1217 Exam #4

A client has a new synthetic leg cast for a right fractured tibia. What health teaching will the nurse include before discharge to home? Select all that apply. A "Elevate your right leg as often as possible to reduce swelling." B "Report increased pain or burning sensation under your cast." C. "Use ice on the affected leg for the first 24-36 hours." D. "Do not bear weight on the affected leg until instructed to do so." E "Do not cover the cast when you are in bed; keep it open to air to dry.

A "Elevate your right leg as often as possible to reduce swelling." B "Report increased pain or burning sensation under your cast." C. "Use ice on the affected leg for the first 24-36 hours." D. "Do not bear weight on the affected leg until instructed to do so."

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A "When I eat shrimp, my tongue swells and I have trouble breathing." B. "I'm feeling more anxious about my surgery than I thought I would be." C "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she didn't like the way she felt."

A "When I eat shrimp, my tongue swells and I have trouble breathing."

Which precaution is most appropriate for the nurse to teach a client with osteoarthritis (OA) who is prescribed to take acetaminophen for mild to moderate pain? A. "Avoid alcoholic beverages while taking this drug." B. "Avoid coffee and other caffeinated drinks while taking this drug." C. "Do not drive or operate dangerous machinery until you know how this drug affects you." D. "If any decrease in vision occurs, stop the drug and notify your primary health care provider immediately."

A. "Avoid alcoholic beverages while taking this drug."

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? (Select all that apply.) A. "I will clean the pins more often if drainage from the pins increases." 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 move my leg by lifting the device in the middle." E. "I will report increased redness at the pin sites."

A. "I will clean the pins more often if drainage from the pins increases." B. "I will use a separate cotton swab for each pin." C. "I will report loosening of the pins to my doctor." E. "I will report increased redness at the pin sites."

The nurse is teaching a client who has osteopenia about alendronate. Which statement by the client indicates a need for further teaching? A. "I will take this drug at night to prevent nausea." B. "I need a dental checkup before taking the drug C. "I need to sit up for 30 minutes after taking the drug." D. "I will drink plenty of water after I take the drug."

A. "I will take this drug at night to prevent nausea."

The nurse is preparing to teach a client about how to promote musculoskeletal health. Which statements will the nurse include in the teaching plan? Select all that apply. A. "If you smoke, you need a smoking cessation plan." B. "Avoid drinking excessive alcohol." C. "Be sure to take in enough calcium and vitamin D." D. "Avoid high-risk activities that could cause an accident." E. "Include weight-bearing exercise like walking on a regular basis."

A. "If you smoke, you need a smoking cessation plan." B. "Avoid drinking excessive alcohol." C. "Be sure to take in enough calcium and vitamin D." D. "Avoid high-risk activities that could cause an accident." E. "Include weight-bearing exercise like walking on a regular basis."

Which statements by a client who has arthritis indicates to the nurse the possibility of Sjögren syndrome? Select all that apply. A. "Lately, my eyes have felt gritty by the end of the day." B. "Ice sometimes helps my joint pain better than heat does." C. "If I don't use a vaginal lubricant, intercourse is painful." D. "Some little bumps have appeared on my arm, but they don't hurt." E. "When my arthritis gets worse in one joint, the pain seems worse in all my joints." F. "It's kind of crazy but I have had more cavities in the past 2 years than in all the rest of my life."

A. "Lately, my eyes have felt gritty by the end of the day." C. "If I don't use a vaginal lubricant, intercourse is painful." F. "It's kind of crazy but I have had more cavities in the past 2 years than in all the rest of my life."

What is the nurse's best response when a client who had a long-leg plaster cast applied an hour ago reports that the cast feels "hot?" A. "Plaster gives off heat as it dries, and the heat does not mean anything is wrong." B. "It is likely that you have an infection and will need to be started on antibiotics immediately." C. "This means you are having an allergic reaction and this cast will have to be removed immediately." D. "Don't worry. This heat is normal and I will apply a cooling blanket over it for your comfort."

A. "Plaster gives off heat as it dries, and the heat does not mean anything is wrong."

A client had a left noncemented posterolateral total hip arthroplasty 2 days ago Which statements will the nurse include in health teaching for the client? Select all that apply. A. "Practice leg exercises each day as instructed." B. "Take deep breaths and use incentive spirometry every 2 hours." C. "Be sure to cross your legs to be more comfortable in a chair." D. "Report sudden increased hip pain or rotation immediately to the nurse." E. "Stand on your right leg and pivot into the chair when getting out of bed."

A. "Practice leg exercises each day as instructed." B. "Take deep breaths and use incentive spirometry every 2 hours." D. "Report sudden increased hip pain or rotation immediately to the nurse." E. "Stand on your right leg and pivot into the chair when getting out of bed."

Which precaution or issue will the nurse reinforce to the postoperative client about correct use of the patient-controlled analgesia (PCA) device? A. "Push the button when you feel the pain beginning rather than waiting until the pain is at its worst." B. "Push the button every 15 minutes whether you feel pain at that time or not." C. "Instruct your family or visitors to press the button for you when you are sleeping." D. "Try to go as long as you possibly can before you press the button."

A. "Push the button when you feel the pain beginning rather than waiting until the pain is at its worst."

A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? (Select all that apply.) A. "Take your heart medication with a sip of water before surgery." B. "Splint the abdominal incision with a pillow when coughing and deep breathing." C. "Bed rest is recommended for the first 48 hours." D. "Anti-embolism stockings are applied before surgery." E. "You can eat solid foods up to 4 hours before surgery."

A. "Take your heart medication with a sip of water before surgery." B. "Splint the abdominal incision with a pillow when coughing and deep breathing." D. "Anti-embolism stockings are applied before surgery."

The nurse is about to give the prescribed pain medication to a client 30 minutes before a scheduled dressing change. The client states that the drug makes him feel sick and he would rather "tough it out." What is the nurse's best first response? A. "Tell me more about the sick feeling." B. "That's fine. You have the right to refuse any drug." C. "Your surgeon would not have prescribed the drug if it wasn't needed." D. "Remember that the pain of the dressing change would be worse than feeling sick."

