Adult Health 2 Exam 1
When assessing gait, what feature(s) would the nurse inspect? (Select all that apply.) a. Balance b. Ease of stride c. Goniometer readings d. Length of stride e. Steadiness
A, B, D, E
A client asks the nurse about what medications may be included for nonopioid multimodal analgesia following a total knee arthroplasty. What medications may be given to the client? (Select all that apply.) a. Gabapentin b. Ketorolac c. Hydrocodone d. Ketamine e. Morphine f. Bupivacaine
A, B, D, F
The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain
A, C
A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best address the client's psychosocial needs? a. Assess the client's coping skills and support systems. b. Explain that the surgery leads to a longer life expectancy. c. Refer the client to the social worker or hospital chaplain. d. Reinforce physical therapy to aid with ambulating normally.
A
After teaching a client who is recovering from a vertebroplasty, the nurse assesses the patient's understanding. Which statement by the client indicates a need for additional teaching? a. "I can drive myself home after the procedure." b. "I will monitor the puncture site for signs of infection." c. "I can start walking tomorrow and increase my activity slowly." d. "I will remove the dressing the day after discharge."
A
After teaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I should drink at least 3 L of fluid every day." b. "I will eliminate all dairy or sources of calcium from my diet." c. "Aspirin and aspirin-containing products can lead to stones." d. "The doctor can give me antibiotics at the first sign of a stone."
A
The client's electronic health record indicates genu varum. What does the nurse understand this term to mean? a. Bow-legged b. Fluid accumulation c. Knock-kneed d. Spinal curvature
A
A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action? a. Pain of 4 on a scale of 0-10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed
B
A nurse reviews a client's laboratory results. Which results from the client's urinalysis would the nurse recognize as abnormal? a. pH of 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color
B
A nurse reviews the health history of a client with an oversecretion of renin. Which disorder would the nurse correlate with this assessment finding? a. Alzheimer disease b. Hypertension c. Diabetes mellitus d. Viral hepatitis
B
A client has a left knee arthrocentesis to remove excess joint fluid. What postprocedure health teaching will the nurse include? a. "Take your opioid medication as prescribed by the primary health care provider." b. "Do not bear weight on your left leg for at least a week after you get home." c. "Monitor the site for bleeding or clear fluid leakage when you are home." d. "Tell your employer that you can't come back to work for 2 to 3 weeks."
C
After a total knee arthroplasty, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the skin of both legs is pale pink, warm, and dry, but the client is unable to dorsiflex or plantarflex the surgical foot. What action would the nurse take next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client's bladder or perform a bladder scan.
C
The nurse is teaching a client who had a left humeral biopsy about home care. Which statement by the client indicatesunderstanding of the nurse's teaching? a. "I will take my opioids only when I have severe pain." b. "I will keep my left arm elevated for 24 hours." c. "I will watch for tenderness and warmth around the biopsy site." d. "I will report any discomfort to my primary health care provider immediately."
C
A nurse is caring for several clients with fractures. Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis? a. An 18-year-old male athlete with a fractured clavicle b. A 36-year-old female with type 2 diabetes and fractured ribs c. A 55-year-old female prescribed ibuprofen for osteoarthritis d. A 74-year-old male who smokes and has a fractured pelvis
D
A nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? a. "You must clean around your catheter daily with soap and water." b. "You will need to be on your drug therapy for life." c. "Operations to repair your bladder are available, and you can consider these." d. "You might want to get pants with elastic waistbands."
D
An older client who fell at home is admitted to the emergency department and reports pain in her left groin and behind her left knee. What action would the nurse anticipate? a. Administer IV push morphine. b. Prepare for application of a leg cast. c. Begin oxygen at 6 L/min via mask. d. Obtain a left hip x-ray.
D
The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client? a. Abdominal assessment b. Oxygen saturation c. Breath sounds d. Visual acuity
D
The nurse is caring for a postoperative client who have a regional nerve blockade for a surgical tibial fracture repair this morning. What assessment finding would the nurse expect? a. Client reports nausea and vomiting. b. Client reports tingling in the surgical leg. c. Client responds well to imagery. d. Client reports little to no pain.
