PNE 111/ Test 18,62, 63 & 66

Which nursing intervention is appropriate for monitoring the client for the development of Volkmann's contracture? Assess for paresthesia in the toes. Assess the radial pulse. Assess capillary refill in the toes. Assess mobility of the shoulder.

Assess the radial pulse. Explanation: Volkmann's contracture is a type of acute compartment syndrome that occurs with a supracondylar fracture of the humerus. The nurse assesses neurovascular function of the hand and forearm.

Which zone consists of the area where the injury is most severe and deepest? Coagulation Stasis Hyperemia Necrosis

Coagulation

The primary nursing interventions that will control swelling while treating a musculoskeletal injury is: Apply cold (moist or dry) Immobilize the injuries area. Elevate the affected area. Apply an elastic compression bandage.

Elevate the affected area

Which of the following actions should a nurse perform to help reduce the accumulation of debris within the burn wound? Use powder-free sterile gloves. Use topical antimicrobial medications. Use cold compresses or sponges. Use sterilized gauze swaps.

Use powder-free sterile gloves.

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement? "I'll stop taking my steroids when I get relief from my symptoms." "I'll make sure I get enough exposure to sunlight to keep up my vitamin D levels." "I'll make sure to monitor my body temperature on a regular basis." "I'll try to be as physically active as possible between flare-ups."

"I'll make sure to monitor my body temperature on a regular basis."

A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the clients injury when documenting? Fill in the blank with a number. 36 18 27 54

36

The nurse is caring for a patient after arthroscopic surgery for a rotator cuff tear. The nurse informs the patient that full activity can usually return after what period of time? 3 to 4 weeks 8 weeks 3 to 4 months 6 to 12 months

6 to 12 months

A client is to undergo surgery to repair a ruptured Achilles tendon and application of a brace. The client demonstrates understanding of activity limitations when stating that a brace must be worn for which length of time? 2 to 4 weeks 6 to 8 weeks 10 to 12 weeks 14 to 16 weeks

6 to 8 weeks

A nurses assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up" The nurse should plan care based on the belief that the client has experienced what injury? A first-degree strain A second-degree strain A first degree sprain A second-degree sprain

A second-degree strain Explanation: A strain, or a "pulled muscle," is an injury to a musculotendinous unit caused by overuse, overstretching, or excessive stress. A sprain is an injury to the ligaments and supporting muscle fibers that surround a joint often caused by a trauma, wrenching or twisting motion.

The surgical nurse is admitting a client from postanesthetic recovery following the clients below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside? A tourniquet A syringe preloaded with vitamin K A unit of packed red blood cells, placed on ice A dose of protamine sulfate

A tourniquet Explanation: Following an amputation, immediate postoperative bleeding may develop slowly or may take the form of massive hemorrhage resulting from a loosened suture. A large tourniquet should be in plain sight at the client's bedside so that if severe bleeding occurs, it can be applied to the residual limb to control the hemorrhage. The nurse immediately notifies the surgeon in the event of excessive bleeding.

During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6m) tall. The client states "How is that possible" I was always 5 feet 1/2? (1.7 m) tall. "which statement is the best response by the nurse? After age 40, height may show a gradual decrease as a result of spinal compression. After menopause the body bone density declines. Resulting in a gradual loss of height. There may be some slight discrepancy between the measuring tools used. The posture begins to stoop after middle age

After menopause the body bone density declines. Resulting in a gradual loss of height.

What special elements of care should be incorporated into the care of a client in traction? Select all that apply All of the answers are true. Provide simple and direct explanations about the traction and its purpose. Point out activities that are allowed or contraindicated. When traction is discontinued prepare the client further treatment, such as casting, and for the appearance of the affected area-skin muscles.

All of the answers are true.

