Adult One Exam IV questions

The nurse is assessing an older client who has bony nodules on finger joints (Heberden and Bouchard nodes). What priority question would the nurse want to ask as part of the client interview? "When did your bony nodules develop?" "How do you feel about having these bony nodules?" "Are you able to independently perform ADLs?" "Are your bony nodules painful or tender?"

"Are you able to independently perform ADLs?" As a result of the client having bony nodules in his or her hands, the most important question for the nurse to ask is to determine if the client is ADL independent. The nurse would also ask the other questions, but they are not the first questions to be asked.

Which statement by a client who has systemic lupus erythematosus (SLE) indicates to the nurse that more education about the disorder and its management is needed?

"At the first sign of a flare, I will begin taking my medication again." The client's statement suggests that he or she believes that daily medication is not needed and would be required only during a flare. However, daily drug therapy is essential to slow the progression of the disease and organ damage.Low-impact exercise such as walking is highly recommended to maintain mobility and promote cardiovascular health. Fevers are often associated with a flare. There is no contraindication to taking both NSAIDs and acetaminophen.

Buck's (skin) traction for a fractured hip is applied to a client while a urinary tract infection is treated before surgery. What instruction will the nurse give assistive personnel (AP) for providing client care related to the traction? "Inspect the pins in the traction for signs of infection." "Remove the boot every shift to inspect the skin." "Do not allow the traction weights to rest on the ground." "Remove traction weights when turning the client."

"Do not allow the traction weights to rest on the ground." Although Buck's traction is not used commonly today because clients have surgical hip repairs to reduce pain, for some clients such as this client, it is used short term until surgery can be performed. The AP should allow the weights to hang freely and not remove them. There are no pins and the boot can be removed by the nurse for skin inspection.

The nurse is planning health teaching for a client starting hydroxychloroquine for rheumatoid arthritis. What instruction would the nurse include in the teaching? "Be aware that the drug may cause secondary types of cancer." "Expect nausea and vomiting for the first week after starting the drug." "Have eye examinations every 6 months while on the drug." "Keep this medication in the refrigerator at all times."

"Have eye examinations every 6 months while on the drug." Hydroxychloroquine is an antimalarial drug with immune modulating and anti-inflammatory properties. Although side effects are usually mild, long-term use of the drug can cause vision problems. The client is taught to have an eye examination prior to starting the drug and every 6 months while on the drug to detect any visual changes.

What response by the nurse would be most therapeutic when a client who has systemic lupus erythematosus (SLE) says, "My face has changed so much. I feel really ugly"?

"I bet that was hard to say. Thank you for trusting me with your feelings." "I bet that was hard to say. Thank you for trusting me with your feelings" is an empathetic response in a hard conversation. It acknowledges the client's bravery for sharing and encourages further therapeutic communication. "You look great. It's what is inside that counts" is dismissive of the client's feelings. "Don't worry we will make everything better" is considered false reassurance, this can discount the client's feelings. "I know what you mean, I feel that way sometimes too" is focused on the nurse at a time when the focus should be on the client. All three responses hinder a continued conversation and therapeutic communication.

The nurse is teaching a client about dietary choices to prevent dumping syndrome after gastric bypass surgery. Which statement by the client indicates a need for further teaching? "I cannot drink alcohol at all." "I will need to avoid sweetened fruit juice beverages." "I can eat ice cream in moderation." "It is okay to have a serving of sugar-free pudding."

"I can eat ice cream in moderation." A need for further teaching about dietary changes related to dumping syndrome is indicated when the client says that ice cream can be eaten in moderation. Milk products such as ice cream must be eliminated from the diet of a patient with dumping syndrome.

The home health nurse is teaching a client about the care of a new colostomy. Which statement by the client demonstrates a correct understanding of the health teaching? "If the skin around the stoma is red or scratched, it will heal soon." "I need to strive for a very tight fit when applying the barrier around the stoma." "A dark or purplish-looking stoma is normal and would not concern me." "I need to check for leakage underneath my colostomy."

