and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones.

A patient is receiving gentamicin (Garamycin) 80 mg IV twice daily for acute osteomyelitis. Which action should the nurse take before administering the gentamicin? a. Ask the patient about any nausea. b. Obtain the patients oral temperature. c. Change the prescribed wet-to-dry dressing. d. Review the patients blood urea nitrogen (BUN) and creatinine levels.

ANS: D Gentamicin is nephrotoxic and can cause renal failure. Monitoring the patients temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.

Which assessment information about a 62-year-old man is most important for the nurse to report to the health care provider when the patient is asking for a prescription for testosterone replacement therapy? a. The patients symptoms have increased steadily over the last few years. b. The patient has been using sildenafil (Viagra) several times every week. c. The patient has had a gradual decrease in the force of his urinary stream. d. The patient states that he has noticed a decrease in energy level for a few years.

ANS: C The decrease in urinary stream may indicate benign prostatic hyperplasia (BPH) or prostate cancer, which are contraindications to the use of testosterone replacement therapy (TRT). The other patient data indicate that TRT may be a helpful therapy for the patient.

When reviewing patient laboratory results, the nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the following four patients. Which patients PSA result is most important to report to the health care provider? a. A 75-year-old who uses saw palmetto to treat benign prostatic hyperplasia (BPH) b. A 38-year-old who is being treated for acute prostatitis c. A 48-year-old whose father died of metastatic prostate cancer d. A 52-year-old who goes on long bicycle rides every weekend

ANS: C The family history and elevation of PSA in the 48-year-old indicate that further evaluation of the patient for prostate cancer is needed. The elevations in PSA for the other patients are not unusual.

When reviewing the results of a patients urinalysis, which information indicates that the nurse should notify the health care provider? a. pH 6.2 b. Trace protein c. WBC: 20-26/hpf d. Specific gravity: 1.021

ANS: C The increased number of white blood cells (WBCs) indicates the presence of urinary tract infection or inflammation. The other findings are normal.

Following a motor vehicle accident, a patient arrives in the emergency department with massive right lower leg swelling. Which action will the nurse take first? a. Elevate the leg on pillows. b. Apply a compression bandage. c. Check leg pulses and sensation. d. Place ice packs on the lower leg.

ANS: C The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

After the health care provider has recommended an amputation for a patient who has ischemic foot ulcers, the patient tells the nurse, If they want to cut off my foot, they should just shoot me instead. Which response by the nurse is best? a. Many people are able to function normally with a foot prosthesis. b. I understand that you are upset, but you may lose the foot anyway. c. Tell me what you know about what your options for treatment are. d. If you do not want the surgery, you do not have to have an amputation.

ANS: C The initial nursing action should be to assess the patients knowledge level and feelings about the options available. Discussion about the patients option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patients current level of knowledge and emotional state.

After teaching a patient with a bunion about how to prevent further problems, the nurse will determine that more teaching is needed if the patient says, a. I will throw away my high heel shoes. b. I will use the bunion pad to relieve the pain. c. I will need to wear open sandals at all times. d. I will take ibuprofen (Motrin) when I need it.

ANS: C The patient can wear shoes that have a wide forefoot. The other patient statements indicate that the teaching has been effective.

While working at a summer camp, the nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse take next? a. Palpate the abdomen. b. Auscultate the heart sounds. c. Ask the patient about recent outdoor activities. d. Question the patient about immunization history.

ANS: C The patients clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patients symptoms do not suggest cardiac or abdominal problems or lack of immunization.

A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes. Which action by the nurse is most appropriate? a. Reassure the patient that dry eyes are a common problem with RA. b. Teach the patient more about adverse affects of the RA medications. c. Suggest that the patient start using over-the-counter (OTC) artificial tears. d. Ask the health care provider about lowering the methotrexate (Rheumatrex) dose.

ANS: C The patients dry eyes are consistent with Sjgrens syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself.

A patient who had a cystoscopy the previous day calls the urology clinic and gives the nurse all the following information. Which statement by the patient should be reported immediately to the health care provider? a. My urine still looks pink. b. My IV site is still bruised. c. I have a temperature of 101. d. I did not sleep well last night.

ANS: C The patients elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia and bruising should be discussed further with the patient but do not indicate a need to notify the health care provider.