A client comes to the emergency department complaining of localized pain and swelling of the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. Which of the following would the nurse suspect as most likely? Fracture Contusion Sprain Strain

Contusion Explanation: A contusion is a soft tissue injury produced by blunt force, such as a blow, kick, or fall, that results in bleeding into soft tissues (ecchymosis, or bruising). A hematoma develops when the bleeding is sufficient to form an appreciable solid swelling

A client comes to the orthopedic clinic and reports having pain that radiates down her forearm and being unable to grasp objects firmly. What does the nurse suspect is occurring with the client? Carpal tunnel syndrome Ganglion cyst Epicondylitis Shoulder dislocation

Epicondylitis

A woman with a family history of breast cancer received a positive result on a breast tumor marking test and is requesting a bilateral mastectomy. This surgery is an example of which type of oncologic surgery? Salvage surgery Reconstructive surgery Palliative surgery Prophylactic surgery

Prophylactic surgery Explanation: Prophylactic surgery is used when there is an extensive family history and nonvital tissues are removed. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach. Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulceration, obstruction, hemorrhage, pain, and malignant effusion. Reconstructive surgery may follow curative or radical surgery in an attempt to improve function or obtain a more desirable cosmetic effect.

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what actions? Select all that apply. Regular bone density testing A high-calcium diet Use of corticosteroids as prescribed Weight-bearing exercise Use of falls prevention precautions

Regular bone density testing A high-calcium diet Weight-bearing exercise Use of falls prevention precautions

A client was burned in a home accident. The ED physician indicated the clients wound, with proper care, should heal within 2 weeks. How was this clients wound classified? Second degree First degree Third degree Fourth degree

Second degree

The nurse is caring for a client with a benign breast tumor. The tumor may have which characteristic? Causes generalized symptoms Undifferentiated cells Slow rate of growth Ability to invade other tissues

Slow rate of growth Explanation: Benign tumors have a slow rate of growth and well-differentiated cells. Benign tumors do not invade surrounding tissue and do not cause generalized symptoms unless the location of the tumor interferes with the functioning of vital organs.

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. Which of the following risk factors should the educator describe? Small frame and female sex Recurrent infections and prolonged use of NSAIDs Male sex, diabetes, and high protein intake High alcohol intake and low body mass index

Small frame and female sex

A client is brought to the emergency department by ambulance after stepping into a hole and falling. While assessing the client the nurse notes that the client's right leg is shorter than the left leg; the right hip is noticeably deformed and the client is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for the clients signs and symptoms? Subluxated right hip Right hip contusion Hip strain Traumatic hip dislocation

Traumatic hip dislocation

The nurse is caring for a client with ankylosing spondylitis. Which educational information will the nurse provide to this client?

Use of analgesics Use of laxatives Use of cough suppressants Use of diuretics Use of analgesics

A client with fibromyalgia asks why physical therapy has been prescrived. Which response will the nurse make? It will take your mind off your health problems. I will ask the health care provider if it is necessary. It is used instead of prescribing medication for the condition. It will help the overall deconditioning that has occurred.

It will help the overall deconditioning that has occurred.

A nurse is preparing to discharge a client from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage what action? Keep an elastic compression bandage on the ankle. Exercise hourly by performing rotation exercises of the ankle. Maintain the ankle in a dependent position. Apply heat for the first 24 to 48 hours after the injury.

Keep an elastic compression bandage on the ankle. Explanation: Treatment of a sprain consists of resting and elevating the affected part, applying cold, and using a compression bandage. After the acute inflammatory stage (usually 24 to 48 hours after injury), heat may be applied intermittently. Rotation exercises would likely be painful.

An older adult with rheumatoid arthritis limits going out with others because of the need to use a cane. Which response will the nurse make to this client? It must be hard to get older Everyone will get older at sometime Invite people over to your home instead Look at the cane as maintaining your independence

Look at the cane as maintaining your independence

Which is not one of the general nursing measures employed when caring for the client with a fracture? providing comfort measures assisting with ADLs administering analgesics cranial nerve assessment

cranial nerve assessment Explanation: Cranial nerve assessment would only be carried out for head-related injuries or diseases. General nursing measures include administering analgesics, providing comfort measures, assisting with ADLs, preventing constipation, promoting physical mobility, preventing infection, maintaining skin integrity, and preparing client for self-care.

