Integumentary/Musculoskeletal NCLEX prep

An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank.

22.5%

An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 18% 24% 36% 48%

36%

A client sustains a burn injury to the entire right and left arms, the right leg, and the anterior thorax. According to the rule of nines, the nurse would assess that this injury constitutes which body percentage? Fill in the blank.

54%

The nurse is planning to teach a client how to stand on crutches. The nurse will incorporate into written instructions that the client should be told to place the crutches in what manner? 3 inches (8 cm) to the front and side of the toes 6 inches (15 cm) to the front and side of the toes 15 inches (38 cm) to the front and side of the toes 20 inches (51 cm) to the front and side of the toes

6 inches to the front and side of toes

The nurse is conducting a screening program to identify clients at risk for an integumentary disorder. Which client seen at the screening would most likely be at risk for development of an integumentary disorder? An athlete An adolescent An older client A client who tans in an indoor tanning bed

A client who tans

A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How should the nurse interpret this client statement? A normal response that indicates the presence of phantom limb pain A normal response that indicates the presence of phantom limb sensation An abnormal response that indicates that the client is in denial about the limb loss An abnormal response that indicates that the client needs more psychological support

A normal response that indicates the presence of phantom limb sensation

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. An irregularly shaped lesion A small papule with a dry, rough scale A firm, nodular lesion topped with crust A pearly papule with a central crater and a waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight

A pearly papule with a central crater and waxy border Location in the bald spot atop the head that is exposed to outdoor sunlight

The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? A trochanter roll to prevent abduction during turning A pillow to keep the right leg abducted during turning A pillow to keep the right leg adducted during turning A trochanter roll to prevent external rotation during turning

A pillow to keep the right leg abducted during turning

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem? A 25-year-old woman who runs A 36-year-old man who has asthma A 70-year-old man who consumes excess alcohol A sedentary 65-year-old woman who smokes cigarettes

A sedentary 65-year-old woman who smokes

The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition? Acne Freckles Psoriasis Sebaceous cysts

Acne

The nurse in the hospital emergency department is caring for a client with a fractured arm and is preparing the client for a reduction of the fracture that will be done in the casting room in the emergency department. The nurse should take which actions? Select all that apply. Obtain an anesthesia consent. Administer a prescribed analgesic. Explain the procedure to the client. Obtain informed consent for the procedure. Inform the anesthesiologist of the time of the procedure.

Administer a prescribed analgesic Explain the procedure Obtain informed consent

The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? Elevating the limb Monitoring vital signs every 4 hours Administering opioid analgesics intramuscularly Monitoring the biopsy site for swelling, bleeding, or hematoma

Administering opioids IM

The nurse is giving a client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? Advance the crutches along with both legs simultaneously. Advance the crutches along with the right leg, and then advance the left leg. Advance the crutches along with the left leg, and then advance the right leg. Advance the left leg along with right crutch, and then the right leg and left crutch.

Advance the crutches along with the left leg, and then advance the right leg

Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the primary health care provider has prescribed which laboratory study? Platelet count Alkaline phosphatase White blood cell count Complete blood cell count

Alkaline Phosphate

The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? "Changes in the shape of the knee are expected." "Fever, redness, and increased pain are expected." "All caregivers should be told about the metal implant." "Bleeding gums or black stools may occur, but this is normal."

All care givers should be told about metal implant

In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? Fatigue Constipation Impaired safety Altered body image

Altered body image

The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. Antibiotic therapy Cold compresses to the affected area Warm compresses to the affected area Intermittent heat lamp treatments 4 times daily Alternating hot and cold compresses continuously

Antibiotic therapy Warm compresses to the affected area

The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? Venous stars noted on trunk and thighs Spider angiomas observed on trunk and thighs Appears to have purpura on trunk and thighs Appears to have cherry angiomas on trunk and thighs

Appears to have cherry angiomas on trunk and thighs

The home care nurse visits an older client who was discharged from the hospital after diagnostic testing. The client complains of chronic dry skin and episodes of pruritus. Which measure should the nurse recommend for the client to alleviate this discomfort? Run a dehumidifier in the home. Apply astringents to the skin twice daily. Apply emollients to the skin after bathing. Take baths twice daily using a dilute solution of alcohol and water.