"I need to check for leakage underneath my colostomy." The client's statement, "I need to check for leakage underneath my colostomy" shows that the patient correctly understands the instructions about how to care for a new colostomy. The pouch system must be checked frequently for evidence of leakage to prevent excoriation. A purplish stoma is indicative of ischemia and necrosis. Redness or scratched skin around the stoma must be reported to prevent it from beginning to break down. An overly tight fit may lead to necrosis of the stoma.

A client who uses a computer for hours each day asks the nurse how to help prevent carpal tunnel syndrome (CTS). Which statement by the client indicates a need for further teaching? "I need to make sure I have an ergonomically sound computer station." "I need to exercise repetitively to strengthen my wrists." "I should stretch my fingers and wrists frequently during the day." "I may need to wear a wrist splint when my wrist gets inflamed."

"I need to exercise repetitively to strengthen my wrists." All of these statements are correct except that CTS is caused by repetitive motion such as that caused by working every day on computers. Repetitive exercises would therefore not be appropriate.

he nurse is teaching a client with irritable bowel syndrome (IBS) who has frequent constipation. Which statement by the client shows an accurate understanding of the nurse's teaching? "Maintaining a low-fiber diet will manage my constipation." "I need to go for a walk every day if possible." "Limiting the amount of fluid that I drink with meals is very important." "A cup of caffeinated coffee with cream & sugar at dinner is OK for me."

"I need to go for a walk every day if possible." The client statement, "I need to go for a walk every evening," shows that the client accurately understands the nurse's teaching plan to treat IBS. Walking every day is an excellent exercise for promoting intestinal motility. Increased ambulation is part of the management plan for IBS, along with increased fluids and fiber and avoiding caffeinated beverages.

The nurse is teaching a client how to prevent recurrent chronic gastritis symptoms before discharge. Which statement by the client demonstrates a correct understanding of the nurse's instruction? "I will need to take vitamin B12 shots for the rest of my life." "I should eat small meals about six times a day." "It is okay to continue to drink coffee in the morning when I get to work." "I should avoid alcohol and tobacco of any type."

"I should avoid alcohol and tobacco of any type." The client's statement that he or she needs to avoid alcohol and tobacco shows that the client correctly understands the nurse's instructions. The client also needs to eliminate caffeine from the diet. The client will need to take vitamin B12 shots only if he or she has pernicious anemia. The client would also not eat six small meals daily. This practice may actually stimulate gastric acid secretion.

The Certified Wound, Ostomy, and Continence Nurse (CWOCN) is teaching a client with colorectal cancer how to care for a newly created colostomy. Which statement by the client indicates a correct understanding of the necessary self-management skills? "If I have any leakage, I'll put a towel over it." "I can put aspirin tablets in the pouch in order to reduce odor" "I will apply a nonalcoholic skin sealant and let it dry before applying the bag." "I will have my spouse change the bag for me."

"I will apply a nonalcoholic skin sealant and let it dry before applying the bag." The nurse would teach the client and family to apply a skin sealant (preferably without alcohol) and allow it to dry before application of the appliance (colostomy bag) to facilitate less painful removal of the tape or adhesive. It is not realistic that the spouse will always change the patient's bag and does not reflect correct understanding of self-management skills. A towel is not an acceptable or effective way to cope with leakage. Putting an aspirin in the pouch will not reduce odor and can lead to ulcers in the stoma.

The nurse is teaching an older client how to prevent a stool impaction that can obstruct the intestines. Which statement by the client indicates a need for further teaching? "I will drink lots of fluids every day, especially water." "I will increase my exercise, especially walking, every day." "I will be sure to take a laxative every night to keep my bowels moving." "I will try to eat more high-fiber foods, such as raw vegetables and whole grains."

"I will be sure to take a laxative every night to keep my bowels moving." All of these statements are correct except that the client should not take laxatives because they can decrease the tone of the abdominal muscles.

The nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which statement by the client demonstrates a correct understanding of the nurse's instructions? "I will take laxatives after the surgery to 'keep things moving?0'." "To help with the pain, I'll apply ice to the surgical area." "I will need to eat a diet high in fiber, including raw vegetables." "Limiting my fluids will help me with constipation."

"I will need to eat a diet high in fiber, including raw vegetables." The statement that shows that the hemorrhoidectomy patient correctly understands the nurse's instruction is, "I will need to eat a diet high in fiber." A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements. Laxatives are discouraged because they can be habit-forming and decrease abdominal muscle tone. Increased amounts of fluids are needed to prevent constipation. Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications.