A. "Tell me more about the sick feeling."

Which clients will the nurse collaborate with a registered dietitian nutritionist to assist in modifying their nutritional risk for osteoporosis? Select all that apply. A. 25-year-old female who drinks six cups of coffee daily B. 30-year-old female who is overweight for height C. 35-year-old male who is on the high protein Atkins diet D. 45-year-old female who drinks unfortified almond milk E. 55-year-old male who drinks one carbonated beverage every day F. 65-year-old male with chronic alcoholism

A. 25-year-old female who drinks six cups of coffee daily C. 35-year-old male who is on the high protein Atkins diet D. 45-year-old female who drinks unfortified almond milk F. 65-year-old male with chronic alcoholism

Which client will the nurse assess most frequently for indications of venous thromboembolism (VTE)? A. 25-year-old weightlifter with a fracture of the right femur B. 45-year-old with metastatic cancer and a spinal compression fracture C. 55-year-old car crash victim with multiple facial fractures D. 65-year-old with a broken elbow and hypertension

A. 25-year-old weightlifter with a fracture of the right femur

Which client will the nurse determine has the highest risk for osteoporosis? A. 30-year-old female who drinks 48 oz (~1250 mL) of diet cola daily and uses high-protection sunscreen B. 40-year-old male who is 72 inches (1.8 m) tall, eats a vegan diet, and participates in competitive martial arts C. 50-year-old male with type 1 diabetes mellitus who lifts weights for exercise D. 60-year-old female who is 15 lb (6.8 kg) overweight and walks 2 miles daily

A. 30-year-old female who drinks 48 oz (~1250 mL) of diet cola daily and uses high-protection sunscreen

Which client will the nurse assess for the possibility of regional osteoporosis? A. 40-year-old who has been in a long leg cast for 10 weeks B. 45-year-old on long-term corticosteroid therapy for a chronic inflammation C. 55-year-old who is being managed for hyperparathyroidism D. 60-year-old who is postmenopausal with a history of falls

A. 40-year-old who has been in a long leg cast for 10 weeks

A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (Select all that apply.) A. A 40-year-old client who has been taking prednisone for 4 months B. A 30-year-old client who jogs 3 miles daily C. A 45-year-old client who takes phenytoin for seizures D. A 65-year-old client who has a sedentary lifestyle E. A 70-year-old client who has smoked for 50 years

A. A 40-year-old client who has been taking prednisone for 4 months C. A 45-year-old client who takes phenytoin for seizures D. A 65-year-old client who has a sedentary lifestyle E. A 70-year-old client who has smoked for 50 years

A nurse is reviewing the medical records of several clients in the postanesthesia care unit (PACU) to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (Select all that apply.) A. A client who has a WBC of 22,500/uL B. A client who uses an insulin pump C. A client who takes warfarin daily D. A client who has heart failure E. A client who has a BMI of 26

A. A client who has a WBC of 22,500/uL B. A client who uses an insulin pump C. A client who takes warfarin daily D. A client who has heart failure

When the nurse is screening a preoperative client, which factors increase the risk for complications during the perioperative period? Select all that apply. A. Age 72 B. 35 pounds overweight C. Walks half a mile every day D. History of hernia repair surgery E. Smokes half a pack of cigarettes per day F. Type 2 diabetes

A. Age 72 B. 35 pounds overweight E. Smokes half a pack of cigarettes per day F. Type 2 diabetes

Which new-onset symptoms in a client who is 2 days postoperative after total hip arthroplasty (THA) suggests to the nurse that hip dislocation may have occurred? Select all that apply. A. Agitation B. Loss of appetite C. Increased pain intensity D. Clear drainage on dressing E. Inability to dorsiflex the foot F. Leg shortening on the operative side

A. Agitation C. Increased pain intensity F. Leg shortening on the operative side

A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestation of a fat embolus? 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 completing discharge teaching to 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 providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (Select all that apply.) A. Apply heat to joints to alleviate pain. B. Ice inflamed joints for 30 min following activity. C. Reduce the amount of exercise done on days with increased pain. D. Prop the knees with a pillow while in bed. E. Active range of motion is more effective than passive.

A. Apply heat to joints to alleviate pain. C. Reduce the amount of exercise done on days with increased pain. E. Active range of motion is more effective than passive.

A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy. Which of the following actions should the nurse perform first? A. Assess bowel sounds. B. Administer antiemetic medication. C. Restart prescribed IV fluids. D. Insert a prescribed nasogastric tube.

A. Assess bowel sounds.

A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following actions should the nurse take? (Select all that apply.) A. Assess color and temperature of the extremity. B. Apply warm compresses to incision sites. C. Place pillows under the extremity. D. Administer analgesic medication. E. Assess pulse and sensation in the foot.

A. Assess color and temperature of the extremity. C. Place pillows under the extremity. D. Administer analgesic medication. E. Assess pulse and sensation in the foot.

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

A. Assess for bruising C. Determine whether the client takes a muscle relaxant. D. Instruct the client to flex muscles during needle insertion.

A nurse is assisting an anesthesiologist who is delivering nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? A. Assess oxygen saturation. B. Measure blood pressure. C. Palpate pulse rate. D. Check temperature.

A. Assess oxygen saturation.

A client who had a plaster splint applied to the ankle at 7 a.m. and received pain medication at 9 a.m. now at 11 a.m. reports that the pain is getting worse, not better. What is the nurse's best first action to prevent harm? A. Assessing the pulses and skin temperature distal to the splint B. Loosening the splint and reassessing the client's pain in 15 minutes C. Requesting a prescription to administer the pain medication IV D. Repositioning the extremity on a pillow and placing an ice pack

A. Assessing the pulses and skin temperature distal to the splint

20. After a client is prepared for surgery and before preoperative drugs are given and the client is transferred to surgery, which intervention can the nurse delegate to the assistive personnel (AP)? A. Assist the client to the bathroom to empty his or her bladder. B. Help the client to remove the hospital gown. C. Recheck the client's identity with another AP. D. Teach the client to use incentive spirometry.

A. Assist the client to the bathroom to empty his or her bladder.

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

A. Begin practicing leg exercises prior to surgery. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

In the early postoperative phase, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 mm Hg B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

A. Blood pressure of 142/90 mm Hg

What is the nurse's first action when a client develops an abdominal wound evisceration after a hard sneeze? A. Call for help and stay with the client. B. Immediately take the client's vital signs. C. Leave the client to immediately call the surgeon. D. Attempt to reduce the evisceration by gently moving the contents back into the abdomen.

A. Call for help and stay with the client.

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

A. Check continuous passive motion device settings. B. Palpate dorsal pedal pulses. D. Elevate heels off bed.

Which assessments are a priority for the nurse to perform to prevent harm on a client who was hit by a motorcycle and has a suspected pelvic fracture? Select all that apply. A. Checking vital signs B. Asking about opioid use C. Examining urine for presence of blood D. Asking the client to rate his or her pain E. Determining the level of consciousness F. Performing neurovascular checks of the lower limbs

A. Checking vital signs C. Examining urine for presence of blood E. Determining the level of consciousness

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (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 with soap and water. C. Sit in a straight-backed armchair. E. Use a raised toilet seat.