D
The nurse teaches a client who has stress incontinence methods to regain more urinary continence. Which health teaching is the most important for the nurse to include for this client? a. What type of incontinence pads to use? b. What types of liquids to drink and when? c. Need to perform intermittent catheterizations. d. How to do Kegel exercises to strengthen muscles?
D
The nurse is teaching assistive personnel about postoperative care for an older adult who had a posterolateral total hip arthroplasty. What teaching will the nurse include? (Select all that apply.) a. "Move the client slowly to prevent dizziness and a possible fall." b. "Encourage the client to deep breathe and cough at least every 2 hours." c. "Help the client use the incentive spirometer at least every 2 hours." d. "Keep the abduction pillow in place at all times while the client is in bed." e. "Let me know if the client has an elevated temperature or pulse." f. "Keep in mind that the client may be a little confused after surgery." g. "Please let me know if you see any reddened or open skin areas during bathing."
A, B, C, D, E, F
A client has rheumatoid arthritis (RA) and the nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort
A, B, D
A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In addition to inquiring about calcium, the nurse also assesses for which other dietary components? (Select all that apply.) a. Alcohol b. Caffeine c. Fat d. Carbonated beverages e. Vitamin D
A, B, D, E
A nurse is visiting a client discharged home after a total hip arthroplasty. What safety precautions would the nurse recommend to the client and family? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.
A, B, D, E
The nurse is caring for an older client who had a total knee arthroplasty. Prior to surgery, the client lived alone independently. With which interprofessional health care team members will the nurse collaborate to ensure positive client outcomes? (Select all that apply.) a. Case manager b. Mental health counselor c. Physical therapist d. Occupational therapist e. Speech-language pathologist f. Clergy/Spiritual leader
A, C
A nurse is planning postoperative care for a client following a total hip arthroplasty. What nursing interventions would help prevent venous thromboembolism for this client? (Select all that apply.) a. Early ambulation b. Fluid restriction c. Quadriceps-setting exercises d. Compression stockings/devices e. Anticoagulant drug therapy
A, C, D, E
A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment
A, C, E
A client who had a surgical fractured femur repair reports new-onset shortness of breath and increased respirations. What is the nurse's first action? a. Place the client in a high-Fowler position. b. Document the client's oxygen saturation level. c. Start oxygen therapy at 2 L/min via nasal cannula. d. Contact the primary health care provider.
A
A client who has rheumatoid arthritis is prescribed etanercept. What health teaching by the nurse about this drug is appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site
A
A nurse assesses a client who presents with renal calculi. Which question would the nurse ask? a. "Do any of your family members have this problem?" b. "Do you drink any cranberry juice?" c. "Do you urinate after sexual intercourse?" d. "Do you experience burning with urination?"
A
A nurse assesses an older adult who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless with an oxygen saturation of 88%. Which action would the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a semi-Fowler position. c. Increase the intravenous flow rate. d. Assess response to pain medication.
A
A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse respond? a. "Skeletal traction will assist in realigning your fractured bone." b. "This treatment will prevent future complications and back pain." c. "Traction decreases muscle spasms that occur with a fracture." d. "This type of traction minimizes damage as a result of fracture treatment."
A
A nurse contacts the primary health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL (12.5 mmol/L) and a serum creatinine of 1.0 mg/dL (88.4 mcmol/L). What collaborative care measure would the nurse recommend? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity
A
A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed? a. "I don't need to go to the hospital after using it." b. "I must carry two autoinjectors with me at all times." c. "I will write the expiration date on my calendar." d. "This can be injected right through my clothes."
A
A nurse is caring for a client with diabetes mellitus who has fractured her arm. Which action would the nurse take first? a. Remove the medical alert bracelet from the fractured arm. b. Immobilize the arm by splinting the fractured site. c. Place the client in a supine position with a warm blanket. d. Cover any open areas with a sterile dressing.
A
A nurse is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which drug does the nurse plan health teaching? a. Acetaminophen b. Cyclobenzaprine hydrochloride c. Hyaluronate d. Ibuprofen
A
A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question would the nurse ask when determining this client's risk factors? a. "Do you smoke cigarettes?" b. "Do you use any alcohol?" c. "Do you use recreational drugs?" d. "Do you take any prescription drugs?"