A male client is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which statement by the client indicates a need for further teaching about this procedure? "I may have trouble urinating immediately after the surgery." "My chances of having complications after this procedure are slim." "I will need to stay in the hospital overnight." "I will not eat after midnight the day of the surgery."

"I will need to stay in the hospital overnight." A need for further teaching about MIIHR is when the patient says, "I will need to stay in the hospital overnight." Usually, the patient is discharged 3 to 5 hours after MIIHR surgery. Male patients who have difficulty urinating after the procedure would be encouraged to force fluids and to assume a natural position when voiding. Patients undergoing MIIHR surgery must be NPO after midnight before the surgery. Most patients who have MIIHR surgery have an uneventful recovery.

Which client statement about the use and care of an epinephrine autoinjector for a peanut allergy indicates to the nurse that more teaching is needed?

"If I keep the injector in the refrigerator, the drug will not expire as quickly." Although it is true that the drug may not deteriorate as quickly if refrigerated, the client needs to have the drug with him or her at all times to use as soon as symptoms of anaphylaxis occur in order to prevent death. All other statements for the use and care of an epinephrine autoinjector are correct.

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? "I can't believe that this has happened to me. I can't stand to look at it." "I do not want any visitors while I'm in the hospital." "My spouse will be the only person to change my dressing." "It will take me some time to get used to this."

"It will take me some time to get used to this." Acknowledging that it will take time to get used to the amputation indicates that the client is expressing acceptance and effective coping. Stating that the spouse will change the dressing indicates the client does not want to participate in self-care. Expressing disbelief and disgust over the amputation indicates the client is unwilling to address what has happened. The client who does not want to receive visitors is having difficulty coping with the change in body image.

An older adult client who has osteoporosis is discharged from the hospital. What does the nurse include in health teaching related to the client's home safety? "Keep walkways free of clutter." "Keep light low to prevent glare." "Walk slowly on wet floor areas after mopping." "Use area rugs on tile floors."

"Keep walkways free of clutter." The nurse teaches the client that walkways in the home must be clear of clutter and obstacles to help prevent falls. Clients with metabolic bone problems should not use area rugs at home because they may cause tripping or falling. Clients with metabolic bone problems must not walk on wet floors because the potential for falling is too great. Keeping the lights low would not allow the client to see adequately to walk safely or avoid an object on the floor.

What is the nurse's best response to a client newly diagnosed with systemic lupus erythematosus (SLE) who asks why nicotine use, especially cigarette smoking or vaping, should be avoided?

"Nicotine reduces blood flow to your organs and increases the risk for permanent damage." Nicotine in any form constricts blood vessels and reduces perfusion. Perfusion is already reduced by the vasculitis that is part of the disease. Thus, use of nicotine greatly increases the risk for necrosis of many tissues and organs. Although smoking or vaping do increase the risk for lung cancer, their effects on blood vessels are a greater issue for the client with SLE. Nicotine neither reduces the effectiveness of drug therapy nor promotes muscle cell loss.

A young female client whose mother and grandmother have osteoporosis asks whether she needs to take steps to prevent this disease in herself. What will the nurse tell this client? "Now is the time to begin building strong bones." "Your risk isn't present until age 50; we can talk about it then." "You do not have to worry about symptoms at your age." "You should begin to take steps to prevent disease at age 30."

"Now is the time to begin building strong bones." The nurse will tell this client that peak bone mass is achieved by about 30 years of age in most women, so building strong bone as a young person may be the best defense against osteoporosis in later adulthood. She needs to begin getting adequate calcium and vitamin D now as well as exercising to help build strong bones. The nurse will not tell the client not to worry about symptoms at her age. Beginning at age 30 may be too late. By the time symptoms appear in older adulthood, it is too late to build strong bones.

A client who has osteopenia is prescribed to begin risedonate. What health teaching would the nurse include about this drug? "Take the drug with dinner or other meal or snack every day." "Remain in an upright position for 30 minutes after taking the drug." "Be sure to follow up with lab work to monitor your liver function." "Be sure to report any new bone pain or infection."