Which points and actions will the nurse include when teaching a client and family after a below-the-knee amputation about care of the residual limb? Select all that apply. A. Demonstrating how to apply a figure eight elastic wrap B. Reviewing the signs and symptoms of wound infection C. Reminding the client and family to rewrap the limb several times each day D. Obtaining a return demonstration of the elastic wrap application E. Reviewing positioning and exercises for prevention of flexion contractures F. Informing the client that after the incision is healed, it can be cleaned during bathing or showering with soap and water

A. Demonstrating how to apply a figure eight elastic wrap B. Reviewing the signs and symptoms of wound infection C. Reminding the client and family to rewrap the limb several times each day D. Obtaining a return demonstration of the elastic wrap application E. Reviewing positioning and exercises for prevention of flexion contractures F. Informing the client that after the incision is healed, it can be cleaned during bathing or showering with soap and water

Which precautions are most important for the nurse to stress to prevent harm when teaching about drug therapy to a 32-year-old female client who is prescribed to take oral methotrexate? Select all that apply. A. Do not drink alcohol while taking this medication. B. Be sure to use a reliable form of contraception. C. If the drug causes you nausea, take it at bedtime. D. Avoid crowds of people and those who are ill. E. If you miss a dose, call your rheumatology health care provider immediately. F. This drug may require weeks to months before a full effect is seen.

A. Do not drink alcohol while taking this medication. B. Be sure to use a reliable form of contraception. D. Avoid crowds of people and those who are ill.

Which assessment data are factors that increase the risk for osteoporosis for an older Euro-American female? Select all that apply. A. Drinks 3 to 4 glasses of wine each day B. Sits at a desk all day at her job C. Smokes a pack of cigarettes a day D. Takes a mile-long walk 5 days a week E. Takes 1000 mg acetaminophen for arthritis daily F. Weighs 110 lb (50 kg)

A. Drinks 3 to 4 glasses of wine each day B. Sits at a desk all day at her job C. Smokes a pack of cigarettes a day F. Weighs 110 lb (50 kg)

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 follow information should the nurse provide? (Select all that apply.) A. Encourage clients who smoke to consider smoking cessation programs. B. Encourage clients who have diabetes mellitus to maintain blood glucose within the expected reference range. C. Instruct clients to unplug electrical equipment when performing repairs. D. Encourage clients who have vascular disease to maintain good foot care. E. Advise clients to wait 2 hr after taking pain medication before driving.

A. Encourage clients who smoke to consider smoking cessation programs. B. Encourage clients who have diabetes mellitus to maintain blood glucose within the expected reference range. C. Instruct clients to unplug electrical equipment when performing repairs. D. Encourage clients who have vascular disease to maintain good foot care.

A nurse is completing 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. Encourage complete autologous blood donation. B. Sit in a low reclining chair. C. Instruct the client to roll onto the operative hip. D. Use an abductor pillow when turning the client. E. Perform isometric exercises.

A. Encourage complete autologous blood donation. D. Use an abductor pillow when turning the client. 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 t apply.) A. Encourage dependent positioning of the residual limb. B. Inspect for presence and amount of drainage. C. Implement shrinkage intervention of the residual limb. D. Wrap the residual limb in a circular manner using gauze. E. Assess for feelings of body image changes.

A. Encourage dependent positioning of the residual limb. B. Inspect for presence and amount of drainage. C. Implement shrinkage intervention of the residual limb. E. Assess for feelings of body image changes.

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Encourage use of the incentive spirometer every 2 hr. B. Instruct the client to splint the incision when coughing and deep breathing. C. Reposition the client every 2 hr. D. Administer antibiotic therapy. E. Assist with early ambulation.

A. Encourage use of the incentive spirometer every 2 hr. B. Instruct the client to splint the incision when coughing and deep breathing. C. Reposition the client every 2 hr. E. Assist with early ambulation.

Which actions will the nurse take for a client after a left total knee arthroplasty (TKA) to prevent harm from venous thromboembolism (VTE)? Select all that apply. A. Encouraging early ambulation B. Instructing the client to keep the legs straight C. Administering the prescribed anticoagulant therapy D. Removing antiembolic stockings for 1 hour every 4 hours E. Ensuring the sequential compression device is in place and functional F. Helping the client to perform dorsiflexion and plantar flexion exercises hourly

A. Encouraging early ambulation B. Instructing the client to keep the legs straight C. Administering the prescribed anticoagulant therapy E. Ensuring the sequential compression device is in place and functional F. Helping the client to perform dorsiflexion and plantar flexion exercises hourly

A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with 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 exercise including walking. D. Create a smoking cessation plan. E. Wear low-heeled shoes.

Which actions are appropriate for the nurse to perform when caring for a client who is placed in Buck's traction after a hip fracture? Select all that apply. A. Ensuring that the weights never rest on the floor B. Removing the boot or belt every 8 hours to assess skin integrity C. Comparing the amount of weights applied with the amount prescribed D. Removing the weights every 8 hours for 30 minutes to prevent muscle spasms E. Assessing circulation distal to the traction device every hour for the first 24 hours F. Instructing all personnel and visitors to not touch or change the position of the weights

A. Ensuring that the weights never rest on the floor B. Removing the boot or belt every 8 hours to assess skin integrity C. Comparing the amount of weights applied with the amount prescribed E. Assessing circulation distal to the traction device every hour for the first 24 hours F. Instructing all personnel and visitors to not touch or change the position of the weights

Which assessment findings will the nurse expect in an older female client who has osteoporosis? Select all that apply. A. Gait changes B. Inability to bear weight C. Muscle atrophy D. History of fractures E. Swelling in the finger joints F. Spinal curvature with postural changes

A. Gait changes D. History of fractures F. Spinal curvature with postural changes

The nurse is caring for a client who was admitted with a draining diabetic ulcer on the lower extremity. What personal protective equipment will the nurse teach the staff to use? Select all that apply. A. Gown B. Gloves C. Mask D. Foot covers E. Goggles

A. Gown B. Gloves

A nurse is assessing 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. Heberden's nodes D. Enlarged joint size E. Limp when walking

Which manifestations would the nurse expect for a client with a history of malignant hyperthermia (MH)? Select all that apply. A. High body temperature B. Decreased serum calcium level C. Tachypnea D. Skin mottling E. Muscle rigidity of jaw and upper chest F. Increased serum potassium level

A. High body temperature C. Tachypnea D. Skin mottling E. Muscle rigidity of jaw and upper chest F. Increased serum potassium level

A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39° C (102.2° F) orally. Which of the following actions should the nurse take? A. Inform the surgeon of the elevated temperature. B. Transfer the client to the preoperative unit. C. Apply ice packs to the groin. D. Encourage the client to increase intake of clear liquids.

A. Inform the surgeon of the elevated temperature.

A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? (Select all that apply.) A. Infuse iced IV fluids. B. Provide 100% oxygen. C. Place a cooling blanket on the client. D. Treat the complication while the surgeon continues surgery. E. Administer IV dantrolene.

