NCLEX Challenge 9

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?

Administer antibiotics to the client.

A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet

Broccoli

A nurse is caring for a client who is 5 hr postop following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first

Check the tubing for kinks

A nurse is caring for a client in the ED. Select the 4 assessment findings on day 2 that require immediate follow up

HR, edema, urine color, and pedal pulses

A nurse is admitting a client who is about to undergo surgery for BPH. the client states, "I dont know what i will do if they find I have cancer" which of the following responses should the nurse make

I'm hearing that you are concerned that it might turn out that you have cancer

A nurse is talking to a client who is taking calcium supplement for osteoporosis. The client tells the nurse she is experiencing flank pain. Which of the following adverse effects should the nurse suspect?

Renal stones

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect

Report of feeling pressure, tenderness over the symphysis pubis, distended bladder, voiding 30 mL frequently

A nurse is providing education on priority setting framework to a group of newly licensed nurses. Which of the following statements should the nurse make regarding acute v. chronic priority setting framework

This framework guides care by recognizing conditions that can worsen rapidly. & this framework recognizes when client conditions have less time to adapt.

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

This service began with the client's admission to the hospital

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

increased RR from 18-44/min.

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching?

buck's extension traction will relieve muscle spasms

A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include?

examine the testicles after a bath or shower

A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

provide high-flow oxygen

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

wrap the residual limb with an elastic bandage in a figure-eight configuration

A nurse is teaching a client who is scheduled for dual energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching?

you will need to remove all jewelry before the test

During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse expect?

infection

A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil?

Isosorbide

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis

A nurse is teaching an older adult client who has osteoporosis abut beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

walking briskly

A nurse at an extended-care facility is instructing a class of AP's about the use of assistive devices during ambulation. Which of the following should the nurse give the AP's about the clients' use of a cane?

when the client moves, he should move the cane forward first

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

wrap the amputated finger in dry, sterile gauze. put the amputated finger in a sealed, waterproof plastic bag. prevent the amputated finger from contacting water.

A nurse is caring for a client who has a femur fracture. The nurse suspects that the client has fat embolism syndrome. Which of the following findings should the nurse identify as an early manifestation of fat embolism syndrome?

hypoxemia

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first

realign the clients position

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching?

report any worsening or unrelieved pain

A nurse is providing postop teaching with a client who had a surgical correction of hallux vagus. Which of the following information should the nurse include in the teaching?

rest frequently with your foot elevated

A nurse is assisting with a routine physical exam of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders

scoliosis

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching?

Take the medication with food

A charge nurse is instructing a newly hired nurse about the general guidelines of safety data sheets (SDS) within the facility. Which of the following statements should the charge nurse make?

The SDS contains every chemical that is listed within the facility, the SDS lists steps to take for chemical exposure, the SDS contains risks for chemical exposure

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

The client develops a lifethreatening situation

A nurse is caring for a client who is postop following repair of a right femur fracture.

The client is at risk for developing constipation due to their oxycodone prescription.

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

skeletal traction is more appropriate than skin traction for reducing a fracture

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postop placement of a prosthesis?

You will do special exercises in advance of getting your prosthesis

A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker

a client who requires placement in an assisted living facility, a client who requests to secure an emergency notification system in the home, a client who requests to get school assignments while hospitalized on a pediatric unit.

A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?

a synthetic cast weighs less

A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse?

speaking to me like that makes me uncomfortable

A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction?

body image changes

a nurse is planning care for a client who has dysphagia. The nurse should plan to request a referral to which of the following members of the health care team?

speech therapist

A nurse is caring for a client. For which of the following interprofessional team members should the nurse anticipate a provider's referral?

case manager, respiratory therapist, physical therapist, occupational therapist

A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?

checking capillary refill distal to the cast

A nurse is providing teaching to a client who has a new diagnosis of testicular cancer. Which of the following information should the nurse include in the teaching

close male relatives are at an increased risk for developing, testicular cancer typically occurs between ages 15 and 35