"Remain in an upright position for 30 minutes after taking the drug." Risedonate is an oral bisphosphonate that can cause esophagitis. Therefore, the nurse would teach the client to take the drug before breakfast on an empty stomach with a glass of water, and stay in an upright position (sitting or standing) for at least 30 minutes after taking the drug.

The nurse is caring for a client who has been treated for osteoporosis for 15 years and is starting on denosumab. What health teaching is appropriate for the nurse to include about this drug? "You will receive an IV infusion once a year by your provider." "Take the drug every morning with a glass of water." "Have a dental examination prior to beginning the drug." "See your primary health care provider for twice yearly injections."

"See your primary health care provider for twice yearly injections." Denosumab is a RANKL inhibitor drug administered subcutaneously by a health care professional twice a year. Dental examinations are recommended for clients who are preparing to take bisphosphates.

The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? "I do not know how long my wife will be able to take care of me at home." "I am helping with the dishes and laundry, but I hurt so badly when I am doing it." "I do not know how much longer my neighbor can continue to help clean my house." "The bus is coming to pick me up from the senior center three times a week so I can play cards."

"The bus is coming to pick me up from the senior center three times a week so I can play cards." Participation in diversional activities is a way to cope with daily stressors of osteoarthritis and shows good use of available resources for support. Caregiving responsibilities can be a source of stress; the client worrying about his wife's caregiving abilities does not indicate that the client is effectively coping. Routine tasks, such as doing dishes and laundry, need to be reassigned or effective pain management should be instituted before activities are undertaken to demonstrate effective coping. Neighbors are not reliable resources for in-home needs, and asking a neighbor to help does not indicate that the client is coping effectively.

What is the nurse's best response to a client who had a severe allergic reaction to shrimp states, "I have had shrimp once before and did not have a reaction. Why is this happening now?"

"The first time your body recognized the shrimp as an allergen, and the second time it reacted to it." Type I reactions have two parts. During the first exposure, the client makes antigen-specific IgE, and becomes sensitized to the allergen. When the sensitized client is re-exposed to the allergen, a more severe reaction occurs. To point out the amount of shrimp eaten is not helpful and could make the client believe that eating only a small amount of shrimp would not cause a reaction. The same is true for option C. Stating that allergies "are tricky" does not help to inform or educate the client about what he or she should do to prevent harm. This response may make the client afraid of everything in his or her environment.

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. The client asks whether he will inherit the disease. How would the nurse respond? "Have you asked your primary health care provider about your chances ?" "It is hard to know what can predispose a person to develop a certain disease." "The only way to know whether you are predisposed to CRC is by genetic testing." "No. Just because they both had CRC doesn't mean that you will have it, too."

"The only way to know whether you are predisposed to CRC is by genetic testing." The nurse's best response to the client who asks if he will inherit CRC is "the only way to know whether you are predisposed to CRC is by genetic testing." Genetic testing is the only definitive way to determine whether the patient has a predisposition to develop CRC.

A client with peptic ulcer disease (PUD) asks the nurse whether licorice and slippery elm might be useful in managing the disease. What is the nurse's best response? "No, they probably won't be useful. You should use only prescription medications in your treatment plan." "These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." "No, herbs are not useful for managing this disease. You can use any type of over-the-counter drugs though. They have been shown to be safe." "Yes, these are known to be effective in managing this disease but make sure you research the herbs thoroughly before taking them."

"These herbs could be helpful. However, you should talk with your primary health care provider before adding them to your treatment regimen." The nurse's best response is that although licorice and slippery elm may be helpful in managing PUD, the client must consult his or her primary health care provider before making a change in the treatment regimen. Alternative therapies may or may not be helpful in managing PUD. The client should not use over-the-counter medications without first discussing it with his or her primary health care provider.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? "Avoid rigorous exercise." "Avoid contact sports." "Wear helmets when riding a motorcycle." "Avoid driving in inclement weather."

"Wear helmets when riding a motorcycle." Those who ride motorcycles or bicycles should wear helmets to prevent head injury. Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic, but it is also opposed to what many health care professionals recommend to maintain health.