A. Infuse iced IV fluids. B. Provide 100% oxygen. C. Place a cooling blanket on the client. E. Administer IV dantrolene.

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

A. Intense pain when the client's left foot is passively moved C. Hard, swollen muscle in the client's left leg D. Burning and tingling of the client's left foot E. Client report of minimal pain relief following a second dose of opioid medication

The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client's priority problem? A. Joint pain B. ADL dependence C. Risk for falls D. Muscle stiffness

A. Joint pain

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor <3 seconds C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

A. Left arm prosthesis C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity

Clients with which problems or factors will the nurse assess most frequently for development of acute compartment syndrome? Select all that apply. A. Lower legs caught between the bumpers of two cars B. Massive infiltration of IV fluid into the forearm C. Bivalve cast on the lower leg D. Multiple insect bites to lower legs E. Daily use of oral corticosteroids F. Severe burns to the upper extremities

A. Lower legs caught between the bumpers of two cars B. Massive infiltration of IV fluid into the forearm D. Multiple insect bites to lower legs F. Severe burns to the upper extremities

A nurse is performing a musculoskeletal assessment on an older adult. What normal physiologic changes of aging does the nurse expect? Select all that apply. A. Muscle atrophy B. Slowed movement C. Kyphosis D. Arthritis E. Widened gait F. Decreased joint range of motion

A. Muscle atrophy B. Slowed movement C. Kyphosis D. Arthritis E. Widened gait F. Decreased joint range of motion

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pinprick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present

A. Perform thorough auscultation of the lungs

A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove throw rugs in walkways. B. Use prescribed assistive devices. C. Remove clutter from the environment. D. Wear soft-bottomed shoes. E. Maintain lighting of doorway areas.

A. Remove throw rugs in walkways. B. Use prescribed assistive devices. C. Remove clutter from the environment. E. Maintain lighting of doorway areas.

Which assessment findings in a client with osteoarthritis scheduled to have a total joint replacement (TJR) will the nurse report to the surgeon immediately? Select all that apply. A. Reports having an abscessed tooth B. Has asthma symptoms with seasonal allergies C. Had a dental implant placed about 3 years ago D. Repeat blood pressure readings are consistently higher than 160/90 E. Pain rating in affected joint is 9 on a 0 to 10 pain rating scale F. Has type 2 diabetes and today's fasting blood glucose level is 102 mg/dL (5.7 mmol/L)

A. Reports having an abscessed tooth D. Repeat blood pressure readings are consistently higher than 160/90

A nurse is assessing a client who has arteriosclerosis and is scheduled for a possible 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. Increased sensitivity to fine touch C. Palpable pounding pedal pulse D. Lack of hair on lower leg E. Blackened areas on several toes

A. Skin cool to touch from mid-calf to the toes D. Lack of hair on lower leg E. Blackened areas on several toes

A nurse is caring for a client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (Select all that apply.) A. Urine output less than 25 mL/hr B. Hematocrit 53% C. BUN 24 mg/dL D. Tenting of skin over the sternum E. Apical pulse rate 62/min

A. Urine output less than 25 mL/hr B. Hematocrit 53% C. BUN 24 mg/dL D. Tenting of skin over the sternum

A client had an open reduction internal fixation (ORIF) of the right wrist. What health teaching is appropriate for the nurse to provide for this client before returning home? Select all that apply. A "Keep your right arm below the level of your heart as often as possible." B "Use an ice pack for the first 24 hours to decrease tissue swelling. C "Report coolness or discoloration of your right hand to your doctor." D. "Don't place any device under the cast to scratch the skin if it itches." E. "Move the fingers of the right hand frequently to promote blood flow."

B "Use an ice pack for the first 24 hours to decrease tissue swelling. C "Report coolness or discoloration of your right hand to your doctor." E. "Move the fingers of the right hand frequently to promote blood flow."

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?"

A nurse is completing preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? (Select all that apply.) A. "Avoid damage or moisture to the cast on your arm." B. "Inspect your incision daily for indications of infection." C. "Apply ice packs to the area for the first 24 hours." D. "Keep your arm in a dependent position." E. "Perform isometric exercises."

B. "Inspect your incision daily for indications of infection." C. "Apply ice packs to the area for the first 24 hours." E. "Perform isometric exercises."

How will the nurse instruct a client to prepare for a dual x-ray absorptiometry (DXA) scan? A. "Blood and urine specimens will be taken immediately before the test." B. "Leave metallic objects such as jewelry, coins, and belt buckles at home." C. "Be sure to have someone come with to drive you home after the test." you D. "Bring a comfortable loose nightgown without buttons or snaps, and a pair of slippers."

B. "Leave metallic objects such as jewelry, coins, and belt buckles at home."

The primary health care provider prescribes daily celecoxib for a client experiencing persistent joint pain in both knees. Which health teaching will the nurse provide for the client regarding this drug for long-term pain control? Select all that apply. A. "Take the prescribed drug before breakfast each day." B. "Report any sign of bleeding, including bloody or dark, tarry stool." C. "Do not take other NSAIDs while on celecoxib." D. "Report any major changes in the amount of urine you excrete each day." E. "Follow up with lab tests to assess liver function."

B. "Report any sign of bleeding, including bloody or dark, tarry stool." C. "Do not take other NSAIDs while on celecoxib." D. "Report any major changes in the amount of urine you excrete each day."

What is the nurse's best response to a 50-year old male client scheduled for a bunionectomy with wire placement who states "Since this is ambulatory surgery and I won't have to spend the night, I can plan on participating in a 10 K race next month."? A. "You may have to change your plans and only run a 5 K next month." B. "This is ambulatory surgery but the healing time is usually at least 6 to 12 weeks." C. "After this surgery, it is unlikely you will ever be able to run more than a mile again." D. "If you wear the orthopedic boot, you can run again as soon as you can tolerate the pain.

B. "This is ambulatory surgery but the healing time is usually at least 6 to 12 weeks."

What is the nurse's best response to a client with a lower limb amputation who says "I think I am going crazy. I know my foot is gone but I still feel my big toe burning and itching."? A. "Are you sure you were awake? Sometimes people dream this pain as part of hoping that the missing body part will grow back." B. "You are not crazy; many people continue to feel pain and other sensations in a limb that was amputated. How severe is this pain?" C. "This complication is usually seen in a person who has not accepted the fact that the limb is gone. A psychologist can help you cope with this." D. "This problem is very common and although nothing can be done about it, we can give you pain medication for the pain you feel at the surgical site."

B. "You are not crazy; many people continue to feel pain and other sensations in a limb that was amputated. How severe is this pain?"