Apply emollients to the skin after bathing

A client is treated in a primary health care provider's office for a sprained ankle after a fall. Radiographic examination has ruled out a fracture. Before sending the client home, the nurse plans to teach the client to avoid which activity in the next 24 hours? Resting the foot Applying a heating pad Applying an elastic compression bandage Elevating the ankle on a pillow while sitting or lying down

Applying a heating pad

A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? Biobrane Autograft Xenograft Homograft

Autograft

A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? "When I have pain, I will take ibuprofen." "I should perform low-impact exercises regularly." "Because I have no symptoms, my disease is not progressing." "I must notify my primary health care provider if I experience any hearing loss."

Because I have no symptoms

The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? "A bone fragment has injured the nerve supply in the area." "An injured artery caused impaired arterial perfusion through the compartment." "Bleeding and swelling caused increased pressure in an area that couldn't expand." "The fascia expanded with injury, causing pressure on underlying nerves and muscles."

Bleeding and swelling caused increased pressure in an area that couldn't expand

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? Provide pin care. Medicate the client. Call the primary health care provider. Remove 2 lb (0.9 kg) of weight from the traction system.

Call the HCP

The nurse is preparing a plan of care for a client who is scheduled to return from the recovery room after a left total knee arthroplasty. The nurse includes in the plan of care to assess the client's neurovascular status the monitoring of which parameter? The pain level of the client Blood pressure and respiratory rate Capillary refill, sensation, color, and pulse of the left foot The range of motion of the left knee when a continuous passive motion machine is used

Capillary refill, sensation, color

A client is admitted to the emergency department with an open fracture of the right tibia. What intervention is most appropriate for this client? Remove the client's shoes. Place the client in a semi-Fowler's position. Check the neurovascular status of the area distal to the extremity. Apply a tourniquet above the area of bleeding and loosen it every 15 minutes.

Check the neurovascular status of the area distal to the extremity

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? Elevate the casted leg. Contact the primary health care provider. Administer another dose of pain medication. Check the neurovascular status of the toes on the casted leg.

Check the neurovascular status of the toes

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? Ensure that the knots are at the pulleys. Check the weights to ensure that they are off of the floor. Ensure that the head of the bed is kept at a 45- to 90-degree angle. Monitor the weights to ensure that they are resting on a firm surface.

Check the weights to ensure that they are off floor

A client has been diagnosed with gout, and the nurse provides dietary instructions. The nurse determines that the client needs additional teaching if the client states that it is acceptable to eat which food? Carrots Tapioca Chocolate Chicken liver

Chicken liver

A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint? Anemia Hypothyroidism Diabetes mellitus Chronic kidney disease

Chronic kidney disease

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? Clear mentation Minimal dyspnea Oxygen saturation of 85% Arterial oxygen level of 78 mm Hg

Clear mentation

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. Capillary refill less than 3 seconds Pulses present and with swollen, pink fingers Client report of severe, deep, unrelenting pain Client report of pain as nurse assesses finger movement Client report of numbness and tingling sensation in the fingers

Client report of severe, deep, unrelenting pain Client report of pain as nurse assesses finger movement Client report of numbness and tingling sensation in the fingers

The nurse is performing an assessment on a client suspected of having herpes zoster. The nurse would expect to note which types of lesions on inspection of the client's skin? Clustered skin vesicles A generalized body rash Small blue-white spots with a red base A fiery-red edematous rash on the cheeks

Clustered skin vesicles

A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What should the nurse include in client teaching to maximize the effects of the treatment? Rub the application into the skin. Place the area under a heat lamp for 20 minutes. Apply a dry sterile dressing over the affected area. Cover the application with a warm, moist dressing and an occlusive outer wrap.

Cover the application with a warm, moist dressing

The home care nurse is providing instructions to a client regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How should the nurse accurately demonstrate this technique? Crutches and the affected leg down, followed by the unaffected leg Crutches and the unaffected leg down, followed by the affected leg Unaffected leg down first, followed by the crutches and the affected leg Affected leg down first, followed by the crutches and the unaffected leg

Crutches and the affected leg down, followed by the unaffected leg

A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the primary health care provider will include a new prescription for which vitamin supplement? A D E K

D

The nurse prepares to assist a primary health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include in the plan for this procedure? Prepare a local anesthetic. Obtain an informed consent. Darken the room for the examination. Shave the skin and scrub with povidone-iodine solution.