A 64-year-old has a perineal radical prostatectomy for prostatic cancer. In the immediate postoperative period, the nurse establishes the nursing diagnosis of risk for infection related to a. urinary stasis. b. urinary incontinence. c. possible fecal contamination of the surgical wound. d. placement of a suprapubic catheter into the bladder.

ANS: C The perineal approach increases the risk for infection because the incision is located close to the anus and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery.

The nurse uses auscultation during assessment of the urinary system to a. check for ureteral peristalsis. b. assess for bladder distention. c. identify renal artery or aortic bruits. d. determine the position of the kidneys.

ANS: C The presence of a bruit may indicate problems such as renal artery tortuosity or abdominal aortic aneurysm. Auscultation would not be helpful in assessing for the other listed urinary tract information.

When teaching a patient who is scheduled for a transurethral resection of the prostate (TURP) about continuous bladder irrigation, which information will the nurse include? a. Bladder irrigation decreases the risk of postoperative bleeding. b. Hydration and urine output are maintained by bladder irrigation. c. Bladder irrigation prevents obstruction of the catheter after surgery. d. Antibiotics are infused on a continuous basis with bladder irrigation.

ANS: C The purpose of bladder irrigation is to remove clots from the bladder and to prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation.

A checkout clerk in a grocery store has repetitive strain syndrome in the left elbow. The nurse will plan to teach the patient about a. surgical options. b. elbow injections. c. utilization of a left wrist splint. d. modifications in arm movement.

ANS: D Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

A client who is on postoperative day 1 after abdominal surgery is requesting a back rub. The nurse realizes this care should be provided by 1. the registered nurse. 2. unlicensed assistive personnel. 3. no one, because the client cannot assume the prone position. 4. the physician.

Correct Answer: 1 Rationale 1: Because the client is on day 1 in recovery from abdominal surgery, the clients condition might not be stable enough to have unlicensed assistive personnel perform the skill.

The client scheduled to undergo minor surgery states, The physician will not give me pain medication after surgery because my surgery is only minor. What is the best response by the nurse? 1. You can experience pain after minor surgery, so you can have pain medication. 2. You are correct. The physician will not order any pain medication. 3. You are correct. I will need to teach you nonpharmacologic pain relief measures. 4. You can only have about half the dose because your surgery is minor.

Correct Answer: 1 Rationale 1: Clients can experience intense pain after minor surgery, so pain medication may be ordered.

A client experiencing pain has been prescribed aspirin. The nurse realizes that this medication will affect which pain process? 1. Transduction 2. Transmission 3. Perception 4. Modulation

Correct Answer: 1 Rationale 1: During the transduction phase, noxious stimuli trigger the release of biochemical mediators, such as prostaglandins, bradykinin, serotonin, histamine, and substance P, that sensitize nociceptors. Noxious or painful stimulation also causes movement of ions across cell membranes, which excites nociceptors. Pain medications such as aspirin can work during this phase by blocking the production of prostaglandin or by decreasing the movement of ions across the cell membrane.

The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the clients arm over the chest. 4. Raise the opposite side rail.

Correct Answer: 1 Rationale 1: Even though the intervention being performed is placing the client on a bedpan, the nurse should first perform hand hygiene. This prevents cross-transmission of infection from one client to another. Performing this hygiene in front of the client also increases the clients perception of the quality of care being provided and the nurses concern about infection control.

The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet.

Correct Answer: 1 Rationale 1: High-topped shoes will place the clients feet in the anatomical position of dorsal flexion.

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data.

Correct Answer: 1 Rationale 1: In order to make this broad nursing diagnosis more specific to the client, the nurse should include what mobility is impaired. For example, if the client cannot transfer from bed to chair, a more specific nursing diagnosis is Impaired Transfer Mobility.

The nurse is performing discharge teaching for a client taking an NSAID. The client states he has heard that taking an antacid with this medication will help decrease the incidence of upset stomach. What is the nurses best response? 1. Antacids reduce the absorption and therefore the effectiveness of the NSAID. 2. Antacids help to reduce the incidence of gastric bleeding that could occur with the use of NSAIDs. 3. Antacids should never be taken with an NSAID. 4. Antacids help to reduce the incidence of pain.

Correct Answer: 1 Rationale 1: It is documented that the use of antacids can reduce the risk of gastric distress, but can also reduce the absorption and the effectiveness of the medication.