What is the nurse's best response when a preoperative client speaks about fear of a reaction if blood is given during his or her surgery? A. "The likelihood that you will need a blood transfusion during your surgery is minimal, so do not worry about it." B. "You could donate some of your own blood, which is an autologous donation, a few weeks before your surgery." C. "With today's technology and procedures, it is very unlikely that you would have a reaction to donated blood." D. "The nursing staff follows very strict rules and procedures to prevent such an event from ever happening."

B. "You could donate some of your own blood, which is an autologous donation, a few weeks before your surgery."

Which clients with fractures will the nurse recognize as being at increased risk for delayed or slow bone healing? Select all that apply. A. 28-year-old male with multiple long-bone fractures B. 35-year-old female with diet-induced osteopenia C. 45-year-old female semiprofessional tennis player D. 58-year-old female taking corticosteroids daily for an autoimmune disorder E. 65-year-old male with arteriosclerosis F. 75-year-old male chronic obstructive pulmonary disease

B. 35-year-old female with diet-induced osteopenia D. 58-year-old female taking corticosteroids daily for an autoimmune disorder E. 65-year-old male with arteriosclerosis F. 75-year-old male chronic obstructive pulmonary disease

With which clients will the nurse remain especially vigilant for respiratory complications during the first 24 hours after surgery? Select all that apply. A. 21-year-old with opioid use syndrome B. 39-year-old with a 55-pack-year smoking history C. 55-year-old with type 2 diabetes mellitus D. 62-year-old with chronic obstructive pulmonary disease E. 70-year-old with early stage Alzheimer disease F. 80-year-old whose last influenza vaccination was 2 years ago

B. 39-year-old with a 55-pack-year smoking history D. 62-year-old with chronic obstructive pulmonary disease F. 80-year-old whose last influenza vaccination was 2 years ago

The surgery for a client scheduled for an 8:00 a.m. procedure is delayed until 11:00 a.m. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 a.m. as originally prescribed. B. Adjust the administration time to be given at 10:00 a.m. C Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

B. Adjust the administration time to be given at 10:00 a.m.

What is the nurse's best first action for a client who is 6 hours postoperative from abdominal surgery and now has profuse bleeding from the incision? A. Notify the surgeon. B. Apply pressure to the wound dressing. C. Assess the client's heart rate and blood pressure. D. Instruct the assistive personnel (AP) to get additional dressing supplies.

B. Apply pressure to the wound dressing.

The nurse is caring for a client who was admitted to the emergency department (ED) with report of left knee pain and swell ing after playing baseball with friends. Which nursing actions are appropriate when caring for the client? Select all that A. Apply heat to the affected area. B. Assess the severity and quality of pain. C. Perform a neurovascular assessment. D. Elevate the affected extremity. E. Immobilize the injured knee joint.

B. Assess the severity and quality of pain. C. Perform a neurovascular assessment. D. Elevate the affected extremity. E. Immobilize the injured knee joint.

18. Which is the priority action for the nurse to perform when caring for a patient who just had a needle bone biopsy under local anesthesia? A. Administering pain medication B. Assessing for bleeding C. Checking the gag reflex D. Assessing the distal pulse

B. Assessing for bleeding

Which health problems or assessment findings in a client with osteoarthritis who reports that he has been taking glucosamine for joint pain causes the nurse to have concern about this complementary therapy? A. Client is 20 lb (9.9 kg) overweight B. Blood pressure is 150/90 C. Resting pulse is 90 beats/min D. A light red rash is present E. Client has type 2 diabetes F. Morning stiffness lasts 2 hours

B. Blood pressure is 150/90 E. Client has type 2 diabetes

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? A. Skeletal traction B. Buck's traction C. Halo traction D. Bryant's traction

B. Buck's traction

Which assessment finding in a client who has a fracture of the right wrist alerts the nurse to a possible early indication of a complication? A. Wiggling fingers causes pain. B. Client reports numbness and tingling. C. Fingers are cold and pale; pulses are impalpable. D. Pain is severe and seems out of proportion to injury.

B. Client reports numbness and tingling.

A client with appendicitis is to have an uncomplicated appendectomy performed. What is the best classification for this surgery? A. Elective B. Curative C. Diagnostic D. Minor

B. Curative

A hypertensive client with a large abdominal aortic aneurysm is having a surgical repair. What is the best category for this surgery? A. Urgent B. Emergent C. Radical D. Curative

B. Emergent

Which drug does the nurse prepare to administer to a postoperative client who has received an overdose of a benzodiazepine? A. Hydromorphone B. Flumazenil C. Midazolam D. Naloxone

B. Flumazenil

A nurse is providing 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. Kale C. Apples D. Brown rice

B. Kale

What lifestyle changes does the nurse suggest to help slow joint degeneration for a client who has been newly diagnosed with osteoarthritis (OA)? Select all that apply. A. Avoiding direct sunlight and other sources of ultraviolet light B. Keeping body weight appropriate for height and body type C. Quitting smoking, vaping, or using nicotine in any form D. Avoiding any participation in outdoor activities E. Avoiding activities that trauma may result in F. Engaging in low-impact exercises daily

B. Keeping body weight appropriate for height and body type C. Quitting smoking, vaping, or using nicotine in any form E. Avoiding activities that trauma may result in F. Engaging in low-impact exercises daily

A nurse is admitting an adult client who has suspected osteoporosis. Which of following findings are risk factors for osteoporosis? (Select all that apply.) A. History of consuming one glass of wine daily B. Loss in height of 2 in (5.1 cm) C. Body mass index (BMI) of 18 D. Kyphotic curve at upper thoracic spine E. History of lactose intolerance

B. Loss in height of 2 in (5.1 cm) C. Body mass index (BMI) of 18 D. Kyphotic curve at upper thoracic spine E. History of lactose intolerance

Which actions will the nurse take to prevent hypoxemia in the postoperative client? Select all that apply. A. Place the client in a supine position. B. Monitor the client's oxygen saturation. C. Encourage the client to cough and breathe deeply. D. Ambulate the client as early as the surgeon permits. E. Instruct the client to rest as much as possible. F. Remind the client to use incentive spirometry every hour while awake.

B. Monitor the client's oxygen saturation. C. Encourage the client to cough and breathe deeply. D. Ambulate the client as early as the surgeon permits. F. Remind the client to use incentive spirometry every hour while awake.

Which client assessment findings or factors indicate to the nurse the possible presence of carpal tunnel syndrome (CTS)? Select all that apply. A. Client has been taking calcium and vitamin D supplements for osteopenia. B. Numbness and pain are reported on performance of the Phalen maneuver. C. Muscle pad below the thumb is flat and atrophied. D. Client's favorite hobby is knitting and crocheting. E. Wrist and hand pain awaken the client at night. F. Lifestyle is very sedentary.

B. Numbness and pain are reported on performance of the Phalen maneuver. C. Muscle pad below the thumb is flat and atrophied. D. Client's favorite hobby is knitting and crocheting. E. Wrist and hand pain awaken the client at night.