The nurse is planning health teaching about omeprazole for a client who has acute gastritis. What would the nurse include in the health teaching? Crushing the drug and mixing in applesauce Avoiding alcohol while taking this drug Taking the drug 30 minutes before a meal Taking the drug when the client has gastric pain

Taking the drug 30 minutes before a meal This drug is a proton pump inhibitor and is activated by the presence of food in the stomach. Therefore, it should be taken before a meal.

Which intervention would the nurse suggest to a client who has undergone a leg amputation to help cope with loss of the limb? Talking with a psychiatrist about the amputation Engaging in diversional activities to avoid focusing on the amputation Talking with an amputee close to the client's age who has a similar amputation Drawing a picture of how the client sees him- or herself

Talking with an amputee close to the client's age who has a similar amputation Meeting with someone of a comparable age who has gone through a similar experience will help the client cope better with his or her own situation. Drawing a picture is not therapeutic and may cause more harm than good. Unless the client is having serious maladjustment problems or has a coexisting psychological disorder, meeting with a psychiatrist would not be necessary. Diversional activities do not help the client deal with loss of the limb.

The nurse is preparing to give apixaban for a client who recently had a total knee arthroplasty. What does the nurse recognize as the advantage of this drug over other anticoagulants? The client does not need to have labs drawn for PT or INR. The client only needs to take the drug while in the hospital. The client is not at risk for bleeding or bruising. The client does not need to wear sequential compression devices.

The client does not need to have labs drawn for PT or INR. Apixaban is a newer factor Xa inhibitor that helps to prevent venous thromboembolism in clients who have a total knee arthroplasty. The client taking this drug will need to continue for several weeks after surgery and is at risk for bleeding or bruising. However, the drug does not affect PT or INR, so that the client does not need to have labs drawn.

Which action is the priority for the nurse to take to prevent harm for the alert 58-year-old client who is admitted to the emergency department with wheezing, dyspnea, angioedema, blood pressure of 70/52 mm Hg, and an irregular apical pulse of 122 beats/min?

-Applying oxygen via a high-flow nonrebreather mask at 90% to 100% The immediate priority is to apply oxygen in order to provide adequate oxygenation for the client who is in respiratory distress. Raising the lower extremities, starting an IV infusion, and reassuring the client are not the first priority for a client in respiratory distress.

Which statement(s) regarding type IV hypersensitivity reactions is/are true? (Select all that apply.)

-The major mechanism of the reaction is the release of mediators from sensitized T-cells that trigger antigen destruction by macrophages. -Type IV responses are usually directed against non-self but the response is excessive. -Rashes and blister formation from poison ivy exposure are a typical response for this type of hypersensitivity reaction. -Antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine. Type IV delayed hypersensitivity reactions have T-lymphocytes (T-cells) as the activated immune system component triggering the excessive responses. A classic example is allergy to poison ivy. Sensitized T-cells (from a previous exposure) respond to an antigen by releasing chemical mediators and triggering macrophages to destroy the antigen; however, histamine is not one of the mediators, making antihistamines of minimal benefit. A type IV response with edema, induration, ischemia, and tissue damage at the site of the exposure typically occurs hours to days after exposure. Angioedema is a type I response, not a type IV response.

Which type of hypersensitivity reaction will the nurse suspect in a client who develops a circular rash on the skin underneath a new necklace worn for 3 days?

-Type IV A type IV delayed hypersensitivity reaction occurs when sensitized T-cells respond to an antigen by releasing chemical mediators and triggering macrophages. This reaction causes a rash as seen in a metal allergy exposure. A type I reaction occurs rapidly after exposure and is mediated by immunoglobulin E (IgE). Type II reactions occur when the body makes autoantibodies directed against self-cells and attack those cells. Type III reactions occur when an abundance of immune complexes are made and they get stuck in small vessels causing inflammation.

Which client with persistent joint and muscle pain will the nurse consider as most likely to have a systemic lupus erythematosus (SLE) diagnosis?

A 33-year-old African-American woman whose mother has psoriasis. SLE is an autoimmune disorder that is much more common in women than in men and has a genetic predisposition related to tissue type. A client with SLE is very likely to have another close relative who also has an autoimmune disorder, such as psoriasis (myocardial infarction, type 2 diabetes mellitus, and thrombotic stroke are not autoimmune disorders). In addition, the incidence of SLE is about eight times greater for African-American women than for white women.