A
A nurse teaches a young female client who is prescribed cephalexin for a urinary tract infection. Which statement would the nurse include in this client's teaching? a. "Use a second form of birth control while on this medication." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heartbeat while on this drug." d. "Watch for blood in your urine while taking this medication."
A
After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? a. "I will limit my total intake of fluids." b. "I must avoid drinking alcoholic beverages." c. "I must avoid drinking caffeinated beverages." d. "I shall try to lose about 10% of my body weight."
A
An older client is distressed at body changes related to kyphosis. What response by the nurse is appropriate? a. Ask the client to explain more about these feelings. b. Explain that these changes are irreversible. c. Offer to help select clothes to hide the deformity. d. Tell the client that safety is more important than looks.
A
The nurse assesses a client after a total hip arthroplasty. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is appropriate? a. Assess neurovascular status in both legs. b. Elevate the surgical leg and apply ice. c. Prepare to administer pain medication. d. Try to place the surgical leg in abduction.
A
The nurse delegates completing a bladder scan to assistive personnel (AP). Which action by the AP indicates that the nurse must provide additional instructions when delegating this task? a. Selecting the female icon for all female patients and male icon for all male patients b. Telling the client, "This test measures the amount of urine in your bladder." c. Applying ultrasound gel to the scanning head and removing it when finished d. Taking at least two readings using the aiming icon to place the scanning head
A
The nurse is teaching a client how to use a cane after a right surgical fractured fibula repair. What health teaching would the nurse include? a. "Place the cane on your left side." b. "Move the cane and your left leg at the same time." c. "Be sure the cane is parallel to your waist." d. "Use the cane only when your right leg is painful."
A
The nurse is teaching a client who is prescribed acetaminophen for control of osteoarthritic joint pain. What statement by the client indicates a need for further teaching? a. "I won't take more than 5000 mg of this drug each day." b. "I'll follow up to get my lab tests done to check my liver." c. "I'll check drugs that I take for acetaminophen in them." d. "I can use topical patches and creams to help relieve pain."
A
What information does the nurse teach a women's group about osteoporosis? a. "Primary osteoporosis occurs in postmenopausal women due to lack of estrogen." b. "Men actually have higher rates of the disease but are underdiagnosed." c. "There is no way to prevent or slow osteoporosis after menopause." d. "Women and men have an equal chance of getting osteoporosis."
A
A client who had a recent total knee arthroplasty will be using a continuous passive motion (CPM) machine after discharge at home. What health teaching about the CPM machine will the nurse include? (Select all that apply.) a. "Keep the machine padded well to prevent skin breakdown." b. "Ensure that your leg is placed properly on the machine." c. "Use the machine as prescribed but not at mealtime." d. "When the machine is not being used, do not store it on the floor." e. "Check that the cycle and range of motion is kept at the level prescribed."
ALL
The nurse is assessing a client with long-term rheumatoid arthritis (RA) who has been taking prednisone for 10 years. For which complications of chronic drug therapy would the nurse assess? (Select all that apply.) a. Osteoporosis b. Diabetes mellitus c. Glaucoma d. Hypertension e. Hypokalemia f. Decreased immunity
ALL
15. A client with osteoporosis is going home where the client lives alone. What action by the nurse is best? a. Refer the client to Meals on Wheels. b. Arrange a home safety evaluation. c. Ensure that the client has a walker at home. d. Help the client look into assisted living.
B
A client asks the nurse about having a total knee arthroplasty to relieve joint pain. Which factor would place the client at the highest risk for impaired postoperative healing? a. Controlled hypertension b. Obesity c. Osteoarthritis d. Mild osteopenia
B
A client has a bone density score of -2.8. What intervention would the nurse anticipate based on this assessment? a. Asking the client to complete a food diary b. Planning to teach about bisphosphonates c. Scheduling another scan in 2 years d. Scheduling another scan in 6 months
B
A client has been newly diagnosed with systemic lupus erythematosus and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to review the material? a. "I will avoid direct sunlight as much as possible." b. "Baby powder is good for the constant sweating." c. "Grouping errands will help prevent fatigue." d. "Rest time will have to become a priority."