A client asks the nurse to please close the door when entering or exiting the room because the noise is more than the client is used to because he lives alone. The nurse identifies the reason for this clients response to sensory stimuli as being due to which factor? 1. Lifestyle 2. Developmental stage 3. Culture 4. Illness

Correct Answer: 1 Rationale 1: Lifestyle influences the quality and quantity of stimulation to which an individual is accustomed. A client who lives alone is exposed to fewer, less diverse stimuli.

The nurse is caring for a client who is using morphine through patient-controlled analgesia (PCA). What medication should the nurse have readily available? 1. Naloxone hydrochloride (Narcan) 2. Acetaminophen (Tylenol) 3. Diphenhydramine hydrochloride (Benadryl) 4. Normal saline

Correct Answer: 1 Rationale 1: Narcan is an opioid antagonist and should be readily available when a client is receiving an opioid.

The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up

Correct Answer: 1 Rationale 1: Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the clients central blood pressure drops when moving from supine to sitting or to standing.

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the clients diet. 3. Protect the clients bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily.

Correct Answer: 1 Rationale 1: Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bones, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weight-bearing activities.

A client experiencing pain after surgery says Something must be wrong because the pain is so severe. What is the best response for the nurse to make to the client? 1. The amount of tissue disrupted from the surgery is not related to the degree of pain you feel. 2. That could be so. 3. Taking pain medication for many years has made the medication ineffective now.

Correct Answer: 1 Rationale 1: Pain is a subjective experience, and the intensity and duration of pain vary considerably among individuals. The amount of tissue damaged or disrupted is not related to the amount of pain experienced.

A client recovering from a left below-the-knee amputation is experiencing left foot pain. The nurse realizes the client is experiencing which type of pain? 1. Phantom limb pain 2. Acute pain 3. Chronic pain 4. Narcotic-induced pain

Correct Answer: 1 Rationale 1: Phantom sensations, the feeling that a lost body part is present, occur in most people after amputation. It is important for the nurse to remember to explain the reasons for phantom limb pain, as clients may have difficulty understanding why they have pain when the limb is gone.

The nurse is providing education for the parents of a 7-month-old child who has just been diagnosed with a hearing loss. What guidance should the nurse provide? 1. Expect that the child will be enrolled in a special hearing intervention program immediately. 2. Keep your child in a quiet environment until additional testing is done. 3. Interventions to support hearing are not useful until the child is at least 9 months old. 4. Hearing loss is not serious until 1 year of age.

Correct Answer: 1 Rationale 1: The Centers for Disease Control and Prevention (CDC) expects that all infants identified with hearing loss will receive early intervention services prior to age 36 months.

A client with pain has had previous episodes of uncontrolled pain in the past and is worried about the current pain pattern. Which diagnosis would be appropriate for the nurse to include for this client? 1. Anxiety 2. Ineffective Coping 3. Deficient Knowledge 4. Hopelessness

Correct Answer: 1 Rationale 1: The diagnosis of Anxiety would be appropriate for the client, as the client has past experiences of poor pain control and is anticipating pain.

The nurse is preparing to discharge a client home with a prescription for ibuprofen (Motrin). What should the nurse instruct as a common side effect of this medication? 1. Gastrointestinal (GI) distress 2. Shakiness 3. Tremors 4. Rash

Correct Answer: 1 Rationale 1: The most common side effect of NSAIDs, including ibuprofen, is gastrointestinal distress, such as heartburn or indigestion.

A client is diagnosed with chronic low back pain syndrome. The nurse realizes that which analgesic delivery route might be beneficial for this client? 1. Topical 2. Rectal 3. Transmucosal 4. Transdermal

Correct Answer: 1 Rationale 1: Topical medications work directly at the point of application on the body. They are useful for painful procedures such as lumbar punctures or bone marrow biopsies, or for injections. These products can also offer effective pain relief for chronic pain syndromes such as low back pain.

A client watching a comedy on television is laughing. When asked about the amount of pain on a scale from 0 to 10, the client reports a level that is 2 below the previous assessment. The nurse realizes the clients pain was influenced by which type of distraction? 1. Visual 2. Tactile 3. Intellectual 4. Behavioral

Correct Answer: 1 Rationale 1: Visual distraction includes watching television.

The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower.

Correct Answer: 1 Rationale 1: When transferring a client from bed to gurney, the bed should be parallel to the stretcher and slightly higher. It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface.