A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform

coordinator, evaluator, and energizer

A nurse is assessing a client who has Paget's dz of the bone. Which of the following findings should the nurse expect? Select all

cranial enlargement, skeletal pain, and waddling gait

A nurse is caring for an older adult client who has had a total hip arthroplasty.

culture of the drainage is indicated, cough and deep breath is indicated, abductor pillow is indicated, antiemetic is contraindicated, antibiotics are anticipated

A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?

hold the wrist at a 90 degree flexion

A nurse is teaching a client who has BPH and has a new prescription for finasteride. Which of the following instructions should the nurse include in the teaching?

decreased libido is an ADR of the medication

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?

decreased muscle mass

A nurse is caring for a client who has BPH. the nurse should expect which of the following findings

difficulty starting the flow of urine

A nurse is assessing a client who is in a body cast. Which of the following manifestations should the nurse identify as possible cast syndrome?

dilated pupils

A nurse is teaching a client who has a prosthetic limb due to a right below the knee amputation about prosthesis and stump care. which of the following instructions should the nurse include in the teaching?

dry the prosthesis socket completely before applying it to the limb

A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following is a trigger for the formation of vitamin D in the body

exposure to sunlight

A nurse is caring for a client who has multiple lone bone fractures caused by a MVA that happened 24 hours ago. The client tells the nurse he is SOB and experiencing chest pain. The nurse should assess the client further for which of the following potential complications

fat embolism syndrome

A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

fever

A nurse is caring for a client who is 3 days postop following an above-the-knee amputation. Which of the following actions should the nurse take?

have the client lie prone several times per day.

A nurse is teaching a client about the musculoskeletal system. The nurse should include that which of the following is a fluid filled capsule that enables movement and flexibility?

synovial joints

A nurse in a providers office is assessing a client who reports shoulder pain. Which of the following findings by the nurse indicates rotator cuff injury?

inability to abduct the arm at the shoulder

A nurse is providing an education program about dietary interventions to reduce the risk for prostate cancer. Which of the following information should the nurse include

increase fatty fish in the diet

A nurse is caring for a client who is prescribed bedrest. the POC indicates that the client should perform isometric exercises q2hr. Which of the following actions should the nurse take as directed by the POC

instruct the client to tighten muscle groups for a short period, and then relax.

A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following ADR should the nurse instruct the client to report to the provider? Select all that apply

jaw pain, blurred vision, and dysphagia

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the xray department. Which of the following actions should the nurse take

keep the drainage system below the level of the client's chest at all times

A nurse is teaching a newly licensed nurse about maintaining correct posture when transferring clients. Which of the following statements should the nurse make?

keep your back straight

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders

kyphosis

A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis?

localized erythema

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

lock the wheels of the bed and the wheelchair

A nurse is preparing to transfer a client who has left sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?

lock the wheels on the clients bed

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

maintain immobilization and alignment.

A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team

occupational therapist

A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his temporomandibular joint. Based of these findings, to which of the following providers should the nurse request a referral for the client?

oral surgeon

A nurse is caring for a client who is 2 hr postop following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?

output of burgundy colored urine

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first

pallor of the toes

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

perform a neurovascular assessment.

A nurse is caring for a client who is postop following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the post op period?

perform neurovascular checks of the extremities

A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome

positive phalen's signs

A nurse is caring for an adolescent who has metastatic osteosarcoma. While the parents are away, the adolescent asks the nurse if she is going to die. Which of the following responses should the nurse make

tell me more about what you are thinking

A nurse is teaching a client who is scheduled for a gallium bone scan of his knee. Which of the following instructions should the nurse include

the isotope is excreted in your stool following the test

A nurse is reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis

thyroid hormones

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

use a powered standing-assist lift

A nurse is providing discharge teaching about clean intermittent self-catherization for a client who has BPH. which of the following instructions should the nurse include?

use soap and water to wash the catheter after each use

A nurse is caring for a client who is 1 day postop following a transurethral resection of the prostate (TURP) and has a continous bladder irrigation in place. Which of the following actions should the nurse take?

use sterile technique when preparing the irrigation solution, ensure the drainage tubing is patent and without obstruction, notify the surgeon if the urine is bright red in appearance or has large clots.