A nurse is assessing 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 when bearing weight C. Joint crepitus D. Swelling of the affected joint E. Limited joint motion

The nurse is assigned to care for a postoperative client who had an open reduction, internal fixation of the right tibia yesterday. The client reports increased right leg pain, numbness, and tingling. What would be the nurse's first action at this time? A. Elevate the surgical leg on a pillow. B. Perform a neurovascular assessment. C. Administer pain medication. D. Call the primary health care provider.

B. Perform a neurovascular assessment.

Which assessment findings in a client with a complete and displaced fracture of the femur indicates to the nurse possible fat embolism syndrome (FES)? Select all that apply. A. Increased swelling over the fracture site B. Petechiae on the neck and chest C. Decreased platelet count D. Dry mucous membranes E. Sudden-onset confusion F. PaO₂ = 72 mm Hg

B. Petechiae on the neck and chest C. Decreased platelet count E. Sudden-onset confusion F. PaO₂ = 72 mm Hg

A nurse is providing care for a client who had a 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.

Which action does the nurse take to prevent harm from skin irritation, wound contamination, and infection for a postoperative client who has a Penrose drain? A. Keeps a sterile safety pin in place at the end of the drain B. Places absorbent pads under and around the exposed drain C. Offers pain medication 30 to 45 minutes before advancing (shortening) the drain D. Shortens the drain by pulling it out a short distance and trimming off the excess external portion

B. Places absorbent pads under and around the exposed drain

A nurse is preparing a plan of care to prevent a client from developing flexion contractions following a below-the-knee amputation 24 hr ago. Which of the following actions should the nurse include? 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 residual limb in a figure-eight pattern. D. Encourage sitting in a chair during the day.

B. Position the client prone several times each day.

A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? A. Monitor blood creatinine levels. B. Provide airway support. C. Turn the client to the right side. D. Administer a diuretic.

B. Provide airway support.

A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from osteoarthritis. Which of the following information should the nurse include in the discussion? A. Continuous pain relief is provided. B. Put on gloves before applying the cream to other parts of the body. C. Leave cream on the hands for 10 min following application. D. Apply the medication every 2 hr during the day.

B. Put on gloves before applying the cream to other parts of the body.

A nurse is caring for a client who received a lower back injury during a fall and describes sharp pain in the back and down the left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease the 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 educating clients at a health fair about dual-energy x-ray absorptiometry (DXA) scans. Which of the following information should the nurse include? (Select all that apply.) A. The test requires the use of contrast material. B. The hip and spine are the usual areas the device scans. C. The scan detects osteoarthritis. D. Bone pain can indicate a need for a scan. E. Females should have a baseline scan during their 40s.

B. The hip and spine are the usual areas the device scans. D. Bone pain can indicate a need for a scan. E. Females should have a baseline scan during their 40s.

Which assessment criteria indicate to the nurse that the client who had surgery 12 hours ago is experiencing respiratory difficulty? Select all that apply. A. Oxygen saturation drops from 98% to 96%. B. Use of accessory muscles during respiratory effort. C. Presence of a high-pitched crowing sound on exhalation. D. Blood pressure decreases from 120/80 to 110/78 mm Hg. E. Respiratory rate is 29/min. F. Hourly urine output decreases from 50 mL to 30 mL.

B. Use of accessory muscles during respiratory effort. C. Presence of a high-pitched crowing sound on exhalation. E. Respiratory rate is 29/min.

A client expresses concern over the presence of external pins and external devices used to manage her fracture and says she wishes it all could have been placed internally so it wouldn't be visible. What advantages will the nurse tell the client that external fixation has over internal fixation of fractures? Select all that apply. A. The risk for infection is reduced. B. You lost less blood than you would have with an internal fixation. C. This device allows you to move and walk earlier than an internal device. D. You will not need surgery to remove these devices after healing is complete. E. Most people have less pain with the external devices than with internal devices. F. This device replaces the need for the use of any other device, such as a cast or a boot, later.

B. You lost less blood than you would have with an internal fixation. C. This device allows you to move and walk earlier than an internal device. D. You will not need surgery to remove these devices after healing is complete. E. Most people have less pain with the external devices than with internal devices.

What is the nurse's best response when a client who has been treated for 4 weeks for osteomyelitis asks why the disease is so difficult to cure? A. "Bones have a poor blood supply and are located so deep in the body that it is hard for antibiotics to reach them." B. "There are no early symptoms of osteomyelitis, so by the time it is detected the infection is widespread." C. "After a bone abscess forms, it gets covered with a new layer of bone that is difficult for drugs to penetrate." D. "The most common organisms that cause osteomyelitis are usually drug-resistant."

C. "After a bone abscess forms, it gets covered with a new layer of bone that is difficult for drugs to penetrate."

The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

Which precautions or care information are appropriate for the nurse to include when teaching a client going home with a synthetic forearm cast? A. "Be sure to change the stockinette at least once a week." B. "Limit movement of the fingers and wrist joints to prevent pain." C. "Keep your hand and arm elevated above the level of your heart to reduce swelling." D. "Use an ice pack on the cast for the first 6-8 hours, and cover the pack with a towel." E. "When upright, wear the sling so that it distributes over your shoulders and not just your neck." F. "Call your primary health care provider immediately if numbness and tingling occur in your hand or fingers."

C. "Keep your hand and arm elevated above the level of your heart to reduce swelling." D. "Use an ice pack on the cast for the first 6-8 hours, and cover the pack with a towel." E. "When upright, wear the sling so that it distributes over your shoulders and not just your neck." F. "Call your primary health care provider immediately if numbness and tingling occur in your hand or fingers."

Which client statement indicates to the nurse the possibility of osteoarthritis (OA)? A. "When I stand too long in one place, my back hurts although walking doesn't bother it." B. "I noticed that my third finger joint seems to be tilting inward toward my other fingers." C. "My knees hurt so much that I end up taking a lot of acetaminophen or aspirin." D. "There is a lot of osteoarthritis in my family. What can I do to prevent it?"

C. "My knees hurt so much that I end up taking a lot of acetaminophen or aspirin."

Which instruction is most appropriate for the nurse to teach a client prescribed to take alendronate 10 mg daily? A. "Be sure to rotate injection sites every week." B. "Be sure to take the drug 1 hour before or at least 2 hours after a meal." C. "Remain in the upright position for at least 30 minutes after taking the drug." D. "Report any headaches you experience to your primary health care provider immediately."

C. "Remain in the upright position for at least 30 minutes after taking the drug."

Assistive personnel (AP) are assigned to care for a client who had a cemented total knee arthroplasty yesterday. Which observation by the AP indicates a need for follow-up by the nurse? A. "The client's surgical knee is very swollen and discolored." B. "The client states that the surgical knee is very painful when moving it." C. "The client's lower leg on the surgical side is painful and red." D. "The client needs assistance with walking to the bathroom."