The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply. dietary substances environmental factors viruses gender age

dietary substances environmental factors viruses Explanation: Carcinogens include chemical agents, environmental factors, dietary substances, viruses, lifestyle factors, and medically prescribed interventions. Although age and gender may increase a person's risk for developing certain types of cancer, they are not carcinogens in and of themselves.

A client has experienced a fracture. Place in the correct order the steps in bone healing that the nurse will explain to the client to prepare her for what to expect. A callus with bone cells forms. Osteoblasts form as the clot retracts. A procallus forms and stabilizes the fracture. Blood seeps into the area and a hematoma forms. Osteoblasts begin to remodel the fracture site.

Blood seeps into the area and a hematoma forms. Osteoblasts form as the clot retracts. A procallus forms and stabilizes the fracture. A callus with bone cells forms. Osteoblasts begin to remodel the fracture site.

The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about? Methotrexate Celecoxib Methylprednisolone Mercaptopurine azathioprine

Methotrexate

The nurse instructs a client receiving chemotherapy on actions to prevent the development of stomatitis. Which client statement indicates to the nurse that teaching has been effective? "I will reduce smoking to after meals only." "I will limit alcoholic beverages to one a day." "I will eat spicy foods with a cool beverage." "I will brush my teeth after every meal."

"I will brush my teeth after every meal."

An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain? Administer prescribed analgesics around-the-clock. Avoid administering too much medication because the client is older. Administer prescribed pain medication only when the client requests it. Give pain medication to the client after providing care.

Administer prescribed analgesics around-the-clock.

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A middle-aged adult who takes ibuprofen daily for rheumatoid arthritis. An older adult client with an infected pressure ulcer in the sacral area. A 17-year-old football player who had orthopedic surgery 6 weeks prior. An infant diagnosed with jaundice.

An older adult client with an infected pressure ulcer in the sacral area

When teaching a client how to prevent low back pain as a result of lifting, the nurse should instruct the client to: Avoid overreaching. Place the load away from the body Use a narrow base of support Bend the knees and loosen the abdominal muscles

Avoid overreaching.

A patient has stepped into a hole in the yard, causing an ankle injury. The ankle is edematous and painful to palpatate. How long should the nurse inform the patient that the acute inflammatory stage will last? Less than 24 hours. Between 24 and 48 hours. About 72 hours. At least 1 week.

Between 24 and 48 hours

Which of the following is the first line medication that would be used to treat and prevent osteoporosis? Bisphosphonates Calcitonin Selective estrogen receptor modulators Anabolic agents

Bisphosphonates

A client with a recent left above-the-knee amputation states, I can feel pain in my left toes. Which is the best response by the nurse? Your left toes have been amputated. The pain is really from the nerves in the upper leg. Pain medication usually does not help this type of pain. Describe the pain and rate it on the pain scale.

Describe the pain and rate it on the pain scale.

A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make? It reduces the risk of complications from an infection. It reduces the amount of scarring that will occur on the skin. It reduces the amount of wound care that you will need as the skin heals. It encourages your bodys natural processes to liquefy any damaged tissue.

It reduces the risk of complications from an infection.

A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis? High chloride, calcium and magnesium levels High parathyroid and calcitonin levels Low serum calcium and magnesium levels Low serum calcium and low phosphorus level

Low serum calcium and low phosphorus level

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool? Rule of nines Lund and Browder method Hand method Parkland formula method

Lund and Browder method

A client has been admitted to the hospital for the treatment of gout. Which is not an appropriate nursing care activity for a gout client? Apply heat for pain Place a bed cradle over the affected joint to protect it from the pressure of the bed linen If colchicine is prescribed, administer hourly until side effects or acute pain subsides. Instruct the client to report gastrointestinal symptoms

Apply heat for pain

A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client? Presence of soot around nasal passages Fracture of the fibula with displacement Elevation of blood pressure and heart rate Partial-thickness burns to hands and wrists

Presence of soot around nasal passages

An oncologist advises a client with an extensive family history of breast cancer to consider a mastectomy. What type of surgery would the nurse include in teaching? Cryosurgery Prophylactic Local excision Palliative

Prophylactic surgery Explanation: Prophylactic surgery is used when there is an extensive family history and nonvital tissues are removed. Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulceration, obstruction, hemorrhage, pain, and malignant effusion

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the clients change in status be best understood. The client is likely experiencing a delayed onset of respiratory complications. The client has likely developed a systemic infection. The clients respiratory complications are likely related to psychosocial stress. The client is likely experiencing an anaphylactic reaction to a medication.

