NUR 326 exam 2
the nurse has given the patient instructions about crutch safety. which statement indicates that the patient understands the instructions? select all that apply
"I should not use someone else's crutches" "I need to remove any scatter rugs at home" "When I'm using the crutches, my arms need to be completely straight"
which of the following statements by a 25 year old female being discharged following a urinary tract infection (UTI) indicates an understanding of how to prevent future UTIs?
"I will be sure to void both before and after intercourse."
what is the best response to a patient with a recent BKA (below the knee amputation) that reports pain in amputated foot?
"on a scale of 0-10, how would you rate your pain?"
a 30 year old male client has just returned from the operating room after having a flap done following a motorcycle accident. the clients wife asks the nurse about the major complications following this type of surgery. what would be the nurses best response?
"the major complication is when the blood supply fails and the tissue in the flap dies." flap has a blood supply skin graft does not
a patient with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. the nurse anticipates which treatment will be done to relieve the obstruction? select all that apply
Insertion of a nephrostomy tube Placement of a ureteral stent with ureteroscopy
the nurse is caring for four patients. which patient does the nurse assess to be at greatest risk of developing a kidney stone?
Caucasian male who is obese
adequate intake of vitamin ______ is essential for absorption of calcium from the GI tract and for bone mineralization
D
which finding is a priority to report HCP about an 80 year old patient that fractured hip 3 days ago?
no bowel movement for 3 days
awakening at night to urinate
nocturia
urine output less than 0.5 ml/kg/hr
oliguria
the most prevalent bone disease in the world is ______
osteoporosis
a client diagnosed with a stasis ulcer has been hospitalized. there is an order to change the dressing and provide wound care. which activity should the nurse first perform when providing wound care?
perform hand hygiene
________ limb pain is described as a sensation that an amputated extremity is still present but is cramped or in an abnormal position
phantom
the nurse is assessing the casted extremity of a patient. which sign is indicative of infection?
presence of a "hot spot" on the cast
a clients blistering disorder has resulted in the formation of multiple lesions in the clients mouth. what intervention should the nurse include in the client plan of care?
provide chlorhexidine solution for rinsing the mouth
a patient 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 patient?
provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels
a nurse in a dermatology clinic is reading the electronic health record for a new client. the nurse notes that the client has a history of a primary skin lesion. what skin lesion may this client have?
pustule
inflammation of the renal pelvis
pyelonephritis
which clinical findings would be appropriate to report with a patient in skeletal traction?
redness at pin site resp rate is 22, up from 16 hrs ago abnormal lung sounds in LLL
excretion of glucose
renal glycosuria
low back pain that radiates down the leg suggests the presence of nerve root involvement known as __________
sciatica
a patient with diabetes has had a right below-the-knee amputation. given the patient's history of diabetes, which complication is the patient at most risk for after surgery?
separation of the wound edges
the degree of concentration of urine
specific gravity
the most common causative organism of osteomylitis is __________
staph a
alendronate is prescribed for a patient with osteoporosis and the nurse is providing instructions on administration of the medication. which instruction should the nurse provide?
take the medication with a full glass of water after rising in the morning
a nurse is working with a family whose 5-year-old daughter has been diagnosed with impetigo. what educational intervention should the nurse include in this family's care?
teaching about the importance of maintaining high standards of hygeine
a nurse is providing care for a client who has developed Kaposi sarcoma secondary to HIV infection. the nurse should be aware that this form of malignancy originates in which part of the body?
the endothelial cells lining the small blood vessels (dark colored from lining of blood vessels)
a principle of effective traction is that is must be continuous to reduce and immobilize fractures
true
compartment syndrome, a serious complication of casting/ splinting, occurs when increased pressure compromises blood flow
true
fracture pain, frequently described as sharp and piercing, is usually relieved by immobilization
true
nursing assessment of the patient following orthopedic surgery includes neurovascular status and tissue perfusion
true
osteosarcoma is the most common, and most often fatal, primary malignant bone tumor
true
symptoms of plantar fasciitis include acute heel pain experienced in the morning upon arising
true
the patient with a rotator cuff tear experiences pain and difficulty when performing activities that involve rising the arms about shoulder level
true
with an open fracture, the wound should be covered with a sterile dressing and no attempt should be made to reduce the fracture
true
what is a priority intervention for elderly patient to prevent complications of immobility?
turn, cough, deep breath every 2 hrs
end product of protein metabolism
urea nitrogen
spread of infection from urinary tract to the bloodstream
urosepsis
which of these nursing interventions are important to prevent complications of immobility in a patient with a fractured femur? select all that apply
use incentive spirometer every 2 hours while awake administer stool softener as ordered ROM on the unaffected extremities 2-3 times per day
The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take?
