MED SURG: chp45-46 ATI

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions should the nurse take? (Select all that apply.) A. Check continuous passive motion device settings. Palpate dorsal pedal pulses. C. Place a pillow under the knees. D.)Elevate heels off the bed. E. Apply heat therapy to the incision

A. check continuous passive motion device B. palpate dorsal pedal pulses D. elevate heels off bed

A nurse is contributing to the plan of care for a client who will undergo an electromyography (EMG). Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Check for bruising. B. Apply ice to insertion sites. C. Determine whether the client takes a muscle relaxant. D. Instruct the client to flex her muscles during needle insertion. E. Expect swelling, redness, and tenderness at the insertion sites.

A. check for bruising B. apply ice C. determine whether the pt takes a muscle relaxant D. instruct the pt to flex her muscles

A nurse is assisting with planning discharge teaching for a client who had a total hip arthroplasty. Which of the following instructions should the nurse include? (Select all that apply.) A. Clean the incision daily with soap and water. B. Turn the toes inward when sitting or lying. C) Sit in a straight-backed armchair. D. Bend at the waist when putting on socks. E. Use a raised toilet seat.

A. clean the incision daily C. sit in a straight backed armchair E. use a raised toilet seat

A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the following information should the nurse provide? (Select all that apply.) A. Clients who smoke should consider smoking cessation programs. B. Clients who have diabetes mellitus should maintain blood glucose within the expected reference range. C. Unplug electrical equipment when performing repairs. D. Clients who have vascular disease should maintain good foot care. E. Wait 2 hr after taking pain medication before driving.

A. clients who smoke B. clients who gave diabetes C. unplug electrical equipment D. clients who have vascular disease

A nurse is assisting with a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (Select all that apply.) A. Complete autologous blood donation. B. Sit in a low reclining chair. C. cross legs when in bed. D. Use an abductor pillow when turning. E. Perform isometric exercises.

A. complete autologous blood donation D. use an abductor pillow E. perform isometric exercises

A nurse is caring for a client following a below-the-elbow amputation. Which of the following actions should the nurse take? (Select all that apply.) A. Encourage dependent positioning of the residual limb. B. Inspect for presence and amount of drainage on the dressing. C. Implement shrinkage intervention of the residual limb. D. Wrap the residual limb in a circular manner using gauze E. Observe for body image changes.

A. encourage dependent B. inspect for presence and amount of drainage C. implement shrinkage E. observe for body image changes

A nurse is collecting data from an older adult client who has arteriosclerosis and is scheduled for a right lower extremity amputation. Which of the following are expected findings in the affected extremity? (Select all that apply.) A. Skin cool to touch from mid-calf to the toes B. Lower leg appearing dusky when client is sitting C. Palpable pounding pedal pulse D. Lack of hair on lower leg E. Blackened areas on several toes

A. skin cool to touch B. lower leg appearing dusty D. lack of hair E. blackened areas

A nurse is caring for a client who injured her lower back during a fall and describes sharp pain in her back and down her left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease her pain? A. Prone without use of pillows B. Semi-Fowler's with a pillow under the knees C. High-Fowler's with the knees flat on the bed D. Supine with the head flat

B. Semi-Fowler's with a pillow under the knees

A nurse is assisting in the admission of an older adult client who has suspected osteoporosis. Which of following findings should the nurse expect? (Select all that apply.) A. History of consuming one glass of wine daily B. Loss in height of 5.1 cm (2 in) E Body mass index (BMI) 21 D. Kyphotic curve at upper thoracic spine E. History of lactose intolerance

B. loss in height C. body mass D. kyphotic curve at upper spine E. history of lactose intolerance

A nurse is collecting data on a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (Select all that apply.) A. Skin reddened over the joint B. Pain when bearing weight C. Joint crepitus D. Swelling of the affected joint E. Limited joint motion

B. pain C. point crepitus D. swelling E. limited motion

A nurse is assisting in the care of a client immediately following vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? A. Apply heat to the puncture site. B. Place the client in a supine position. C. Turn the client every 1 hr. D. Ambulate the client within the first hour postprocedure.

B. place the client in a supine position

5. A nurse is assisting with preparing a plan of care to prevent a client from developing flexion contractures following a below-the-knee amputation 24 hr ago. Which of the following actions should the nurse include in the plan of care? A. Limit any type of exercise to the residual limb for the first 48 hr after surgery. B. Position the client prone several times each day C. Wrap the stump in a figure-eight pattern. D. Encourage sitting in a chair during the day.