Darken the room for examination

The nurse is caring for a client diagnosed with osteomyelitis. Which mechanism of the disease process can result in necrosis of the bone? Devascularization Infection of the bone Decreased bone mass Decreased bone density

Devascularization

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? Purpura Petechiae Erythema Ecchymosis

Ecchymosis

The nurse is caring for a client who has just had a plaster leg cast applied. The nurse should plan to prevent the development of compartment syndrome by performing which action? Elevate the limb slightly. Elevate the limb above heart level. Keep the leg horizontal and cover the limb with bath blankets. Place the leg in a slightly dependent position, and apply ice to the affected leg.

Elevate the limb slightly

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? Elevated for 3 hours, then flat for 1 hour Flat for 3 hours, then elevated for 1 hour Flat for 12 hours, then elevated for 12 hours Elevated on pillows continuously for 24 to 48 hours

Elevated on pillows continuously

The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity? Pallor Cyanosis Jaundice Erythema

Erythema

The nurse is gathering subjective and objective data from a client with a diagnosis of suspected rheumatoid arthritis (RA). The nurse would expect to note which early signs and symptoms of RA? Select all that apply. Fatigue Weight gain Restlessness Morning stiffness Pain with movement only

Fatigue Morning stiffness

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client? Pillow Foam pad Folded blankets Plastic-lined absorbent pad

Foam pad

A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? Strain Sprain Fracture Contusion

Fracture

The nurse is assessing a client with a shortened, adducted, and externally rotated left leg. On the basis of this finding, which condition should the nurse anticipate? Fractured knee Dislocated knee Fracture of the femoral neck Fracture of the midshaft of the femur

Fracture of the femoral neck

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? Disorientation to time only Heart rate of 95 beats/minute +1 palpable peripheral pulses Urine output of 30 mL over the past 2 hours

Heart rate 95bpm

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. Ice Heat Analgesics Muscle relaxers Intermittent traction

Heat Analgesics Muscle relaxers Intermittent traction

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary? Pallor of all extremities Pulse oximetry reading of 93% Peripheral pulses are diminished High pressure alarm keeps sounding on the ventilator

High pressure alarm keeps sounding

The nurse teaches a client who is going to have a plaster cast applied about the procedure. Which statement by the client indicates a need for further teaching? "The cast will give off heat as it dries." "I can bear weight on the cast in one-half hour." "The cast edges may be trimmed with a cast knife." "A stockinette will be placed over the leg area to be casted."

I can bear weight on the cast in one-half hour

The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching? "I will inspect my skin daily." "I can sit in my favorite chair all day." "I need to drink at least 2 liters of fluid daily." "I will make sure that my skin is clean and well moisturized."

I can sit in my favorite chair all day

A client with a short-leg plaster cast complains of an intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which client statement indicates an understanding of appropriate measures to relieve the itching? "I can use the blunt part of a ruler to scratch the area." "I can trickle small amounts of water down inside the cast." "I need to obtain assistance when placing an object into the cast for the itching." "I can use a hair dryer on the low setting and allow the cool air to blow into the cast."

I can use a hair dryer on the low setting

The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions? "I need to assess my skin for ring-shaped lesions." "I have to monitor for the presence of linear skin lesions." "I need to assess my skin for lesions that appear net-like." "I have to monitor for the presence of arc-shaped skin lesions."

I need to assess my skin for lesions that appear net-like

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? "I need to avoid getting the cast wet." "I need to cover the casted leg with warm blankets." "I need to use my fingertips to lift and move my leg." "I need to use something like a padded coat hanger end to scratch under the cast if it itches."

I need to avoid getting cast wet

A client has had a bone scan done. The nurse determines that the client demonstrates understanding of postprocedure care when the client makes which statement? "Flushing indicates a complication." "I should stay on liquids for a couple of days." "I need to ambulate every couple of hours faithfully for a few days." "I need to drink plenty of water for 1 to 2 days after the procedure."

I need to drink plenty of water for 1-2 days

The nurse has provided home care instructions to a client after dermabrasion. Which statement by the client indicates a need for further instruction? "I need to apply wet soaks to my skin." "I need to apply an emollient to my skin." "I need to keep my skin dry to allow it to heal." "I need to use sunscreen if I plan to be outdoors."