The client is likely experiencing a delayed onset of respiratory complications.

A client has presented to the emergency department with an injury to the wrist. The client is diagnosed with a third-degree strain. Why would the health care provider prescribe an x-ray of the wrist? Nerve damage is associated with third-degree strains. Compartment syndrome is associated with third-degree strains. Avulsion fractures are associated with third-degree strains. Greenstick fractures are associated with third-degree strains

Avulsion fractures are associated with third-degree strains.

A client with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location rules out the use of enteral feeding. What intervention will best meet this clients nutritional needs? Administration of parenteral feeds via a peripheral IV. Parenteral nutrition given via a peripherally inserted central catheter. Insertion of an NG tube for administration of feeds. Maintaining NPO status and IV hydration until treatment completion.

Parenteral nutrition given via a peripherally inserted central catheter.

While performing a clients ordered would care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the numbers technique. How should the nurse best interpret this clients behavior? The client may be experiencing an adverse drug reaction that is affecting cognition and behavior. The client may be experiencing neurologic or psychiatric complications of the clients injuries. The client may be experiencing inconsistencies in the care being provided. The client may be experiencing anger about current circumstances that the client is deflecting towards the nurse.

The client may be experiencing anger about current circumstances that the client is deflecting towards the nurse.

The results of a 22-year-old college students most recent Papanicolaou (Pap) test are suggestive of cervical cancer. Since learning of this news, the client has asked numerous questions of all members of the health care team about how she could have gotten cancer. What client teaching should the nurse at the clinic prioritize in this patients care? Environmental influences on the etiology of genitourinary cancers The relationship between viruses and cervical cancer Genetic and familial factors in the development of cervical cancer The role that the immune system normally plays in preventing cancer

The relationship between viruses and cervical cancer

The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse? Random, rapid growth of the tumor Cells colonizing to distant body parts Tumor pressure against normal tissues Emission of abnormal proteins

Tumor pressure against normal tissues Explanation: Benign tumors grow more slowly than malignant tumors and do not emit tumor-specific antigens or proteins. Benign tumors do not metastasize to distant sites. Benign tumors can compress tissues as it grows, which can result in impaired organ functioning.

The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of graft-versus-host disease. metastasis. nadir. acute leukopenia.

graft-versus-host disease.

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: fluid resuscitation. infection. pain management. body image.

pain management. Explanation: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is "You will experience menopause now." "You will continue having your menses every month." "You will be unable to have children." "You will need to practice birth control measures."

You will need to practice birth control measures." Explanation: Following chemotherapy female clients may experience normal ovulation, early menopause, or permanent sterility. Clients are advised to use reliable methods of birth control until reproductivity is known.

The nurse is caring for a client with ankylosing spondylitis (AS). Which medication will the nurse expect to be prescribed for this client? Antibiotics Anticoagulants Oral corticosteroids Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs)

A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall? Impacted fracture Transverse fracture Compound fracture Pathologic fracture

Pathologic fracture

The nurse is assisting with an examination of a client suspected of having carpal tunnel syndrome. The physician has the client flex the wrist for 30 seconds and percusses the median nerve. The client complains of pain and numbness when this is done. What does the nurse know this positive sign is documented as? Tinel sign Phalen sign Crepitus Spasm

Phalen sign

Which of the following laboratory findings, would be identified by the nurse as the greatest risk for a cancer client scheduled for implantable port? White blood cell count 10,800/mm3 Hemoglobin 10 g/dl Platelet count 98,000/mm3 Hematocrit 36.0%

Platelet count 98,000/mm3 Explanation: Although the WBC, HGB, and HCT are all slightly outside the normal range, the platelet count is very low and places the client at risk for bleeding. This is especially a concern with a surgical procedure.