B
A client has been prescribed denosumab. What health teaching about this drug is most appropriate for the nurse to include? a. "Drink at least 8 ounces (240 mL) of water with it." b. "Make appointments to come get your injection." c. "Sit upright for 30 to 60 minutes after taking it." d. "Take the drug on an empty stomach."
B
A client is admitted to the emergency department with a fractured femur resulting from a motor vehicle crash. What the nurse's priority action? a. Keep the client warm and comfortable. b. Assess airway, breathing, and circulation. c. Maintain the client in a supine position. d. Immobilize the injured extremity with a splint.
B
A client who had a fractured ankle open reduction internal fixation (ORIF) 4 weeks ago reports burning pain and tingling in the affected foot. For which potential complication would the nurse anticipate? a. Delayed bone healing b. Complex regional pain syndrome c. Peripheral neuropathy d. Compartment syndrome
B
A client who had a traumatic above-the-knee amputation states that he fears he will never have an intimate relationship again. What is the nurse's best response? a. "You'll be able to get a leg prosthesis soon." b. "You think you won't be able to have sex again?" c. "I will ask the social worker to talk with you." d. "Are you married now or have a girl friend?"
B
A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic intervention does the nurse recommend? a. Heating pad b. Ice packs c. Splint d. Paraffin dip
B
A nurse assesses a client who is recovering from extracorporeal shock-wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client's right lower back. What action would the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.
B
A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit
B
A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How would the nurse respond? a. "Your immune system becomes less effective as you age." b. "Low estrogen levels can make the tissue more susceptible to infection." c. "You should be more careful with your personal hygiene in this area." d. "It is likely that you have an untreated sexually transmitted disease."
B
A nurse plans care for a client who is recovering from a below-the-knee amputation of the left leg. Which intervention would the nurse include in this client's plan of care? a. Place pillows between the client's knees. b. Encourage range-of-motion exercises. c. Administer prophylactic antibiotics. d. Implement strict bedrest in a supine position.
B
A nurse reviews the laboratory findings of a client with a urinary tract infection (bacterial cystitis). The laboratory report notes a "shift to the left" in the client's white blood cell count. What action would the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the primary health care provider and start an intravenous line for parenteral antibiotics. c. Ask assistive personnel (AP) to strain the client's urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.
B
After delegating care to assistive personnel (AP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the AP's understanding. Which action indicates that the AP needs additional teaching? a. Toileting the client after breakfast b. Changing the client's incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the client's incontinence episodes
B
The nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question would the nurse ask first? a. "Are you drinking plenty of water?" b. "What medications are you taking?" c. "Have you tried laxatives or enemas?" d. "Has this type of thing ever happened before?"
B
The nurse assesses a client with diabetes and osteoarthritis (OA) during a checkup. The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you following the prescribed diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"
B
The nurse is assessing a group of clients for their risk of kidney disease. Which racial/ethnic group is at the greatest risk as they age? a. Latino Americans b. African Americans c. Jewish Americans d. Asian Americans
B
The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? a. Administering steroids for a positive TB test b. Correctly identifying the client prior to a blood transfusion c. Keeping the client free of the offending agent d. Providing a latex-free environment for the client
B
The nurse is teaching assistant personnel (AP) about care of an older ambulatory adult who has osteopenia. Which statement by the AP indicates understanding of the teaching? a. "I will tell the client to change positions frequently to prevent pressure injury." b. "I will remind the client to take frequent walks to strengthen bones." c. "I will assist the client with activities of daily living as needed." d. "I will apply warm compresses to the joints to relieve pain."