I need to keep my skin dry to allow it to heal

A client has undergone laser surgery to remove 2 nevi. The nurse determines that the client has understood discharge instructions if the client makes which statement? "I can expect significant discomfort after the procedure." "I need to cleanse the operated areas daily using scrubbing motions." "I need to protect the operated areas from direct sunlight for at least 3 months." "I need to report any signs of swelling or redness immediately to the primary health care provider."

I need to protect the operated areas from direct sunligh for at least 3 months

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? "I can resume regular exercise tomorrow." "I can't eat food for the remainder of the day." "I need to stay off the leg entirely for the rest of the day." "I need to report a fever or swelling to my orthopedic surgeon."

I need to report a fever or swelling

The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction? "I should use tepid water for bathing." "I need to keep my skin lubricated and cool." "After bathing, I should pat my skin dry rather than rubbing it." "I should apply a lubricant to my skin after bathing when my skin is thoroughly dry."

I should apply a lubricant to my skin after bathing when my skin is thoroughly dry

The nurse has given the client instructions about crutch safety. Which statement indicates that the client understands the instructions? Select all that apply. "I should not use someone else's crutches." "I need to remove any scatter rugs at home." "I can use crutch tips even when they are wet." "I need to have spare crutches and tips available." "When I'm using the crutches, my arms need to be completely straight."

I should not use someone else's crutches I need to remove scatter rugs I need to have spare crutches and tips

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? "I will use a straw for drinking." "I will drive only during the daytime." "I will be careful because the device alters balance." "I will wash the skin daily under the lamb's wool liner of the vest."

I will drive only during the daytime

A client has been experiencing muscle weakness over a period of several months. The primary health care provider suspects polymyositis. Which client statement correctly identifies a confirmation of test results and this diagnosis? "If I have polymyositis, there will be a decrease in elastic tissue." "I will know I have polymyositis if the muscle fibers are inflamed." "The primary health care provider said there would be more fibers and tissue with polymyositis." "The primary health care provider said if the muscle fibers were thickened, I would have polymyositis."

I will know I have polymyositis if the muscle fibers are inflamed

A client who sustained a severe sprain of the ankle is told by the primary health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions should the nurse anticipate will be included in the client's initial plan of care? Select all that apply. Ice bags Elevation Heating pad Compression bandage Range-of-motion exercises

Ice bags Elevation Compression bandages

Which teaching point is the priority when the nurse is teaching the client about caring for a plaster cast? The cast gives off heat as it dries. The client can bear weight on the cast in 1 hour. A stockinette and soft padding are put over the leg area before casting. Immediately report any increase in drainage or interruption in cast integrity.

Immediately report any increase in drainage or interruption in cast integrity

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? Out-of-bed activities Bathroom privileges Immobilization of the affected leg Placing the affected leg in a dependent position

Imobilization of the affected leg

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? Arterial insufficiency Impaired venous return Impaired arterial circulation The presence of an infection

Impaired venous return

A client is seen in the health care clinic 2 weeks after rhinoplasty. The client tells the nurse that the upper lip is numb. Which nursing response would be appropriate? "The numbness is normal and is likely to be permanent." "In many cases the nose and upper lip are numb for up to 6 months." "Numbness usually indicates nerve damage that occurred during the procedure." "You will need to see the primary health care provider because this may indicate a complication of the procedure."

In many cases the nose and upper lip are numb for up to 6 months

A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? Lack of control Lack of physical mobility Inability to entertain self Inability to maintain health

Inability to entertain self

The nurse is planning discharge teaching for a client admitted with a fracture of the leg that does not extend all the way through the bone. The nurse should include information about which types of fractures? Open Displaced Complete Incomplete

Incomplete

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? A fall and further injury Injury to the brachial plexus nerves Skin breakdown in the area of the axilla Impaired range of motion while the client ambulates

Injury to the brachial plexus nerve

The nurse is caring for a client with a hip fracture who has just been placed in Buck's traction. What intervention is most important for the nurse to perform? Ensure that the weight used as a pulling force is at least 20 lb (9 kg). Ensure that the weights rest on the floor and are not freely hanging. Inspect the skin at least every 8 hours for signs of irritation or inflammation. Remove the weights for at least 5 minutes every hour to give the client a rest.