With fractures of the femoral neck, the leg is? Shortened, adducted and externally rotated. Shortened, abducted, and internally rotated. Abducted and internally rotated. Abducted and externally rotated.

Shortened, adducted and externally rotated.

A nurse is caring for a client in the emergent//resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? Sodium deficit Decreased prothrombin time (PT) Potassium deficit Decreased hematocrit

Sodium deficit

A client is taking ibuprofen for the treatment of osteoarthritis. What education will the give the client about the medication? Take the medication on a empty stomach in order to increase effectiveness. Since the medication is able to be obtained over the counter. It has few side effects. Take the medication with food to avoid stomach upset. Inform the health care provider if there is ringing in the ears.

Take the medication with food to avoid stomach upset.

A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears and audible click when the client is moving the jaw. What does the nurse suspect may be happening? Trigeminal neuralgia Temporomandibular disorder Loose teeth Dislocated jaw

Temporomandibular disorder

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for grain-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the clients burns. The nurse provides information to the client about medication. Which statement made by the client indicated an understanding about this treatment? Select all that apply. This medication is an antibacterial. this medication will be applied directly to the wound. This medication will stain my skin permanently. This medication will help my burn heal.

This medication is antibacterial. this medication will be applied directly to the wound. This medication will help my burn heal.

A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery? Removing the tumor is a primary treatment for colon cancer. This surgery will prevent further tumor growth. Once the tumor is removed, cell pathology can be determined. Tumor removal will promote comfort.

Tumor removal will promote comfort.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg. Urine output of 20 ml/hour. White pulmonary secretions. Rectal temperture of 100.4 F (38 C).

Urine output of 20 ml/hour.

A client who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? Client can perform activities of daily living independently. Client has a healed, nontender, nonadherent scar. Client is free of pain. Client can demonstrate safe use of assistive devices.

Client can demonstrate safe use of assistive devices. Explanation: A client should be able to use assistive devices appropriately and safely prior to discharge. Scar formation will not be complete at the time of hospital discharge. It is anticipated that the client will require some assistance with ADLs post discharge. Pain should be well managed, but may or may not be wholly absent.

A client is admitted to the emergency room after being hit by a care while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention? Compound Greenstick Oblique Spiral

Compound Explanation: A compound fracture is one in which the skin or mucous membrane wound extends to the fractured bone. A complete fracture involves a break across the entire cross section of the bone and is frequently displaced. An incomplete fracture involves a break through only part of the cross section of the bone. A simple fracture is one that does not cause a break in the skin.

A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? Use your continuous passive motion machine for 2 hours each day. You need to perform weight bearing exercises twice a week. You need to limit the amount of protein and calcium in your diet. You will receive IV antibiotics for 3 to 6 weeks.

You will receive IV antibiotics for 3 to 6 weeks.

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern? Zone in burn center Zone of coagulation Zone of hyperemia Zone of stasis

Zone of stasis

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? "I take a stool softener every morning." "I use an electric razor to shave." "I floss my teeth every morning." "I removed all the throw rugs from the house."

"I floss my teeth every morning." Explanation: A client with a platelet count of 30,000/mm3 is at risk for bleeding and shouldn't floss his teeth. Flossing may increase the risk of bleeding in a client with a platelet count less than 40,000/mm3. Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving. Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? Are the victims suffering from thermal burns? How many victims are anticipated for transport? Are the burns associated with chemicals used in the plant? Are any of the victims expected to have electrical burns?

Are the burns associated with chemicals used in the plant?

While administering an intravenous chemotherapeutic medication to a client, the nurse assesses swelling at the insertion site. What is the nurses first action? Administer a neutralizing solution. Apply a warm compress. Aspirate as much of the fluid as possible. Discontinue the intravenous medication.

Discontinue the intravenous medication. Explanation: chemotherapeutic vesicants can cause severe tissue damage. The nurse should stop the administration of the drug immediately and then notify the patient's health care provider. Ice can be applied to the site once the drug therapy has stopped.