B
The nurse is teaching assistive personnel (AP) about the risk for osteoporosis associated with race or ethnicity. Which population typically has a decreased incidence of osteoporosis when compared to Euro-Americans? a. Irish Americans b. African Americans c. American Indians d. Asian Americans
B
An older client's serum calcium level is 8.7 mg/dL (2.18 mmol/L). What possible etiology(ies) does the nurse consider for this result? (Select all that apply.) a. Good dietary intake of calcium and vitamin D b. Normal age-related decrease in serum calcium c. Possible occurrence of osteoporosis or osteopenia d. Potential for metastatic cancer or Paget disease e. Recent bone fracture in a healing stage
B, C
The nurse is teaching a client with mild rheumatoid arthritis (RA) about how to protect synovial joints. Which health teaching will the nurse include? (Select all that apply.) a. "Use small joints rather than larger ones during tasks." b. "Use both hands instead of one with holding objects." c. "When getting out of bed or a chair, use the palms of your hands." d. "Bend your knees instead of your waist and keep your back straight." e. "Do not use multiple pillows under your head to prevent neck flexion." f. "Use a device or rubber grip to open jars or bottle tops." g. "Use long-handled devices such as a hairbrush with an extended handle."
B, C, D, E, F, G
The nurse assesses a client with long-term rheumatoid arthritis (RA) for late signs and symptoms. Which assessment findings will the nurse document as late signs and symptoms of RA? (Select all that apply.) a. Anorexia b. Felty syndrome c. Joint deformity d. Low-grade fever e. Weight loss
B, C, E
A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3 months. What explanation by the nurse is best? a. "The bones in your feet are hard to operate on." b. "The surrounding bones and tissue are damaged." c. "Your feet have less blood flow, so healing is slower." d. "Your feet bear weight so they never really heal."
C
A client has long-term rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is appropriate? a. "Let's ask your provider about increasing your pain pills." b. "Hold ice bags against your hands before quilting." c. "Try a paraffin wax dip 20 minutes before you quilt." d. "You need to stop quilting before it destroys your fingers."
C
A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below: What action by the nurse takes is most appropriate? a. Administer epinephrine 1:1000, 0.3 mg IV push immediately. b. Apply oxygen by facemask at 100% and a pulse oximeter. c. Ensure a patent airway while calling the Rapid Response Team. d. Reassure the client that these symptoms will go away.
C
A client is prescribed celecoxib for joint pain. What statement by the client indicates a need for further teaching? a. "I'll report any signs of bleeding or bruising to my primary health care provider." b. "I'll take this drug only as prescribed by my primary health care provider." c. "I'll be sure to take this drug three times a day only on an empty stomach." d. "I'll monitor the amount of urine that I excrete every day and report any changes."
C
A client with pneumonia and dementia is admitted with an indwelling urinary catheter in place. During interprofessional rounds the following day, which question would the nurse ask the primary health care provider? a. "Do you want daily weights on this client?" b. "Will the client be able to return home?" c. "May we discontinue the indwelling catheter?" d. "Should we get another chest x-ray today?"
C
A hospitalized client's strength of the upper extremities is rated at a 4. What does the nurse understand about this client's ability to perform activities of daily living (ADLs)? a. The client is able to perform ADLs but not lift some items. b. The client is unable to perform ADLs alone. c. No difficulties are expected with ADLs. d. The client would need almost total assistance with ADLs.
C
A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to my kidney problem?" How would the nurse respond? a. "Red blood cells produce erythropoietin, which increases blood flow to the kidneys." b. "Your anemia and kidney problem are related to inadequate vitamin D and a loss of bone density." c. "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow." d. "Kidney insufficiency inhibits active transportation of red blood cells throughout the blood."
C
A nurse assesses clients in an osteoporosis clinic. Which client would the nurse assess first? a. Client taking calcium with vitamin D who reports flank pain 2 weeks ago. b. Client taking ibandronate who cannot remember when the last dose was. c. Client taking raloxifene who reports unilateral calf swelling. d. Client taking risedronate who reports occasional dyspepsia.
C
A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, "My pain has suddenly increased from a 3 to a 10 on a scale of 0-10." Which action would the nurse take first? a. Reposition the client on the operative side. b. Administer the prescribed opioid analgesic. c. Assess the client's pulse rate and blood pressure. d. Examine the color of the client's urine.
C
A nurse has presented an educational program to a community group on Lyme disease. What statement by a participant indicates the need to review the material? a. "I should take precautions against ticks, especially in the summer." b. "A red rash that looks like a bull's-eye may be one of the symptoms." c. "If Lyme disease is not treated successfully, it is usually fatal." d. "For Stage I disease, antibiotics are usually needed for 14 to 21 days."