Inspect the skin at least every 8 hours for sings of irritation or inflammation

A client has Buck's extension traction applied to the right leg. Which intervention should the nurse plan to prevent complications of the device? Give pin care once a shift. Inspect the skin on the right leg. Massage the skin of the right leg with lotion. Release the weights on the right leg for daily range-of-motion exercises.

Inspect the skin on the right leg

The nurse is assigned to care for a client who is in Buck's traction. The nurse prepares a plan of care for the client and includes which nursing action in the plan? Make sure that the knots are at the pulleys. Inspect the skin under the boot at least every 8 hours. Make sure the head of the bed is kept at a 45- to 90-degree angle. Monitor the weights to be sure that they are resting on a firm surface.

Inspect the skin under the boot

A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint? It is strained. It is contused. It has completely dislocated. It has incompletely dislocated.

It has incompletely dislocated

The nurse is providing an educational session to community members regarding Lyme disease. The nurse should provide what information regarding this disease? It is caused by a tick bite. It can be contagious by skin contact with an infected person. It can be caused by the inhalation of spores from bird droppings. It is caused by contamination from cat feces or the consumption of rare or raw meat.

It is caused by a tick bite

The nurse is preparing a client for an arthroscopy of the knee. When providing teaching, which information is essential for the nurse to include? It will drain fluid that has accumulated below the knee. It is used to obtain a muscle biopsy for pathology studies. It will determine the degree of range of motion of the joint. It will identify if there is joint injury and provide a route for surgical repair if indicated.

It will identify if there is a joint injury and provide a route for surgical repair if indicated

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. Keep the cast clean and dry. Allow the cast 24 to 72 hours to dry. Keep the cast and extremity elevated. Expect tingling and numbness in the extremity. Use a hair dryer set on a warm to hot setting to dry the cast. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.

Keep the cast clean and dry Allow the cast 24 to 72 hours to dry Keep the cast and extremity elevated

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? Allow the client to have full liquids. Give the client small glasses of clear liquids. Order the client a full meal tray with extra liquids. Keep the client on NPO (nothing by mouth) status.

Keep the client on NPO

A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse should include which interventions to maintain client safety after this procedure? Select all that apply. Use the overhead trapeze. Keep the head of the bed flat. Place pillows under the length of the legs. Use a logrolling technique for repositioning. Assist the client with eating meals and drinking fluids.

Keep the head of the bed flat Place pillows under the length of the legs Use a logrolling technique for repositioning Assist the client with eating meals and drinking fluids

The nurse is creating a plan of care for a client scheduled for a left total hip arthroplasty. Which interventions should the nurse include in the plan to prevent complications of the surgery? Select all that apply. Keep the leg slightly abducted. Teach leg exercises to the client. Use aseptic technique for wound care. Prevent hip flexion beyond 90 degrees. Keep the client's knees flexed whenever the client is in bed. Massage the legs daily to increase circulation and venous return.

Keep the leg slightly abducted Teach leg exercises to the client Use aseptic technique for wound care Prevent hip flexion beyond 90 degrees

The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. What should the nurse instruct the client to do? Wear the sling at nighttime. Keep a sling on the arm at all times. Avoid range-of-motion exercises to the affected arm. Lift the shoulder of the casted arm over the head periodically throughout the day.

Lift the shoulder of the casted arm over the head periodically throughout the day

The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure? Limit caffeine intake. Limit intake of vitamin D. Limit participation in activities such as walking and swimming. Limit protein in the diet because it contributes to the incidence of bone demineralization.

Limit caffeine intake

A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care to the fasciotomy site will be prescribed? Dry sterile dressings Hydrocolloid dressings Moist sterile saline dressings One-half strength povidone-iodine dressings

Moist-sterile saline dressing

The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? Brown-red macules with scales Pustules on the trunk of the body White patches noted on the elbows and knees Multiple straight or wavy thread-like lines underneath the skin

Multiple straight or wavy thread-like lines underneath skin

The presence of which finding leads the home health nurse to suspect infestation of a client with scabies? Patchy hair loss and round red macules with scales The presence of white patches scattered about the trunk Multiple straight or wavy, thread-like lines beneath the skin The appearance of vesicles or pustules with a thick honey-colored crust

Multiple straight or wavy, thread-like lines beneath the skin

A client is being discharged to home after spinal fusion with insertion of instrumentation (rod). The unit nurse should consult with the continuing care nurse regarding the need for modification of the home environment if the client makes which statement? "The bathroom has hand railings in the shower." "There are three steps to get up to the front door." "My family has rented a commode for me to use." "My bedroom and bathroom are on the second floor of my home."