For which hypersensitivity situation will the nurse prepare a client for management with plasmapheresis?

A 35 year old with drug-induced hemolytic anemia Drug-induced hemolytic anemia is a type II hypersensitivity reaction in which the body makes autoantibodies directed against red blood cells that have foreign proteins from the drug attached to them. In this type of reaction, the autoantibody binds to red blood cells, forming immune complexes that destroy red blood cells along with the attached protein. Management starts with discontinuing the offending drug and, performing plasmapheresis (filtration of the plasma to remove specific substances) to remove the formed autoantibodies. Plasmapheresis is not beneficial with other types of hypersensitivity reactions.

The nurse is caring for a client with osteoarthritis (OA) in the left knee. What factor does the nurse suspect is the most likely cause of this client's OA? Trauma to the joint Aging Osteoporosis Familial history

Trauma to the joint The client has OA in one knee which suggests that the client has secondary OA rather than primary disease. Secondary OA occurs as a result of joint injury or obesity.

Which information about a client who was admitted with a pelvic fracture after being crushed by a tractor is most important for the nurse to assess to monitor for serious complications from this type of injury? Lungs for bilateral normal breath sounds Urine specimen to assess for the red blood cells Pain score and level of alertness Skin to evaluate lacerations and abrasions

Urine specimen to assess for the red blood cells It is most important for the nurse to determine the presence of blood in the urine as well as assessing the abdomen for rigidity. Clients with crushing injuries to the pelvis are at increased risk of internal hemorrhage. Pelvic injuries are the second cause of death from trauma after head injuries.Assessing the skin for external trauma and monitoring pain and alertness will be performed as part of the overall assessment but are not critical nursing actions at this time. Assessing lung sounds is more critical with chest injuries and rib fractures.

A client was recently diagnosed with osteoarthritis and asks the nurse which over-the-counter drug would be the best to take? What would the nurse's recommendation be? Ibuprofen Acetaminophen Tramadol Gabapentin

Acetaminophen Several major medical organizations, including the American Pain Society and OARSI committee recommend acetaminophen as the primary drug of choice.

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? Surgical repair of the rotator cuff Patient-controlled analgesia with morphine Activity limitations for the affected arm Prescribed exercises of the affected arm

Activity limitations for the affected arm The immediate conservative treatment for this client is to limit activity in the injured arm.Surgical intervention is not considered immediate conservative treatment. Exercises are prohibited immediately after a rotator cuff injury. The client with a rotator cuff injury is treated primarily with nonsteroidal anti-inflammatory drugs to manage pain.

A rock climber has sustained an open fracture of the right tibia after a 20-foot (6 m) fall 2 days ago. The nurse plans to assess the client for which potential complications? (Select all that apply.) Urinary tract infection (UTI) Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Osteomyelitis Heart failure

Acute compartment syndrome (ACS) FES Osteomyelitis ACS is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. A fat embolus is a serious complication in which fat globules are released from yellow bone marrow into the bloodstream within 12 to 48 hours after the injury. FES usually results from long bone fracture or fracture repair but is occasionally seen in clients who have received a total joint replacement. Bone infection, or osteomyelitis, is most common in open fractures. Heart failure is not a potential complication for this client; pulmonary embolism is a potential complication of venous thromboembolism, which can occur with fracture. The client is at risk for wound infection resulting from orthopedic trauma, not a UTI.

The nurse is teaching a client preparing to have a total knee replacement about interventions to help prevent surgical infection. What interventions would the nurse include in this teaching? (Select all that apply.) Using nasal mupirocin for at least a week before surgery Avoiding sleeping with pets in the client's bed Showering the night before and the morning of surgery with chlorhexidine Giving antibiotics before and after surgery for at least 3 days Sleeping on clean linen wearing clean nightwear

All of these interventions are used to help prevent infection except for the use of long-term antibiotics. Long-term antibiotic therapy is used to treat rather than prevent postoperative infection.

Which assessment findings will the nurse expect to see in a client who is suspected to have systemic lupus erythematosus (SLE)? (Select all that apply.)