C
A nurse is caring for a client recovering from an above-the-knee amputation of the right leg. The client reports pain in the right foot. Which prescribed medication would the nurse most likely administer? a. Intravenous morphine b. Oral acetaminophen c. Intravenous calcitonin d. Oral ibuprofen
C
A nurse is caring for an older client who is recovering from a leg amputation surgery. The client states, "I don't want to live with only one leg. I should have died during the surgery." What is the nurse's best response? a. "Your vital signs are good, and you are doing just fine right now." b. "Your children are waiting outside. Do you want them to grow up without a father?" c. "This is a big change for you. What support system do you have to help you cope?" d. "You will be able to do some of the same things as before you became disabled."
C
A nurse is caring for four clients. After the hand-off report, which client would the nurse see first? a. Client with osteoporosis and a white blood cell count of 27,000/mm3 (27 × 109/L) b. Client with osteoporosis and a bone fracture who requests pain medication c. Post-microvascular bone transfer client whose distal leg is cool and pale d. Client with suspected bone tumor who just returned from having a spinal CT
C
A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/kg (1200 mmol/kg). Which action would the nurse take? a. Contact the primary health care provider to recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Encourage the client to drink more fluids. d. Obtain a suction device and implement seizure precautions.
C
A nurse teaches a client who is starting urinary bladder training. Which statement would the nurse include in this client's teaching? a. "Use the toilet when you first feel the urge, rather than at specific intervals." b. "Initially try to use the toilet at least every half hour for the first 24 hours." c. "Try to consciously hold your urine until the scheduled toileting time." d. "The toileting interval can be increased once you have been continent for a week."
C
After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I will not take this drug with food or milk." b. "I will have my partners tested for STIs." c. "An orange color in my urine should not alarm me." d. "I will drink two glasses of cranberry juice daily."
C
An older client with diabetes is admitted with a heavily draining leg wound. The client's white blood cell count is 38,000/mm3 (38 × 109/L) but the client is afebrile. Which nursing action is most appropriate at this time? a. Administer acetaminophen as needed. b. Educate the client on amputation. c. Place the client on Contact Precautions. d. Refer the client to the wound care nurse.
C
The nurse assesses a client who has possible bladder cancer. What common assessment finding associated with this type of cancer would the nurse expect? a. Urinary retention b. Urinary incontinence c. Painless hematuria d. Difficulty urinating
C
The nurse is caring for a client who had a closed reduction of the left arm and notes a large wet area of drainage on the cast. What action is the most important? a. Cut off the old cast. b. Document the assessment. c. Notify the primary health care provider. d. Wrap the cast with gauze.
C
The nurse is caring for a client who has severe osteoarthritis. What primary joint problems will the nurse expect the client to report? a. Crepitus b. Effusions c. Pain d. Deformities
C
The nurse is caring for a client with urinary incontinence. The client states, "I am so embarrassed. My bladder leaks like a young child's bladder." How would the nurse respond? a. "I understand how you feel. I would be mortified." b. "Incontinence pads will minimize leaks in public." c. "I can teach you strategies to help control your incontinence." d. "More people experience incontinence than you might think."
C
The nurse is performing an assessment of a client with possible plantar fasciitis in the right foot. What assessment finding would the nurse expect in the right foot? a. Multiple toe deformities b. Numbness and paresthesias c. Severe pain in the arch of the foot d. Redness and severe swelling
C
The nurse is teaching a client who is planning to have a total hip arthroplasty. What statement by the client indicates a need for further teaching? a. "I will get an IV antibiotic right before surgery to prevent infection." b. "I may request a regional nerve block as part of the surgical anesthesia." c. "I will receive IV heparin before surgery to decrease the risk of clots." d. "I will receive tranexamic acid to help reduce blood loss during surgery."
C
The nurse teaches assistive personnel (AP) about care of an older adult diagnosed with osteoporosis. What teaching would the nurse include? a. "Teach the client to eat high-calcium foods in the diet." b. "Assist the client with activities of daily living." c. "Osteoporosis places the client is at risk for fractures." d. "The client should stay in bed to prevent falling."