My bedroom and bathroom are on the second floor of my home

The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first? Nails Hair follicles Pilosebaceous glands Epithelial layer of skin

Nails

The nurse is performing an assessment on a client with a diagnosis of pemphigus vulgaris. How should the nurse assess for the presence of Nikolsky's sign? Note a foul odor to the skin. Look for blisters that are draining. Look into the mouth for white patches. Note skin blistering and sloughing with finger pressure.

Note skin blistering and sloughing with finger pressure

A client who had a body cast applied 2 days earlier begins to complain of anorexia, nausea, and abdominal discomfort. The nurse should take which immediate action? Test the client's stool for guaiac. Notify the primary health care provider. Administer the prescribed as-needed antacid. Administer the prescribed as-needed antiemetic.

Notify HCP

A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? Sprained left ankle Decreased calcium intake Open trauma to the left leg Starting to smoke cigarettes

Open trauma to the left leg

The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? Sclera Oral mucosa Soles of the foot Palms of the hand

Oral mucosa

A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? pH Pao2 HCO3 Paco2

Pa02

The nurse is caring for a client who sustained an open fracture and is diagnosed with acute osteomyelitis of the right lower extremity. Which intervention should the nurse plan to perform? Apply ice to the affected area. Perform sterile dressing changes. Instruct the client on leg exercises. Measure the leg circumference daily.

Perform sterile dressing changes

The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? Contact the primary health care provider. Massage the skin at the edges of the cast. Petal the cast edges with appropriate material. Place a small facecloth in the cast around the edges of the cast.

Petal the cast edges with appropriate material

A client who has experienced a stroke has partial hemiplegia of the left leg. The nurse interprets that the client could benefit from the support and stability provided by which item? Quad cane Wheelchair Lofstrand crutch Aluminum crutch

Quad cane

The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. Physical therapy Knee immobilizer Aspiration of joint fluid Ambulation with a walker Anti-inflammatory medications

Physical therapy Knee immobilizer Aspiration of joint fluid Anti-inflammatory medications

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? Apply restraints to the client. Ask the family to stay with the client. Place a clock and calendar in the client's room. Ask the laboratory to perform electrolyte studies.

Place a clock and calendar in room

A client who has experienced nonunion of a fracture is scheduled for bone grafting using cadaver bone. The client appears restless and anxious about the procedure. After determining that the client understands the surgical procedure, the nurse should explore which item next? Concern about the level of postoperative pain The availability of assistance for the client after discharge Whether the client needs a PRN prescription for an antianxiety agent Potential worry about contracting hepatitis or possibly human immunodeficiency virus infection

Potential worry about hepatitis HIV infection

The nurse is assisting in performing a physical assessment of a right-handed client's musculoskeletal system. Which would be an abnormal finding? Presence of fasciculations Muscle strength of normal power Symmetrical movements bilaterally Hypertrophy of right upper arm of 1 cm

Presence of fasciculations

A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? Allows bony healing to begin before surgery and involves pins and screws Provides rigid immobilization of the fracture site and involves pulleys and wheels Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply. Pyrexia Elevated potassium level Elevated white blood cell count Elevated erythrocyte sedimentation rate Bone scan impression indicative of infection

Pyrexia Elevated WBC Elevated ESR Bone scan impression indicative of infections

The nurse is providing skin care instructions to a female client with acne vulgaris. What should the nurse instruct the client to do? Use oil-based cosmetics. Vigorously rub her face when washing it. Remove cosmetics from her face at bedtime. Wash her face once daily with an astringent cleanser.

Remove cosmetics from her face at bedtime

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? Return of distal pulses Brisk bleeding from the site Decreasing edema formation Formation of granulation tissue

Return of distal pulses

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? Apply ice to the site. Call the primary health care provider (PHCP). Rewrap the residual limb with an elastic compression bandage. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.