A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply Wound care Nutritional support Fluid loss Fluid shift Hypotension

Fluid loss Fluid shift Hypotension

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? Ineffective airway clearance related to edema of the respiratory passages. Impaired physical mobility related to the disease process. Disturbed sleep pattern related to facility environment. Risk for infection related to breaks in the skin

Ineffective airway clearance related to edema of the respiratory passages.

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? Family history Preexisting conditions Age Weight

Preexisting conditions Explanation: Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? Administration of beta adrenergic blockers Choosing appropriate splints and functional devices Prevention of venous thromboembolism Maintenance of bed rest to aid healing

Prevention of venous thromboembolism Explanation: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what actions? Select all that apply. Weight-bearing exercise A high-calcium diet Regular bone density testing Use of corticosteroids as prescribed Use of falls prevention precautions

Regular bone density testing A high-calcium diet Use of falls prevention precautions Weight-bearing exercise Explanation: Health promotion measures after an older adult's hip fracture include weight-bearing exercise, promotion of a healthy diet, falls prevention, and bone density testing. Corticosteroids have the potential to reduce bone density and increase the risk for fractures.

At the scene of a fire, the first priority is to prevent further injury. Which are interventions at the site that cane help to prevent injury? Select all that apply Roll the client in a blanket to smother the fire Place the client in a horizontal position Place the client in a verticle position Open a door and encourage air in an enclosed space

Roll the client in a blanket to smother the fire Place the client in a horizontal position Explanation: At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication? Bone fracture Loss of estrogen Negative calcium balance Dowager hump

Bone fracture Explanation: Bone fracture is a major complication of osteoporosis; it results when loss of calcium and phosphate increases the fragility of bones. Estrogen deficiencies result from menopause — not osteoporosis. Calcium and vitamin D supplements may be used to support normal bone metabolism, but a negative calcium balance isn't a complication of osteoporosis. Dowager's hump results from bone fractures. It develops when repeated vertebral fractures increase spinal curvature.

The hospice nurse has just admitted a new client to the program. What principle guides hospice care? The care team prioritizes the client's physical needs and the family is responsible for the client's emotional needs. Care is focused on the client centrally and the family peripherally. Care addresses the needs of the client as well as the needs of the family. The focus of all aspects of care is solely on the client.

Care addresses the needs of the client as well as the needs of the family. Explanation: The focus of hospice care is on the family as well as the client. The family is not solely responsible for the client's emotional well-being.

The nurse manager is orienting a new nurse to the oncology unit. When reviewing the safe administration of antineoplastic agents, which action should the nurse manager emphasize? Use gloves and a lab coat when preparing the medication. Wash hands with an alcohol-based cleanser following administration. Dispose of the antineoplastic wastes in the hazardous waste receptacle. Adjust the dose to the client's present symptoms.

Dispose of the antineoplastic wastes in the hazardous waste receptacle. Explanation: The nurse should use surgical gloves and disposable long-sleeved gowns when administering antineoplastic agents. The antineoplastic wastes are disposed of as hazardous materials. Dosages are not adjusted on a short-term basis. Hand and arm hygiene must be performed before and after administering the medication.

A high school student who was injured in a football game presents with knee pain with internal rotation of the foot. Which interventions are appropriate nursing actions? Select all that apply Administer morphine sulfate Elevate the affected leg Apply ice packs to the affected knee Assist the client to Walk off the pain Apply a knee brace or wrap the affected knee

Elevate the affected leg Apply ice packs to the affected knee Apply a knee brace or wrap the affected knee

The nursing caring for a client who is recovering from full-thickness burns is aware of the clients risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? Apply skin emollients as prescribed after granulation has occurred. Keep injured areas immobilized whenever possible to promote healing. Administer oral or IV corticosteroids as prescribed. Encourage physical activity and range of motion exercises.

Encourage physical activity and range of motion exercises.