C
The primary health care provider prescribes methotrexate (MTX) for a client with a new diagnosis of rheumatoid arthritis. The nurse provides health teaching about the drug. What statement by the nurse is appropriate to include about methotrexate? a. "It will take at least 1 to 2 weeks for the drug to help relieve your symptoms." b. "The drug is very expensive but there are pharmacy plans to help pay for it." c. "The drug can increase your risk for infection, so you should avoid crowds." d. "It's OK for you to drink about 2 to 3 glasses of wine each week while taking the drug."
C
A nurse is providing education to a community women's group about lifestyle changes helpful in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.) a. Cut down on tobacco product use. b. Limit alcohol to two drinks a day. c. Strengthening exercises are important. d. Take recommended calcium and vitamin D. e. Walk for 30 minutes at least three times a week.
C, D, E
The nurse reviews a list of drugs that can cause secondary osteoporosis.Which drugs are most commonly associated with this health problem? (Select all that apply.) a. Antianxiety agents b. Antibiotics c. Barbiturates d. Corticosteroids e. Loop diuretics
C, D, E
The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which laboratory value(s) would the nurse expect to be elevated? (Select all that apply.) a. Calcium (Ca) b. Phosphate (PO4) c. Creatine kinase (CK) d. Lactic dehydrogenase (LDH) e. Aspartate aminotransferase (AST) f. Aldolase (ALD)
C, D, E, F
A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority? a. Might make the client feel jittery or nervous. b. Can cause sodium and fluid retention. c. Long-term effects include fat redistribution. d. Never stop prednisone abruptly.
D
A nurse plans care for a client who has an external fixator on the lower leg. Which intervention would the nurse include in the plan of care to decrease the client's risk for infection? a. Washing the frame of the fixator once a day b. Releasing fixator tension for 30 minutes twice a day c. Avoiding moving the extremity by holding the fixator d. Scheduling for pin care to be provided every shift
D
A nurse plans care for a client with overflow incontinence. Which intervention does the nurse include in this client's plan of care to assist with elimination? a. Stroke the medial aspect of the thigh. b. Use intermittent catheterization. c. Provide digital anal stimulation. d. Use the Valsalva maneuver.
D
A nurse reviews the urinalysis of a client and notes the presence of glucose. What action would the nurse take? a. Document findings and continue to monitor the client. b. Contact the primary health care provider and recommend a 24-hour urine test. c. Review the client's recent dietary selections over 3 days. d. Perform a finger stick blood glucose assessment.
D
A nurse teaches assistive personnel (AP) about providing hygiene for a client in traction. Which statement would the nurse include as part of the teaching about this client's care? a. "Remove the traction when re-positioning the client." b. "Assess the client's skin when performing a bed bath." c. "Provide pin care by using alcohol wipes to clean the sites." d. "Ensure that the weights remain freely hanging at all times."
D
After teaching a client with a fractured humerus, the nurse assesses the client's understanding. Which dietary choice demonstrates that the client correctly understands the nutrition needed to assist in healing the fracture? a. Baked fish with orange juice and a vitamin D supplement b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement c. Vegetable lasagna with a green salad and a vitamin A supplement d. Roast beef with low-fat milk and a vitamin C supplement
D
The nurse interviews an older client with moderate osteoarthritis and her husband. What psychosocial assessment question would the nurse include? a. "Do you feel like hurting yourself or others?" b. "Are you planning to retire due to your disease?" c. "Do you ask your husband for assistance?" d. "Do you experience discomfort during sex?"
D
The nurse is caring for a young client who has been diagnosed with osteopenia. Which risk factor in the client's history most likely contributed to the bone loss? a. Osteoarthritis b. Hypothyroidism c. Addison disease d. Rheumatoid arthritis
D
The nurse is caring for an older client who has kyphosis and a widened gait. For which health problems is the client at risk? a. Osteoporosis b. Contracture c. Osteopenia d. Falls
D
The nurse is caring for several clients with osteoporosis. For which client would bisphosphonates not be a good option? a. Client with diabetes who has a serum creatinine of 0.8 mg/dL (61 mcmol/L). b. Client who recently fell and has vertebral compression fractures. c. Hypertensive client who takes calcium channel blockers. d. Client with a spinal cord injury who cannot tolerate sitting up.