Rewrap the residual limb

A client has sustained a superficial skin tear to the arm. The nurse should apply which dressing as the best type of bandage for this wound? Dry sterile dressing Wet to dry dressing Gelfoam sponge dressing Semipermeable film dressing

Semipermeable film dressing

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? Hemorrhage Edema of the residual limb Slight redness of the incision Separation of the wound edges

Separation of the wound edges

The nurse is caring for a client admitted for a fractured hip status post fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted? Shortening and abduction Abduction and internal rotation Shortening and internal rotation Shortening and external rotation

Shortening and external rotation

A client is fearful about having an arm cast removed. Which action by the nurse would be the most helpful? Telling the client that the saw makes a frightening noise Reassuring the client that no one has had an arm lacerated yet Stating that the hot cutting blades cause burns only very rarely Showing the client the cast cutter and explaining how it works

Showing the client the cast cutter

The nurse is creating a plan of care for a client in skin traction. Which frequent assessment should the nurse include in the plan as a priority intervention? Urinary incontinence Signs of skin breakdown The presence of bowel sounds Signs of infection around the pin sites

Signs of skin breakdown

The nurse has given activity guidelines to a client with chronic low back pain. The nurse determines that the client understands the instructions if the client states to do which activities? Select all that apply. Lying prone Sitting using a lumbar roll or pillow Standing with one foot on a step or stool Lying on the side, with knees and hips straight Lifting objects that need to be carried above elbow level Leaning forward to reach objects, keeping the legs and knees straight

Sitting using a lumbar roll or pillow Standing with one foot on a step or stool

A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? Using a footboard Providing an overhead trapeze Slightly elevating the foot of the bed Slightly elevating the head of the bed

Slightly elevating the foot of the bed

The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure. Deep tissue injury Stage II pressure ulcer Stage III pressure ulcer Stage IV pressure ulcer

Stage IV pressure ulcer

A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item? A walker A wooden crutch A straight leg cane A Lofstrand crutch

Straight leg cane

The clinic nurse is performing an assessment on a client with a diagnosis of rheumatoid arthritis (RA). The nurse checks for which assessment finding that is associated with RA? Age of onset is generally 65 years of age or older Complaints of pain that is more severe after activity Systemic symptoms such as fatigue, anorexia, and weight loss Joint pain is asymmetrical and associated with past injuries to the joint

Systemic symptoms

A client has just been admitted to the hospital with a fractured femur and pelvic fractures. The nurse should plan to carefully monitor the client for which signs/symptoms? Fever and bradycardia Fever and hypertension Tachycardia and hypotension Bradycardia and hypertension

Tachycardia and hypotension

A client was admitted to the hospital 2 hours ago following multiple fractures to the pelvis and soft tissue injury to the abdomen. Diagnostic studies have ruled out perforation of abdominal organs. The nurse places highest priority on monitoring this client for which changes in vital signs? Fever, bradycardia Fever, hypertension Tachycardia, hypotension Bradycardia, hypertension

Tachycardia, hypotension

The nurse prepares to assist the primary health care provider to examine the client's skin with a Wood's lamp. Which should be included in the preprocedure plan of care? Shave the skin site. Prepare a local anesthetic. Obtain an informed consent. Tell the client that the procedure is painless.

Tell the client that the procedure is painless

The nurse is caring for a client diagnosed with a rotator cuff lesion. The nurse assesses the client knowing that the client most likely has which structure affected? Nerve Tendon Ligament Synovial fluid

Tendon

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the most reassurance by making which statement? "Canes prevent falls; they do not cause them." "The cane would help to break a fall, even if you do slip." "The cane has a flared tip with concentric rings to give stability." "The physical therapist will determine if the cane is inadequate."

The cane has a flared tip with concentric rings to give stability

The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? The client's fear related to the use of crutches The client's feelings about the restricted mobility The client's understanding of the need for increased mobility The client's vital signs, muscle strength, and previous activity level

The client's VS, muscle strenght, previous activity level

The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply. The exact cause of acne is unknown. Acne requires active treatment for control until it resolves. Oily skin and a genetic predisposition may be contributing factors for acne. Acne is an acute skin disorder that usually begins in puberty and is more common in females. The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules.

The exact cause of acne is unknown Acne requires active treatment for control until it resolves Oily skin and a genetic predisposition may be factors The types of lesions in acne include...

The nurse is caring for a client admitted for a torn meniscus. What is the focus of the nurse's immediate assessment? The hip The knee The ankle The great toe

The knee

Which information should the nurse include while providing education for a client scheduled for a rhinoplasty? General anesthesia is always administered. Packing will need to be removed in 1 week. Incisions are made around the outside of the nose. The nasal bone is fractured, and the cartilage and bone are remolded into the desired shape.