The nurse is planning an education program for women of childbearing years. What does the nurse recognize as the primary prevention of osteoporosis? Engaging in non-weight bearing exercise daily. Ensuring adequate calcium and vitamin D intake. Undergoing assessment of serum calcium levels every year. Having a DXA beginning at age 35 years.

Ensuring adequate calcium and vitamin D intake.

A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis? Ensuring adequate exposure to sunlight Eating a low-purine diet Performing cardiovascular exercise while avoiding weight-bearing exercises Taking thyroid supplements as prescribes.

Ensuring adequate exposure to sunlight

A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). Which skin manifestation would the nurse expect to observe on inspection? Petechia Erythematous rash Jaundice Skin sloughing

Erythematous rash

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? Avascular necrosis of bone Compartment syndrome Fat embolism syndrome Complex regional pain syndrome

Fat embolism syndrome Explanation: Fat embolism syndrome occurs most frequently in young adults and elderly clients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.

A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? Autografts Heterografts Homografts Xenografts

Homografts

A client with a recent history of GI disturbance has been scheduled for a barium study. The physician ordered this particular test for this client because it will: show movement of the GI tract. show tumor "hot spots" in the GI tract. provide a three-dimensional cross-sectional view. remove a tissue sample from the GI tract.

show movement of the GI tract. Explanation: A barium study is an example of fluoroscopy, which is used to show continuous x-ray images on a monitor, allowing the movement of a body structure to be viewed. Fluoroscopy does not involve the biopsy of tissue samples. Nuclear imaging, not a barium study, uses IV tracers to reveal tumor hot spots. CT scans provide three-dimensional cross-sectional views of tissues to determine tumor density, shape, size, volume, and location as well as highlighting blood vessels that feed the tumor

A patient with a diagnosis of renal cell carcinoma is being treated with chemotherapy. During a previous round of chemotherapy, the patient's tumor responded well to treatment but the chemotherapy caused intense nausea and vomiting. How should the patient's potential nausea and vomiting be addressed during this current round of treatment? Prioritize nonpharmacological treatments over medications. Administer antiemetics if the patient vomits or believes he will soon vomit. Administer antiemetics in anticipation of the patient's nausea. Provide the patient with antiemetics at his first complaint of nausea.

Administer antiemetics in anticipation of the patient's nausea. Explanation: The prevention of chemotherapy-induced nausea and vomiting is a priority. It is inappropriate to reject pharmacological treatments or to wait until the patient experiences nausea and/or vomiting before providing medication.

A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug? I have a ringing in my ears that just wont go away. I feel so foggy in the mornings and it take me so long to wake up. When I eat a meal thats high in fat, I get really nauseous. I seem to have lost my appetite which is unusual for me.

I have a ringing in my ears that just wont go away.

An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the client of the diagnosis or to keep it quiet. Which is the best response from the nurse? "This is a private concern that should include the physician, not me." "The shock of learning the diagnosis may be too much stress for an elderly person." "I wouldn't tell, if I were you." "In my experience, clients who know are more likely to be involved with their plan of care."

In my experience, clients who know are more likely to be involved with their plan of care." Explanation: Sharing known facts that can enhance client care is advocating for the client and family. Clients do have the right to know their diagnosis so informed decisions can be made. Comments of not telling or saying it would be too much stress on the client are a reflection of personal opinion of the nurse, and opinions should be avoided. Stating the diagnosis is a private concern and did not involve the nurse may leave the family feeling as if the nurse is cold and uncaring.

The nurse is caring for a client who has just been told that stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the client the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer? Salvage Prophylactic Palliative Reconstructive

Palliative Explanation: When cure is not possible, the goals of treatment are to make the client as comfortable as possible and to promote quality of life as defined by the client and family. Palliative surgery is performed in an attempt to relieve complications of cancer, such as ulceration.

A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action? Have visitors wear dosimeters for safety. Place a chair next to the bed to allow the spouse to sit. Allow visitors to telephone only. Place the client in a private room.

Place the client in a private room. Explanation: Safety precautions are used for the client with a radioactive implant. They include assigning the client to a private room, seeing that visitors maintain a 6-foot distance from the radiation source, prohibiting visits by children, and preventing exposure to those who may be or are pregnant. Staff needs to wear dosimeters. Family may visit for up to 30 minutes per day.