A client reports pain as being a 2 on a scale from 0 to 10. Which pain medications should the nurse consider for the client at this time? Standard Text: Select all that apply. 1. Acetaminophen (Tylenol) 2. Ibuprofen (Motrin) 3. Naproxen (Naprosyn) 4. Hydrocodone (Vicodin) 5. Methadone (Dolophine)

Correct Answer: 1, 2, 3 Rationale 1: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as acetaminophen (Tylenol). Rationale 2: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as ibuprofen (Motrin). Rationale 3: Reporting pain as a 2 on a scale from 0 to 10 means the client is experiencing mild pain. According to the WHO approach to pain management, the client should be provided with a nonopioid analgesic such as naproxen (Naprosyn).

A client is experiencing acute confusion. What nursing actions would be appropriate for this client? Standard Text: Select all that apply. 1. Eliminate unnecessary noise. 2. Keep eyeglasses within reach. 3. Place a calendar in the room, and identify each day. 4. Keep the room well lit during waking hours. 5. Provide dark glasses.

Correct Answer: 1, 2, 3, 4

The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this clinical decision? Standard Text: Select all that apply. 1. Excessive sleeping 2. Confusion at night 3. Anger over minor issues 4. Easily distracted 5. Sitting quietly reading a book

Correct Answer: 1, 2, 3, 4

The nurse is caring for an adolescent client who is experiencing postoperative pain. What interventions should the nurse use to help this client? Standard Text: Select all that apply. 1. Talk with the client about pain. 2. Provide privacy. 3. Present choices for dealing with pain. 4. Encourage distraction with music or television. 5. Allay fears and anxiety.

Correct Answer: 1, 2, 3, 4 Rationale 1: Nursing interventions to assist with pain management for an adolescent client include talking with the client about the pain. Rationale 2: Nursing interventions to assist with pain management for an adolescent client include providing privacy. Rationale 3: Nursing interventions to assist with pain management for an adolescent client include presenting choices for dealing with the pain. Rationale 4: Nursing interventions to assist with pain management for an adolescent client include encouraging distraction with music or television.

The nurse is preparing to conduct a pain assessment. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. Duration 2. Location 3. Intensity 4. Etiology 5. Neurology

Correct Answer: 1, 2, 3, 4 Rationale 1: Pain may be described in terms of duration. Rationale 2: Pain may be described in terms of location. Rationale 3: Pain may be described in terms of intensity. Rationale 4: Pain may be described in terms of etiology.

The nurse documents that a client is fully conscious. What did the nurse assess in this client? Standard Text: Select all that apply. 1. Client responded to verbal stimuli. 2. Client responded to written words. 3. Client oriented to time, place, and person. 4. Client demonstrated poor memory. 5. Client alert.

Correct Answer: 1, 2, 3, 5

The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion? Standard Text: Select all that apply. 1. Sleeplessness 2. Anxiety 3. Apathy 4. Racing thoughts 5. Somatic complaints

Correct Answer: 1, 2, 4 Rationale 1: Sleeplessness is an indication of sensory overload. Rationale 2: Anxiety is an indication of sensory overload.Rationale 4: Racing thoughts are an indication of sensory overload.

The nurse is preparing to instruct a client on nonpharmacologic interventions that target the body for pain control. What should the nurse include in these instructions? Standard Text: Select all that apply. 1. Massage 2. Acupressure 3. Self-hypnosis 4. Exercise 5. Nutritional supplements

Correct Answer: 1, 2, 4, 5 Rationale 1: Massage is a nonpharmacologic intervention that targets the body for pain control. Rationale 2: Acupressure is a nonpharmacologic intervention that targets the body for pain control. Rationale 4: Exercise is a nonpharmacologic intervention that targets the body for pain control. Rationale 5: Nutritional supplements are a nonpharmacologic intervention that target the body for pain control.

Which recent change, reported by a clients family, would indicate that the clients hearing ability is decreasing? Standard Text: Select all that apply. 1. Inability to follow directions 2. Mood swings 3. Decreased appetite 4. Complaints of dizziness 5. Answering questions incorrectly

Correct Answer: 1, 2, 4, 5 Rationale 1: The client who has difficulty hearing might have an inability to follow directions because the directions were not heard. Rationale 2: The client who has difficulty hearing might have mood swings because of the stress of not hearing well.Rationale 4: The client who has difficulty hearing might have complaints of dizziness associated with inner ear disturbances. Rationale 5: The client who has difficulty hearing might answer questions incorrectly because a question was not heard or was misinterpreted.