B. position the pt prone

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? A. Age 78 years B. History of cancer C. Previous joint replacement D. Bronchitis 2 weeks ago

D. Bronchitis 2 weeks ago

4. A nurse is caring for a client who had an above-the-knee amputation. The client reports a sharp, stabbing type of phantom pain. Which of the following actions should the nurse take? A. Remove the initial pressure dressing. B. Encourage use of cold therapy. C. Question whether the pain is real. D. Administer an antiepileptic medication.

D. administer an antiepileptic med

A nurse is reinforcing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following foods should the nurse include in the instructions? A. White bread B. White beans C. White meat of chicken D. White rice

White beans

A nurse is assisting with health screenings at a health fair. The nurse should identify that which of the following clients are at risk for osteoporosis? (Select all that apply.) A. 40-year-old client who takes prednisone for asthma B. 30-year-old client who jogs 3 miles daily C. 45-year-old client who takes phenytoin for seizures D. 65-year-old client who has a sedentary lifestyle E. 70-year-old client who has smoked for 50 years

a. 40 year old c. 45 yr old d. 65 yr old e. 70 yr old

A nurse is collecting data from a client who has a casted compound fracture of the femur. The nurse should identify which of the following findings as a manifestation of fat emboli? A. Altered mental status B. Reduced bowel sounds C. Swelling of the toes distal to the injury D. Pain with passive movement of the foot distal to the injury

a. altered mental status

A nurse is reinforcing discharge teaching with a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include? A. Antibiotic therapy should continue for 3 months. B. Relief of pain indicates the infection is eradicated. C. Airborne precautions are used during wound care. D. Expect paresthesia distal to the wound.

a. antibiotic therapy should continue for 3 months

A nurse is reviewing information with a client who has osteoarthritis of the hip and knee. Which of the following instructions should the nurse reinforce? (Select all that apply.) A. Apply heat to joints to alleviate pain. B. Ice inflamed joints following activity. C. Install an elevated toilet seat. D. Take tub baths. E. Complete high-energy activities in the morning.

a. apply heat to joints to alleviate pain b. ice inflamed joints c. install an elevated toilet seat e. complete high-energy activities

A nurse is reinforcing teaching with a client who has a history of low- back injury. Which of the following instructions should the nurse reinforce with the client to prevent low-back pain? (Select all that apply) A. Engage in regular exercise, including walking. B. Sit for up to 10 hr each day to rest the back. C. Maintain weight within 25% of ideal body weight, D. Create a smoking cessation plan E. Wear low heeled shoes,

a. engage in regular exercises d. create a smoking cessation plan e. wear low-heeled shoes

A nurse is collecting data from a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Heberden's nodes B. Swelling of all joints C. Small body frame D. Enlarged joint size E. Limp when walking

a. heberdens nodes d. enlarged joint size e. limp when walking

1. A nurse is reinforcing teaching with a client about how to manage an external fixation device upon discharge. Which of the following client statements indicate understanding? (Select all that apply.) A. "I will clean the pins twice a day." B. "I will use a separate cotton swab for each pin." C.'I will report loosening of the pins to my doctor." D."I will clean the pins with tap water and antibacterial soap." E. "I will report increased redness at the pin sites."

a. i will clean the pins 2 times/day b. i will use a separate cotton c. i will report loosening of pins e. i will report increased redness

A nurse is collecting data from a client who had an external fixation device applied 2 hr ago for a fracture of the left tibia and fibula. The nurse should identify which of the following findings as manifestations of compartment syndrome? (Select all that apply.) A. Intense pain when the left foot is passively moved B. Capillary refill of 3 sec on the left toes C. Hard, swollen muscle in the left leg D. Burning and tingling of the left foot E. Client report of minimal pain relief following a second dose of opioid medication

a. intense pain c. hard, swollen muscle d. burning and tingling e. client report of minimal pain

A nurse is reinforcing discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include? (Select all that apply.) A. Remove throw rugs in walkways. B. Use prescribed assistive devices. C. Remove clutter from the environment. D. Walk with caution on icy surfaces. E. Maintain lighting of doorway areas.

a. remove throw rugs b. use prescribed assistive devices c. remove clutter e. maintain lighting

5. A nurse is caring for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate? A. Skeletal traction B. Buck's traction C. Halo traction D. Bryant's traction

b. bucks traction

A nurse is reviewing information about capsaicin cream with a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse reinforce? A. Continuous pain relief is provided. B. Inspect for skin irritation and cuts prior to application. C. Cover the area with tight bandages after application. D. Apply the medication every 2 hr during the day.

b. inspect for skin irritation and cuts