Stay with the victim and encourage him or her to remain still.
which patient is at highest risk to develop DVT?
a 60 year old in traction for a fractured hip
a nurse is planning the care for a patient with herpes zoster. what medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster?
acyclovir (antiviral)
priority intervention for post op knee replacement patient about to go to PT in 45 minutes?
administer pain meds as ordered
patients usually begin ______ one day following joint replacement surgery
ambulation
a client has just undergone surgery for malignant melanoma. which of the following nursing actions should be prioritized?
anticipate the need for, and administer, appropriate analgesic medications
urine output of less than 50 ml in 24 hrs
anuria
a nurse is doing a shift assessment on a group of clients after first taking report. an elderly client is having her second dose of IV antibiotics for a diagnosis of pneumonia. the nurse notices a new rash on the clients chest. the nurse should ask what priority question regarding the presence of a reddened rash?
are you allergic to any foods or medication?
a 22 year old male reports burning and difficult with urination. what priority question will the nurse ask?
are you sexually active?
this procedure allows direct visualization of a joint through the use of a fiberoptic endoscope
arthroscopy
abnormal concentration of nitrogenous waste products
azotemia
a public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. what action has the greatest potential to achieve this goal?
educating participants about the early signs and symptoms of skin cancer
nursing care for a patient in skeletal traction requires pin inspection at least every 24 hours for s/sx of inflam/ infection
false
a strain is an injury to ligaments supporting muscle fiber around a joint
false strain- muscle/ tendons sprain- ligaments
amount of plasma filtered through the glomeruli per unit of time
glomerular filtration rate
a client comes to the clinic reporting a red rash of small, fluid-filed blisters and in suspected of having herpes zoster. what presentation is most consistent with this diagnosis?
grouped vesicles in linear patches along a dermatome (nerve path)
a patient being measured for crutches asks the nurse why the crutches cannot rest underneath the arm for extra support. the nurse responds knowing that which most likely would result from this improper crutch measurement?
injury of the brachial plexus nerve
while waiting to see the physician a client shows the nurse skin areas that are flat, non palpable and have had a change of color. the nurse demonstrates that the client is demonstrating?
macules (flat, port wine stain)
what's the nurses priority for a patient that returns from OR after carpal tunnel repair?
monitor vital signs, including pulse oximetry
________ is death of a tissue secondary to poor perfusion and hypoxemia
necrosis
anything that destroys the kidney tissue
nephrotoxic
a client is diagnosed with atrial fibrillation and the physician orders warfarin. for what skin lesion should the nurse monitor this client?
ecchymosis (bruising)
The treatment of contusions, strains, and sprains consists of intermittent application of moist or dry cold packs for up to ____ hours after injury.
72
For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter?
74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice for end-of-life care
a diabetic patient has all of the following changes after a percutaneous nephrolithotomy procedure. which change is most important for the nurse to immediately report to the HCP?
Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula
a male patient has a tentative diagnosis of urethritis. the nurse should assess the patient for which manifestation of the disorder?
Dysuria and penile discharge
What would be considered a normal finding in the skin assessment of an older adult?
Uneven pigmentation
which patient is most likely to experience renal compromise assessed by decreased urine production?
blood pressure of 92/46 mmHg for 12 hours
A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?
by protecting older adults against shearing injuries
a client has just been diagnosed with psoriasis and frequently has lesions around his right eye. what should the nurse teach the client about topical corticosteroid use on these lesions?
cataract development is possible. because of steroids around eye, it's a side effect
the acronym RICE represents: rest, ice, ______, elevation and is treatment used for sprains and strains
compression
endogenous waste product of muscle energy metabolism
creatinine
inflammation of the bladder
cystitis