The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Standard Text: Select all that apply. 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor

Correct Answer: 1, 2, 5 Rationale 1: Hot baths can cause venous pooling in the lower extremities. Rationale 2: Heavy meals divert blood to the gastrointestinal organs.Rationale 5: Bending to the floor can cause rapid changes in blood pressure upon standing up again.

When teaching a patient scheduled for a cystogram via a cystoscope about the procedure, the nurse tells the patient, a. Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidney. b. Your doctor will place a catheter into an artery in your groin and inject a dye that will visualize the blood supply to the kidneys. c. Your doctor will inject a radioactive solution into a vein in your arm and the distribution of the isotope in your kidneys and bladder will be checked. d. Your doctor will insert a lighted tube into the bladder through your urethra, inspect the bladder, and instill a dye that will outline your bladder on x-ray.

ANS: D In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, Your doctor will place a catheter describes a renal arteriogram procedure. The response beginning, Your doctor will inject a radioactive solution describes a nuclear scan. The response beginning, Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted describes a retrograde pyelogram.

A patient has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level. The nurse will anticipate that the patient will need teaching about a. cystourethroscopy. b. uroflowmetry studies. c. magnetic resonance imaging (MRI). d. transrectal ultrasonography (TRUS).

ANS: D In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to visualize the prostate for biopsy. Uroflowmetry studies help determine the extent of urine blockage and treatment, but there is no indication that this is a problem for this patient. Cystoscopy may be used before prostatectomy but will not be done until after the TRUS and biopsy. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process.

When giving home care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include? a. Keep the hand immobile to prevent soft tissue swelling. b. Keep the right shoulder elevated on a pillow or cushion. c. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury. d. Call the health care provider for increased swelling or numbness.

ANS: D Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling.

A client experiencing pain has been prescribed a coanalgesic. The nurse should prepare to administer what medications to the client? Standard Text: Select all that apply. 1. Nortriptyline 2. Amitriptyline 3. Tramadol 4. Meloxicam 5. Gabapentin

Correct Answer: 1, 2, 5 Rationale 1: Nortriptyline is a tricyclic antidepressant used as a coanalgesic to treat pain. Rationale 2: Amitriptyline a tricyclic antidepressant used as a coanalgesic to treat pain.Rationale 5: Gabapentin is an anticonvulsant used as a coanalgesic to treat pain.

The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Standard Text: Select all that apply. 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible.

Correct Answer: 1, 2, 5 Rationale 1: Placing a turn sheet on the bed will help overcome inertia and friction during moving. Rationale 2: Using two personnel will allow a lift and move rather than pulling or sliding the client over linens.Rationale 5: Encouraging the client to assist as much as possible will lighten the workload.

The health care provider is writing medication orders for a client recovering from spinal fusion surgery. When the client reports pain as a 9 on a scale from 0 to 10, which medications should the nurse consider providing to the client? Standard Text: Select all that apply. 1. Oxymorphone (Opana) 2. Hydrocodone (Vicodin) 3. Oxycodone (OxyContin) 4. Morphine sulfate (morphine) 5. Hydromorphone hydrochloride (Dilaudid)

Correct Answer: 1, 3, 4, 5

The nurse wants to assign back rubs to unlicensed assistive personnel (UAP). Before doing so, the nurse should first determine whether Standard Text: Select all that apply. 1. unlicensed assistive personnel know how to perform a back rub. 2. there any clients who have intravenous fluids infusing. 3. there any clients who should not have a back rub performed. 4. there any clients who are prescribed to take nothing by mouth. 5. there any clients who do not want a back rub done by unlicensed assistive personnel.

Correct Answer: 1, 3, 5 Rationale 1: The nurse can delegate this skill to UAP; however, the nurse first should assess for the UAPs comfort and ability.Rationale 3: The nurse can delegate this skill to UAP; however, the nurse first should assess for client contraindications.Rationale 5: The nurse can delegate this skill to UAP; however, the nurse first should assess for client willingness to participate.

The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client? Standard Text: Select all that apply. 1. Ongoing pain 2. Confusion at night 3. Inability to sleep 4. Easily angered 5. Worrying about upcoming diagnostic tes

Correct Answer: 1, 3, 5Rationale 1: Pain can contribute to sensory overload.Rationale 3: Sleeplessness can contribute to sensory overload.Rationale 5: Worry can contribute to sensory overload.