The nurse is providing education to a client that is scheduled for mechanical debridement of a wound. The nurse knows that mechanical debridement involves which element? A spontaneous separation of dead tissue from the viable tissue. Removal of eschar until the point of pain and bleeding occurs. Shaving of burned skin layers until bleeding, viable tissue is revealed. Early closure of the wound.

Removal of eschar until the point of pain and bleeding occurs.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The are of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: Stasis Coagulation Hyperemia Hypotension

Stasis

After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority? Imbalanced nutrition: Less than body requirements Anxiety Risk for injury Risk for infection

Risk for infection Explanation: Risk for infection takes highest priority in clients with severe bone marrow depression because they have a decrease in the number of white blood cells, the cells that fight infection. Making clients aware that they are at risk for injuries can help prevent such injuries as falls. The nurse should institute the facility's falls prevention protocol and supply assistive devices, such as a walker, cane, or wheelchair, when needed. Imbalanced nutrition: Less than body requirements is also of concern but doesn't take priority over preventing infection. Anxiety is likely present in clients with severe bone marrow depression; however, anxiety doesn't take priority over preventing infection.

A client with rheumatoid arthritis comes to the clinic reporting pain in the joint of his great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize? Take OTC calcium supplements consistently. Restrict consumption of foods high in purines. Ensure fluid intake of at least 4L per day. Restrict weight-bearing on right foot.

Restrict consumption of foods high in purines.

When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care? Time, distance, and shielding Inspect the skin frequently. Avoid showering or washing over skin markings. The use of disposable utensils and wash cloths

Inspect the skin frequently. Explanation: Inspecting the skin frequently will allow early identification and intervention of skin problems associated with external radiation therapy. The external markings should not be removed, but clients may shower and lightly wash over the skin. Time, distance, and shielding are key in the management of sealed, internal radiation therapy and not external beam radiation. The use of disposable utensils and care items would be important when caring for clients following systemic, unsealed, internal radiation therapy.

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? Emergent Acute Rehabilitation Immediate resuscitative

Acute Explanation: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

Your patient has recently completed her first round of chemotherapy in the treatment of lung cancer. When reviewing this morning's blood work, what findings would be suggestive of myelosuppression? Increased white blood cells and c-reactive protein (CRP) Decreased sodium levels and decreased potassium levels Increased creatinine and blood urea nitrogen (BUN) Decreased platelets and red blood cells

Decreased platelets and red blood cells Explanation: Most chemotherapeutic agents cause myelosuppression (depression of bone marrow function), resulting in decreased production of blood cells. Myelosuppression decreases the number of WBCs (leukopenia), red blood cells (RBCs) (anemia), and platelets (thrombocytopenia), and increases the risk of infection and bleeding. It does not typically affect electrolytes, creatinine, BUN, and CRP levels.

A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient? Wear a lead apron when providing direct patient care. Alert family members that they should restrict their visiting to 5 minutes at any one time. Maintain as much distance as possible from the patient while in the room. Explain to the patient that she will continue to emit radiation while the implant is in place.

Explain to the patient that she will continue to emit radiation while the implant is in place. Explanation: When the patient has a radioactive implant in place, the nurse and other health care providers need to protect themselves, as well as the patient, from the effects of radiation. Patients receiving internal radiation emit radiation while the implant is in place; therefore, contact with the health care team is guided by principles of time, distance, and shielding to minimize exposure of personnel to radiation. Safety precautions used in caring for a patient receiving brachytherapy include assigning the patient to a private room, posting appropriate notices about radiation safety precautions, having staff members wear dosimeter badges, making sure that pregnant staff members are not assigned to the patient's care, prohibiting visits by children or pregnant visitors, limiting visits from others to 30 minutes daily, and seeing that visitors maintain a 6-foot distance from the radiation source.

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing: Complex regional pain syndrome Delayed union Compartment syndrome Fat embolism syndrome

Fat embolism syndrome Explanation: fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.