The nasal bone is fractured

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? The need for sensory stimulation The amount of home care support available The ability to perform activities of daily living The type of transportation available for follow-up care

The need for sensory stimulation

A client is having a plaster cast placed on the lower extremity that will extend from mid-thigh to the center of the foot. Which instruction should be given to the client before hospital discharge? How to petal the edges of the cast to prevent crumbling of these edges The need to notify the nurse if the plaster cast becomes warm during the first 24 hours The correct method of using a thin object when the client needs to scratch the area beneath the cast The need to notify the primary health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale

The need to notify the primary health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale

The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? The client's mobility status The renal and endocrine systems The cardiovascular and renal systems The neurological and respiratory systems

The neurological and respiratory systems

The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? The entire period of time during which rehabilitation occurs The period from the time the client is stable to the time when all burns are covered with skin The period from the time the burn was incurred to the time when the client is admitted to the hospital The period from the time the burn was incurred to the time when the client is considered physiologically stable

The period from the time the burn was incurred to the time when the client is considered physiologically stable

The nurse has been working with the client diagnosed with candidiasis (thrush). What should the nurse assess for in this client? The presence of blisters The presence of white patches The presence of purple patches The presence of numerous small, red, pinpoint lesions

The presence of white patches

The nurse is planning to teach the client with below-the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? The residual limb is washed gently and dried every other day. The socket of the prosthesis must be dried carefully before it is used. A residual limb sock must be worn at all times and changed twice a week. The socket of the prosthesis is washed with a harsh bactericidal agent daily.

The socket of the prosthesis must be dried carefully before it is used

The nurse is providing care for a client admitted 3 days ago with a severe left ankle contusion. The nurse determines that heat application to the area has been effective if which has occurred? Signs of infection are absent. The muscles are beginning to relax. Abscess formation has not occurred. There is reabsorption of blood noted at the injured site.

There is reabsorption of blood noted at the injured site

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? Redness around the pin sites Pain on palpation at the pin sites Thick, yellow drainage from the pin sites Clear, watery drainage from the pin sites

Thick, yellow drainage from the pin sites

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. Presence of striae Palpable radial pulses Absence of any ecchymosis on the extremities Thinner and decrease in number of reddish papules Scarce amount of silvery-white scaly patches on the arms

Thinner and decreased in number of reddish papules Scarce amount of silvery-white scaly patches on the arms

The nurse determines that a client's skeletal traction needs correction if which observation is made? Weights are not touching the floor. Weights are hanging free of the bed. Traction ropes rest against the footboard. Traction ropes are aligned in each pulley.

Traction ropes rest against the footboard

The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. Twisting of the spine Curvature of the spine Hyperflexion of the spine Sciatic nerve inflammation Degeneration of the facet joints Herniation of an intervertebral disk

Twisting of spine Hyperflexion of spine Herniation of intervertebral disk

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? Calcium level of 9.0 mg/dL (2.25 mmol/L) Uric acid level of 9.0 mg/dL (0.54 mmol/L) Potassium level of 4.1 mEq/L (4.1 mmol/L) Phosphorus level of 3.1 mg/dL (1.0 mmol/L)

Uric acid

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? Vital signs Urine output Mental status Peripheral pulses

Urine output

The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply. Use night-lights. Remove scatter rugs. Use staircase railings. Remove wall-to-wall carpeting. Place hand rails in the bathroom.

Use night-lights Remove scatter rugs Use staircase railings Place hand rails in the bathroom

The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? In 48 hours In 24 hours In approximately 8 hours Within 20 to 30 minutes of application

Within 20-30 minutes

The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? "Each treatment will last at least 30 minutes." "Your entire body will be exposed to the light treatment." "You will need to wear cotton clothes during the treatment." "You will need to wear dark eye goggles during the treatment."

You will need to wear dark goggles during treatment

The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information should the nurse include? "You will use full weight bearing by discharge." "You will use partial weight bearing by discharge." "You will use toe-touch weight bearing by discharge." "You will need to remain on bed rest even after discharge."

You will use full weight bearing by discharge

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? Dependent edema Diminished distal pulse Presence of a "hot spot" on the cast Coolness and pallor of the extremity

presence of a "hot spot"