The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowlers position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed

Correct Answer: 2 Rationale 2: The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion.

The nurse informs the patient undergoing cystoscopy that following the procedure, the patient a. will be NPO for 8 hours to prevent nausea and vomiting. b. is expected to be on strict bed rest for about 4 to 6 hours. c. should ask for the ordered narcotics as necessary for pain. d. may experience blood-tinged urine and urinary frequency.

ANS: D Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination is common, but pain that requires opioids for relief is not expected. A good fluid intake is encouraged after this procedure. Bed rest is not required following cystoscopy.

A 58-year-old woman who has a family history of osteoporosis is diagnosed with osteopenia following densitometry testing. In teaching the woman about her osteoporosis, the nurse explains that a. estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. b. continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. c. with a family history of osteoporosis, there is no way to prevent or slow gradual bone resorption. d. calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

ANS: D Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy does help prevent osteoporosis, but it is not the only treatment and is not appropriate for some patients. Corticosteroid therapy increases the risk for osteoporosis.

Which information obtained by the emergency department nurse when admitting a patient with a left femur fracture is most important to report to the health care provider? a. Bruising of the left thigh b. Complaints of left thigh pain c. Outward pointing toes on the left foot d. Prolonged capillary refill of the left foot

ANS: D Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.

When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to a. do stretching and warm-up exercises before starting work. b. wrap the wrists with a compression bandage every morning. c. use acetaminophen (Tylenol) instead of nonsteroidal anti-inflammatory drugs (NSAIDs) for wrist pain. d. obtain a keyboard pad to support the wrist while word processing.

ANS: D Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.

Which of these nursing actions included in the care of a patient after laminectomy can the nurse delegate to experienced nursing assistive personnel (NAP)? a. Ask about pain control with the patient-controlled analgesia (PCA). b. Determine the patients readiness to ambulate. c. Check ability to plantar and dorsiflex the foot. d. Turn the patient from side to side every 2 hours.

ANS: D Repositioning a patient is included in the education and scope of practice of NAP, and experienced NAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patients readiness to ambulate after surgery require higher level nursing education and scope of practice.

Which menu choice by a patient with osteoporosis indicates that the nurses teaching about appropriate diet has been effective? a. Pancakes with syrup and bacon b. Whole wheat toast and fruit jelly c. Two-egg omelet and a half grapefruit d. Oatmeal with skim milk and fruit yogurt

ANS: D Skim milk and yogurt are high in calcium. The other choices do not contain any high calcium foods.

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH) the nurse will ask the patient about a. blood in the urine. b. lower back or hip pain. c. erectile dysfunction (ED). d. strength of the urinary stream.

ANS: D The American Urological Association (AUA) Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, etc. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH.

After a transurethral resection of the prostate (TURP), a patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes a decrease in urine output and clots in the urine. Which action should the nurse take first? a. Increase the flow rate of the bladder irrigation. b. Administer the prescribed IV morphine sulfate. c. Give the patient the prescribed belladonna and opium suppository. d. Manually instill and then withdraw 50 mL of saline into the catheter.

ANS: D The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurses first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot.

A patient in the emergency department who is experiencing severe pain is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a. a knee immobilizer. b. gentle knee flexion. c. activity restrictions. d. monitored anesthesia care (conscious sedation).

ANS: D The first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care (MAC), formerly called conscious sedation. Immobilization, gentle range of motion (ROM) exercises, and discussion about activity restrictions will be implemented after the knee is realigned.

A patient is admitted to the emergency department with possible left lower leg fractures. The initial action by the nurse should be to a. elevate the left leg. b. splint the lower leg. c. obtain information about the tetanus immunization status. d. check the popliteal, dorsalis pedis, and posterior tibial pulses.

ANS: D The initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.

The home health nurse is doing a follow-up visit to a patient with recently diagnosed rheumatoid arthritis (RA). Which assessment made by the nurse indicates that more patient teaching is needed? a. The patient requires a 2-hour midday nap. b. The patient has been taking 16 aspirins daily. c. The patient sits on a stool when preparing meals. d. The patient sleeps with two pillows under the head.

ANS: D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. The other information is appropriate for a patient with RA and indicates that teaching has been effective.

A patient with a comminuted fracture of the right femur has Bucks traction in place while waiting for surgery. To assess for pressure areas on the patients back and sacral area and to provide skin care, the nurse should a. loosen the traction and have the patient turn onto the unaffected side. b. place a pillow between the patients legs and turn gently to each side. c. turn the patient partially to each side with the assistance of another nurse. d. have the patient lift the buttocks by bending and pushing with the left leg.