Anemia Joint pain and swelling Hair loss Fever Fatigue Facial redness Each of these assessment findings has been associated with systemic lupus erythematosus (SLE).

Which type of drug therapy will the nurse prepare a client in the early disseminated stage of Lyme disease to take for control or cure of this disease?

Antibiotics The goal of therapy during the initial and disseminated stages of Lyme disease is to eradicate the organism causing the infection with antibiotic therapy. Common antibiotics prescribed, sometimes for up to 30 days, include doxycycline, amoxicillin, and erythromycin. None of the other types of therapy listed are focused on this outcome.

A client has a nasogastric tube (NGT) connected to low continuous suction. What is the nurse's priority to ensure client safety? Assess for peristalsis at least once every 8 to 12 hours. Assess placement of the NGT for placement every 4 hours. Measure the gastric drainage every 8 to12 hours and document. Monitor the nasal skin and membranes around the tube for irritation.

Assess placement of the NGT for placement every 4 hours. Assessing the NGT for placement every 4 hours can help prevent aspiration which could lead to pneumonia. The other actions are appropriate for some clients, checking tube placement is the priority for care.

A client who had a right elective above-the-knee amputation reports severe pain in the right lower leg and foot. What is the nurse's best action at this time? Assess the level of the client's pain. Change the subject and talk about the client's hobbies. Distract the client with stories about the nurse's family. Remind the client that the lower leg was removed.

Assess the level of the client's pain. The nurse should recognize that the pain (phantom limb pain) is real to the client and perform a pain assessment in preparation for pain management. The other options are not examples of acknowledging the client's concern or therapeutic responses to the client in this situation.

The nurse is caring for a client who is at risk for osteoporosis. What lifestyle changes might the client be able to implement to decrease this risk? (Select all that apply.) Select all that apply. Avoiding excessive alcohol consumption Increasing foods high in phosphorus Decreasing consumption of carbonated beverages Preventing a sedentary daily lifestyle Seeking a smoking cessation program, if needed Including more calcium-rich foods into the diet

Avoiding excessive alcohol consumption Decreasing carbonated beverages preventing sedentary lifestyle smoking cessation more calcium All of these lifestyle changes are needed to avoid modifiable risk factors that contribute to the development of osteoporosis except that foods high in phosphorus should be avoided. If the serum phosphorous/phosphate level increases, the serum calcium level decreases due to their inverse relationship. Low calcium levels can result in bone loss.

The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the primary health care provider will request which supplement? Vitamin D3 Vitamin C Calcium Phosphorus

Vitamin D3 Osteomalacia is loss of bone related to vitamin D deficiency. The major treatment for osteomalacia is vitamin D in an active form such as ergocalciferol (Calciferol).Vitamin C is not indicated for the treatment of osteomalacia, which is related to vitamin D deficiency. Phosphorus interferes with the absorption of calcium. Calcium is not indicated in the treatment of osteomalacia.

The nurse is teaching a client about the use of crutches following a foot fracture. When adjusting the crutches to ensure a correct fit, what action will the nurse take? Ensure that each crutch fits firmly into the client's armpit. Be sure that the top of each crutch is well padded. Use the crutch on the affected side only. Check to see how many steps the client can take with the crutches.

Be sure that the top of each crutch is well padded. The crutches are used a set and require that the nurse ensure that the client does not develop axillary nerve damage. The tops of the crutches should be well padded and should be at least 2 to 3 finger-breadths below the armpit.

The nurse is monitoring a client with gastric cancer for signs and symptoms of upper gastrointestinal bleeding. Which change in vital signs would the nurse expect? Temperature from 97.9° to 98.9° F (36.6° to 37.2° C) Respiratory rate from 24 to 20 breaths/min Apical pulse from 80 to 72 beats/min Blood pressure from 140/90 to 110/70 mm Hg

Blood pressure from 140/90 to 110/70 mm Hg A decrease in blood pressure from 140/90 to 110/70 indicates that the client has hypovolemia from loss of body fluid (in this case, blood).