D
The nurse is performing a neurovascular assessment for an older client who has an extremity fracture. How many seconds would the nurse expect for a capillary refill in it is within normal range? a. 20 seconds b. 15 seconds c. 10 seconds d. 5 seconds
D
The nurse is taking a history from an older client who reports having frequent falls. Which dietary habit could be contributing to the client's problem? a. Consumes high-protein foods. b. Eats few concentrated sweets. c. Limits fatty or greasy foods. d. Avoids dairy products.
D
A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first? a. Assess the neurovascular status of the right leg. b. Document the findings in the patient's chart. c. Elevate the left leg on at least two pillows. d. Notify the primary health care provider immediately.
A
A client has a metastatic bone tumor in the left leg. What action by the nurse is appropriate? a. Administer pain medication as prescribed. b. Elevate the extremity and apply moist heat. c. Teach the client about amputation care. d. Place the client on protective precautions.
A
A client has been advised to perform weight-bearing exercises to help slow bone loss, but has not followed this advice. What response by the nurse is appropriate at this time? a. Ask the client about fear of falling. b. Instruct the client to increase calcium. c. Suggest other exercises the client can do. d. Tell the client to try weight lifting.
A
A client is getting out of bed into the chair for the first time after an uncemented total hip arthroplasty. What action by the nurse is appropriate? a. Have adequate help to transfer the patient. b. Provide socks so the patient can slide easier. c. Tell the patient full weight bearing is allowed. d. Use a footstool to elevate the patient's leg.
A
A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate? a. "Antihistamines do not help poison ivy." b. "There are different antihistamines to try." c. "You should be seen in the clinic right away." d. "You will need to take some IV steroids."
A
The nurse takes a history on a male client reporting chronic back pain. Which factor(s) in the client's history may have contributed to his pain? (Select all that apply.) a. Had a motor vehicle crash 10 years ago. b. Played football in college and high school. c. Has installed carpet and other flooring for 30 years. d. Typically takes walks 3 to 4 days each week. e. Eats two servings of dark, green leafy vegetables daily.
A, B, C
A female client is preparing to have open magnetic resonance imaging (MRI) of the spine. What action(s) by the nurse is (are) most important to assess before the test? (Select all that apply.) a. Ask if the client has a history of kidney disease. b. Ask the client if she could possibly be pregnant. c. Ensure that the patient has no metal or electronic implants. d. Assess the client for the ability to communicate. e. Assess the client for a history of claustrophobia.
A, B, C, D
A nurse cares for a client with a urine specific gravity of 1.040. What action would the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the client's creatinine level. d. Increase the client's fluid intake.
D
A nurse is caring for a client who is recovering from an above-the-knee amputation and reports pain in the limb that was removed. How would the nurse respond? a. "The pain you are feeling does not actually exist." b. "This type of pain is common and will eventually go away." c. "Would you like to learn how to use imagery to minimize your pain?" d. "How would you describe the pain that you are feeling?"
D
A client is scheduled to have a total hip arthroplasty. What preoperative teaching by the nurse is most important? a. Teach the need to discontinue all medications for 5 days before surgery. b. Teach the patient about foods high in protein, Vitamin C, and iron. c. Explain to the client the possible need for blood transfusions postoperatively. d. Remind the client to have all dental procedures completed at least 2 weeks prior to surgery.
D
A nurse assesses a client with a pelvic fracture. Which assessment finding would the nurse identify as a complication of this injury? a. Hypertension b. Diarrhea c. Infection d. Hematuria
D
A nurse cares for a client who had a wrist cast applied 3 days ago. The client states, "The cast is loose enough to slide off." How would the nurse respond? a. "Keep your arm above the level of your heart." b. "As your muscles atrophy, the cast is expected to loosen." c. "I will wrap a bandage around the cast to prevent it from slipping." d. "You need a new cast now that the swelling is decreased."
D
A nurse cares for a client who has kidney stones from gout ricemia. Which medication does the nurse anticipate administering? a. Phenazopyridine b. Doxycyline c. Tolterodine d. Allopurinol
D