ANS: D The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. A statement by the patient that indicates a need for additional discharge instructions is a. I should not cross my legs while sitting. b. I will use a toilet elevator on the toilet seat. c. I will have someone else put on my shoes and socks. d. I can sleep in any position that is comfortable for me.

ANS: D The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate that the patient has understood the teaching.

The second day after admission with a fractured pelvis, a patient develops acute onset confusion. Which action should the nurse take first? a. Take the blood pressure. b. Assess patient orientation. c. Check pupil reaction to light. d. Assess the oxygen saturation.

ANS: D The patients history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation. The other actions also are appropriate but will be done after the nurse assesses gas exchange.

A patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia tells the nurse, I hate the way I look! I never go anywhere except here to the health clinic. An appropriate nursing diagnosis for the patient is a. activity intolerance related to fatigue and inactivity. b. impaired social interaction related to lack of social skills. c. impaired skin integrity related to itching and skin sloughing. d. social isolation related to embarrassment about the effects of SLE.

ANS: D The patients statement about not going anywhere because of hating the way he or she looks supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

Following a laminectomy with a spinal fusion, a patient reports numbness and tingling of the right lower leg. The first action indicated by the nurse is to a. report the patients complaint to the surgeon. b. check the vital signs for indications of hemorrhage. c. turn the patient to the side to relieve pressure on the right leg. d. check the chart for preoperative neuromuscular assessment data.

ANS: D The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient will not relieve the numbness.

The nurse is concerned that a client is not aware of being in the hospital. For what aspects of the sensory process should the nurse assess the client? Standard Text: Select all that apply. 1. Speech 2. Stimuli 3. Receptor 4. Perception 5. Impulse conduction

Correct Answer: 2, 3, 4, 5 Rationale 2: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these aspects is a stimulus, which is an agent or act that stimulates a nerve receptor. Rationale 3: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is a receptor, which is the ability to convert the stimulus to a nerve impulse. Rationale 4: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is perception, which is the awareness and interpretation of the stimuli in the brain. Rationale 5: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is impulse conduction, which means the impulse travels along the nerve pathways to either the spinal cord or directly to the brain.

The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk for developing this sensory disorder? Standard Text: Select all that apply. 1. Client has severe pain. 2. Client has impaired vision. 3. Client is unable to ambulate. 4. Client is on medication that alters sensory perception. 5. Client has no family in the immediate area.

Correct Answer: 2, 3, 4, 5 Rationale 2: Impaired vision increases a clients risk for developing sensory deprivation. Rationale 3: Mobility restrictions increase a clients risk for developing sensory deprivation. Rationale 4: Medications that affect the central nervous system increase a clients risk for developing sensory deprivation. Rationale 5: Limited social contact with family and friends increases a clients risk for developing sensory deprivation.

An older client who refuses medication for pain is irritable and unable to sleep. What should the nurse explain to the client to encourage the use of pain medication? Standard Text: Select all that apply. 1. There are high-dose medications that will eradicate the pain. 2. The lack of pain control is causing the inability to sleep. 3. The lack of pain control is causing irritability. 4. The risks of taking pain medication are low in the older population. 5. The lack of pain control will affect mobility and activity tolerance.

Correct Answer: 2, 3, 5 Rationale 2: If pain is not effectively controlled in the older client, the ability to sleep will be affected. Rationale 3: If pain is not effectively controlled in the older client, irritability can occurRationale 5: If pain is not effectively controlled in the older client, mobility and activity tolerance will be affected.

The nurse is caring for a client receiving pain medication through an epidural catheter. What should the nurse include to ensure safety when caring for this client? Standard Text: Select all that apply. 1. Secure all tubing connections with gauze. 2. Apply tape over all injection ports on the tubing. 3. Cleanse the insertion site with alcohol swabs once a day. 4. Label the tubing, infusion bag, and pump with the word epidural. 5. Post a sign above the clients bed indicating that an epidural is being used.

Correct Answer: 2, 4, 5 Rationale 2: Apply tape over all injection ports on the epidural line to avoid the injection of substances intended for IV administration into the epidural catheter.Rationale 4: Label the tubing, the infusion bag, and the front of the pump with tape marked epidural to prevent confusion with similar-looking IV lines. Rationale 5: Post a sign above the clients bed indicating that an epidural is in place.