C. "The client's lower leg on the surgical side is painful and red."

The nurse teaches assistive personnel (AP) how to position a client who had an above-the-knee amputation (AKA) last week. Which statement by the AP indicates understanding of the teaching? A. "We should keep the surgical leg elevated on two pillows at all times." B. "We should keep the client in a sitting position as long as possible." C. "We should keep the surgical leg as flat on the bed as possible." D. "We should keep the client in a prone position most of the day."

C. "We should keep the surgical leg as flat on the bed as possible."

When interviewing a client who is suspected to have osteoarthritis (OA), which question is most important for the nurse to ask? A. "Can you tell if your pain and mobility are worse after eating certain foods?" B. "In looking at your family, who has more arthritis, the men or the women?" C. "What activities would you like to do but don't because of your joint pain?" D. "When pain is present, is it usually accompanied by a headache?"

C. "What activities would you like to do but don't because of your joint pain?"

A blind client is to have a surgical procedure. What is the nurse's best response when the client asks if he or she will be permitted to sign the consent form? A. "Yes, but you will need to make an X instead of signing your name." B. "No, but you can give instructions for a responsible adult to sign for you." C. "Yes, but your signature will need to be witnessed by two people." D. "No, but your next of kin can sign the informed consent for you."

C. "Yes, but your signature will need to be witnessed by two people."

Which clients will the nurse be sure to assess as having an increased risk for developing osteoarthritis (OA)? Select all that apply. A. 30-year-old woman with a family history of rheumatoid arthritis B. 35-year-old man who is 10 lb (4.5) underweight and has never smoked C. 40-year-old woman with multiple knee injuries from playing soccer in high school D. 45-year-old man who worked construction for 25 years E. 50-year-old man who is 10 lb (4.5 kg) overweight and plays golf twice weekly F. 65-year-old obese woman who lives alone after working as a hairdresser for 40 years

C. 40-year-old woman with multiple knee injuries from playing soccer in high school D. 45-year-old man who worked construction for 25 years F. 65-year-old obese woman who lives alone after working as a hairdresser for 40 years

Which client will the nurse recognize as having the greatest risk for developing chronic osteomyelitis? A. 25-year-old who performs heavy manual labor B. 35-year-old who stepped on a rusty 10 years ago nail C. 45-year-old with diabetes who has a recurrent foot ulcer D. 55-year-old with osteoporosis who has sprained the same wrist twice

C. 45-year-old with diabetes who has a recurrent foot ulcer

Which client with a nonhealing fracture of the humerus will the nurse recognize as having a contraindication for use of electrical bone stimulation? A. 30-year-old with a seizure disorder B. 40-year-old smoker with hypertension C. 50-year-old with an implanted cardiac pacemaker D. 60-year-old with reduced immunity from corticosteroid use

C. 50-year-old with an implanted cardiac pacemaker

What is the nurse's priority when doing an admission for a client who returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry. B. Check the surgical dressing to ensure that it is intact. C. Assess neurovascular assessment in the affected arm. D. Monitor intake and output.

C. Assess neurovascular assessment in the affected arm.

The nurse is caring for a client immediately after a bunionectomy. What is the nurse's priority action? A. Relieve or reduce the client's pain. B. Maintain the client's airway. C. Assess neurovascular status in the surgical foot. D. Apply a hot compress to the surgical area.

C. Assess neurovascular status in the surgical foot.

Which action will the nurse perform first when a client in a body cast reports a painful "hot spot" underneath the cast and an unpleasant odor? A. Requesting a cast change B. Offering the client a PRN pain medication C. Assessing the client's temperature and other vital signs D. Elevating the extremity and applying an ice pack over the spot

C. Assessing the client's temperature and other vital signs

A preoperative client's vital signs before transport to the surgery holding area are: (BP 90/60 mm Hg, HR 110/minute, RR 24/minute, T 100.9°F [38.3°C]). What is the nurse's priority action? A. Administer acetaminophen with just a sip of water. B. Recheck the vital signs in 15 minutes. C. Call and notify the surgeon immediately. D. Instruct the client to cough and take deep breaths.

C. Call and notify the surgeon immediately.

A client returns to the postanesthesia care unit (PACU) after an arthroscopy to repair a shoulder injury. What is the nurse's priority when caring for this client? A. Keep the affected arm elevated and immobilized. B. Ensure that the client uses the patient-controlled analgesia (PCA) pump. C. Check the neurovascular status of the affected arm. D. Instruct the client to stay in bed for 24 hours.

C. Check the neurovascular status of the affected arm.

A nurse is assessing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? (Select all that apply.) A. Potassium 3.9 mEq/L B. Sodium 145 mEq/L C. Creatinine 2.8 mg/dL D. Blood glucose 235 mg/dL E. WBC 17,850/mm³

C. Creatinine 2.8 mg/dL D. Blood glucose 235 mg/dL E. WBC 17,850/mm³

The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 mm Hg B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E Has not had food or water since 9:00 p.m. last night

C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday

What is the most appropriate action for the nurse to take when assessment on a client with external fixation reveals crusts have formed around the pin sites? A. Assessing the client's temperature B. Notifying the surgeon immediately C. Documenting the finding as the only action D. Removing the crusts and culturing the drainage

C. Documenting the finding as the only action

The nurse assesses a client recently diagnosed with metastatic vertebral bone cancer. Which intervention is the priority when caring for this client? A. Consultation with rehabilitative therapy B. Referral to hospice care C. Drug therapy to manage persistent pain D. Oxygen therapy to prevent dyspnea

C. Drug therapy to manage persistent pain

A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (Select all that apply.) A. Explain to the client the purpose of having the procedure. B. Inform the client of risks to having the procedure. C. Ensure the client understands information about the procedure. D. Witness the client signing the informed consent form. E. Determine if the client is capable of understanding the reason for the procedure.

C. Ensure the client understands information about the procedure. D. Witness the client signing the informed consent form. E. Determine if the client is capable of understanding the reason for the procedure.

A nurse administered midazolam IV bolus to a client before a procedure. The client's blood pressure is 86/40 mm Hg, and the heart rate is 134/min. Which of the following IV medications should the nurse administer? A. Naloxone B. Morphine C. Flumazenil D. Atropine

C. Flumazenil

Which assessment information obtained from a 60-year-old male client with severe osteoarthritis of the right knee will the nurse consider the greatest contributing factor? A. Is 10 lb (4.5 kg) overweight B. Has ridden a motorcycle for 35 years C. Has worked laying carpet for the past 20 years D. Has a 25 pack-year history of cigarette smoking

C. Has worked laying carpet for the past 20 years

How will the nurse document the assessment observation in which the client's spinal thoracic vertebrae curve sideways to the right and then return to midline? A. Dextrosis B. Lordosis C. Kyphosis D. Scoliosis

C. Kyphosis

Which assessment finding on an older client who fell while getting out of bed indicates to the nurse a possible fracture? A. The client is extremely confused and trying to get up. B. The client cries out when the nurse attempts to examine him. C. One leg is shorter than the other and has a protruding bump on the side. D. The skin of both legs is cooler and darker than that of the upper extremities.

C. One leg is shorter than the other and has a protruding bump on the side.

Which assessment is the priority for the nurse to perform on a client admitted to the emergency department with multiple rib fractures? A. Pulses in all four extremities B. Pulse rate and rhythm C. Oxygen saturation D. Pain intensity

C. Oxygen saturation

A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? A. Decrease the client's fluid intake. B. Apply pressure to the puncture site. C. Place the head of the bed flat. D. Instruct the client to lie prone.

C. Place the head of the bed flat.

Which suggestion will the nurse make to help a client who has complex regional pain syndrome (CRPS) in the right arm weeks after an open reduction was required to repair a broken elbow and fractured radius to reduce the discomfort? A. Take pain medications around the clock even when the pain is not present. B. When the sensations occur, immobilize and ice the limb until they pass. C. Use a dry wash cloth and rub the skin on the arm several times daily. D. Wrap the arm in warm, wet compresses as soon as the pain starts.

C. Use a dry wash cloth and rub the skin on the arm several times daily.

Which drugs belong to the estrogen agonist/antagonist class? Select all that apply. A. Alendronate B. denosumab C. estrogen/bazedoxifene D. ibandronate E. raloxifene F. risedronate G. zoledronic acid

C. estrogen/bazedoxifene E. raloxifene

Which responses, from a client with advanced osteoarthritis, alert the nurse that the client may be having a problem coping with the image and role changes related to disease progression? Select all that apply. A. "It seems that I am getting younger. I used to tie my shoes; now I am using Velcro closures just like my grandkids." B. "Washing dishes in very warm water makes my hands feel so good that I don't use the dishwasher much." C. "I used to be a playground assistant; now I contribute by working with children who need help with reading." D. "Because my joints hurt so much, I just look out the window instead of working in my garden." E. "I no longer wear my rings so I don't draw attention to how awful my hands look." F. "Although I can no longer play the piano, I really enjoy going to concerts."

D. "Because my joints hurt so much, I just look out the window instead of working in my garden." E. "I no longer wear my rings so I don't draw attention to how awful my hands look."

Which question is most important for the nurse to ask a client who is about to receive a prescribed preoperative dose of IV cefazolin before total joint replacement surgery to prevent harm? A. "Did you shower with chlorhexidine gluconate this morning?" B. "When did you last take aspirin or any other NSAID?" C. "Do you have a sulfa drug allergy?" D. "Do you have a penicillin allergy?"

D. "Do you have a penicillin allergy?"

A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was amputated last week. What is the nurse's most appropriate response to the client's pain? A. "The pain will go away after the swelling decreases." B. "That's phantom limb pain, and every amputee has that." C. "Your foot has been amputated, so it's in your head." D. "On a scale of 0 to 10, how would you rate your pain?"

D. "On a scale of 0 to 10, how would you rate your pain?"

Which question is most appropriate for the nurse to ask a client who has been receiving scheduled and PRN opioids for severe pain with multiple fractures who now has a distended abdomen and hypoactive bowel sounds? A. "Did you use opioids or other recreational drugs before your injury?" B. "What specific foods have you eaten in the past 2 days?" C. "How would you rate your pain on a 0 to 10 scale?" D. "When was your last bowel movement?"

D. "When was your last bowel movement?"

A nurse is teaching a client who is going to have a bone scan. Which of the following statements should the nurse include? A. "You will receive an injection of a radioactive isotope when the scanning procedure begins." B. "You will be inside a tube-like structure during the procedure." C. "You will need to take radioactive precautions with your urine for 24 hours after the procedure." D. "You will have to urinate just before the procedure."

D. "You will have to urinate just before the procedure."

Which client will the nurse consider to be at highest risk for nonunion after a fracture? A. 40-year-old who is 20 lb overweight and has a Colles fracture of the wrist B. 50-year-old female with comminuted fracture of the humerus C. 60-year-old male with multiple fractured ribs D. 70-year-old female with a "tib-fib" fracture

D. 70-year-old female with a "tib-fib" fracture

With which client will the nurse remain most alert for indications of acute hematogenous osteomyelitis? A. 30-year-old male with a leg fracture and external skeletal pins B. 50-year-old female in an ICU with pneumonia C. 65-year-old female with MRSA infection D. 72-year-old male with a catheter-related urinary tract infection

D. 72-year-old male with a catheter-related urinary tract infection

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 medication.

Which serum laboratory finding is of concern for the nurse and should be reported to the primary health care provider? A. Calcium = 9 mg/dL (2.10 mmol/L) B. Phosphorus 4.5 mg/dL (1.45 mmol/L) C. Lactate dehydrogenase 150 units/L (150 IU/L) D. Alkaline phosphatase = 210 units/L (210 IU/L)

D. Alkaline phosphatase = 210 units/L (210 IU/L)

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

What is the nurse's priority action when interviewing a preoperative client who had a right hip replacement? A. Document this in the client's preoperative chart. B. Mark the right hip with an indelible pen. C. Use caution when positioning the client. D. Communicate this to the operative personnel.

D. Communicate this to the operative personnel.

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A. Compare and contrast the peripheral B. Apply a warm blanket. C. Assess dressings. D. Place the client in a lateral position.

D. Place the client in a lateral position.

A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A. Encourage the client to void after preoperative medication administration. B. Administer antibiotics 2 hr prior to surgical incision. C. Remove hair using a manual razor. D. Remove nail polish on fingers and toes.

D. Remove nail polish on fingers and toes.

Which assessment findings will the nurse recognize as modifiable risk factors when planning strategies to prevent harm from progression of a client's osteopenia? Select all that apply. A. Has rheumatoid arthritis B. Mother has osteoporosis C. Is 11 lb (5 kg) underweight for height D. Smokes one pack of cigarettes per day E. Drinks one glass of red wine with dinner nightly F. Takes a calcium supplement containing vitamin D daily

D. Smokes one pack of cigarettes per day E. Drinks one glass of red wine with dinner nightly

The nurse is caring for a client who had an anterior total hip arthroplasty yesterday. For which commonly occurring post operative complication will the nurse monitor for this client? A. Pneumonia B. Paralytic ileus C. Wound dehiscence D. Venous thromboembolism

D. Venous thromboembolism