The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

Correct Answer: 2, 4, 5 Rationale 2: The cane should be moved forward while the body weight is borne by both legs.Rationale 4: The weaker leg is moved forward while the weight is borne by the cane and stronger leg. Rationale 5: The stronger leg is moved forward while the weight is borne by the cane and weak leg.

The nurse has completed a back massage for a client. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Effectiveness of pain medication using a rating scale from 0 to 10 2. Position to perform the massage 3. Content of communication that occurred during the back massage 4. Amount of lotion used during the back massage 5. Client response

Correct Answer: 2, 5 Rationale 2: The nurse should document the position in which the massage was performed on the client.Rationale 5: The nurse should document the clients response to the massage.

The nurse is preparing to massage a clients back. Place in order the steps the nurse will follow, after conducting hand hygiene and preparing the client, to perform the back massage. Standard Text: Click and drag the options below to move them up or down. Choice 1. Move the hands down the sides of the back. Choice 2. Pour lotion into the palms of the hands to warm the lotion. Choice 3. Massage the areas over the right and left iliac crests. Choice 4. Move the hands up the center of the back. Choice 5. With the palms, massage the sacral area with smooth, circular strokes. Choice 6. Move the hands to the scapulae and massage this region using circular strokes.

Correct Answer: 2, 5, 4, 6,1, 3

The clients chief complaint is, I just cant get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired. Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: 1. Level 1. 2. Level 2. 3. Level 3. 4. Level 4.

Correct Answer: 3 Rationale 3: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 3 (this clients level) indicates ability to walk no more than 50 feet on level ground without stopping and inability to climb one flight of stairs without stopping.

The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the clients legs when turning? Standard Text: Select all that apply. 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg

Correct Answer: 3, 4, 5 Rationale 1: A pillow between the legs when logrolling does not stabilize the spine. Rationale 2: A pillow between the legs when logrolling does not prevent hip contractures. Rationale 3: A pillow between the clients legs when logrolling supports the upper leg when the client is turned. Rationale 4: A pillow between the clients legs when logrolling keeps the legs parallel and aligned. Rationale 5: A pillow between the clients legs when logrolling prevents adduction of the upper leg.

From an assessment, the nurse learns that the client is having difficulty sleeping because of pain in the hips and knees due to arthritis. The client is weak and fatigued. Which diagnoses would be applicable to the client at this time? Standard Text: Select all that apply. 1. Anxiety 2. Hopelessness 3. Ineffective Health Maintenance 4. Insomnia 5. Impaired Physical Mobility

Correct Answer: 3, 4, 5 Rationale 3: The diagnosis of Ineffective Health Maintenance would be applicable, as the client is experiencing chronic arthritic pain and is fatigued. Rationale 4: The diagnosis of Insomnia would be applicable, as the client is experiencing increased pain perception at night, affecting sleep. Rationale 5: The diagnosis of Impaired Physical Mobility would be applicable, as the client is experiencing arthritic pain in the hips and knees.

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this clients plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation

Correct Answer: 3Rationale 3: Once contractures occur they are irreversible except by surgical intervention. The best nursing intervention is to keep the contractures from getting tighter (or worse) by providing range-of-motion exercises.

The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility.

Correct Answer: 4 Rationale 4: The only option that has any influence on frequency of back injury is a practice prohibiting solo lifting.

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement? 1. Use short phrases. 2. Overarticulate words. 3. Vary the volume of the voice. 4. Face the client during conversation.

Rationale 4: The best intervention is to face the client during conversation so that the client can employ any lip-reading skills.

A client is experiencing changes in taste. What can the nurse do to improve this clients gustatory sense? Standard Text: Select all that apply. 1. Suggest eating each food separately. 2. Offer foods with a variety of flavors. 3. Recommend eating foods that are cold. 4. Promote sips of water between eating different foods. 5. Encourage the client to consume foods of different textures.

orrect Answer: 1, 2, 4, 5 Rationale 1: To improve the sense of taste, the nurse should encourage the client to eat each food separately. Rationale 2: To improve the sense of taste, the nurse should encourage the client to eat foods with a variety of flavors. Rationale 4: To improve the sense of taste, the nurse should encourage the client to take sips of water between eating different foods. Rationale 5: To improve the sense of taste, the nurse should encourage the client to consume foods of different textures.