The nurse is preparing a client for a total hip arthroplasty today. What IV antibiotic would the nurse likely administer if the client has no drug allergies? Penicillin Clindamycin Vancomycin Cefazolin

Cefazolin Cephalosporins are the drug class of choice for clients without allergies who are having a total joint arthroplasty.

A client who has colorectal cancer is scheduled for a colostomy. Which referral is initially the most important for this client? Home health nursing agency Social worker Certified Wound, Ostomy, and Continence Nurse (CWOCN) Hospital chaplain

Certified Wound, Ostomy, and Continence Nurse (CWOCN) A CWOCN (or an enterostomal therapist) will be of greatest value to the client with colorectal cancer because the client is scheduled to receive a colostomy. The client is newly diagnosed, so it is not yet known whether home health nursing will be needed. A referral to hospice may be helpful for a terminally ill client. Referral to a chaplain may be helpful later in the process of adjusting to the disease.

What is the pathophysiologic basis for Lyme disease progression to stage III?

Changing the organism's surface antigens leading to chronic inflammation and elevated cytokine levels The causative organisms can switch out parts of its unique surface proteins, which changes the ability of immune sensitized system cells and antibodies to recognize the existing infecting organism allowing it to "hide." Every time a switch occurs, the immune system treats them like a new infection, and develops new antibodies and inflammatory responses to them, resulting in keeping all general and specific immunity actions in continual but ineffective attack mode through all stages of the disease process. This prolonged and continuous process results in persistent and enhanced damage to a variety of tissues and organs.

The nurse is reviewing the laboratory test results of a client with a recently diagnosed osteosarcoma. What abnormal laboratory finding would the nurse expect for this client? Elevated alkaline phosphatase Decreased hematocrit Increased calcium Increased white blood cell count

elevated alkaline phosphatase An osteosarcoma is a type of primary malignant bone tumor. Alkaline phosphatase is an enzyme that is released from the bone when it is diseased or damaged. All of these lab values would be expected in clients who have bone metastasis.

The nurse is caring for a client who has a continuous femoral nerve blockade following a total knee arthroplasty. What nursing assessment does the nurse need to perform to ensure client safety? Monitor vital signs frequently to detect early complications. Perform focused cardiovascular and respiratory assessments. Check that the client can dorsiflex and plantar flex the foot on the operative leg. Monitor for excessive blooding and bruising during the infusion.

Check that the client can dorsiflex and plantar flex the foot on the operative leg. To ensure that the client is not receiving excessive anesthesia, the client should be able to dorsiflex and plantar flex the foot on the operative leg. The purpose of the continuous femoral nerve blockade is to help control postoperative pain.

A client with an open fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is essential for the nurse to take first? Check the dorsalis pedis pulses. Administer the prescribed analgesic. Place a dressing on the affected area. Immobilize the left leg with a splint.

Check the dorsalis pedis pulses. The essential nursing action is to check the dorsalis pedis pulses. It is necessary to assess the circulatory status of the leg because the client is at risk for acute compartment syndrome, which can begin as early as 6 to 8 hours after an injury. Severe tissue damage can also occur if neurovascular status is compromised. Immobilization will be needed, but the nurse must assess the client's condition first. Administering an analgesic and placing a dressing on the affected area would both be done after the nurse has assessed the client.

The nurse and the registered dietitian nutritionist are planning sample diet menus for a client who is experiencing dumping syndrome. Which sample meal is most appropriate for this client? Liver, bacon, and onions Chicken and white rice Chicken salad on whole wheat bread Green vegetable salad with buttermilk ranch dressing

Chicken and white rice Chicken and rice is the most appropriate sample meal for this client. It is the only selection suitable for the client who is experiencing dumping syndrome because it contains high protein without the addition of milk or wheat products. The client with dumping syndrome should not have much mayonnaise, onions, or buttermilk ranch dressing. Buttermilk dressing is made from milk products. The client may have whole wheat bread only in very limited amounts.

A client had a fractured tibia repair several weeks ago and tells the nurse that she has persistent burning pain, ongoing edema, and muscle spasms in her affected leg. For which chronic complication is the client at risk? Chronic osteomyelitis Complex regional pain syndrome Severe osteoporosis Compartment syndrome

Complex regional pain syndrome When pain is not managed appropriately or interventions are not implemented to prevent complex regional pain syndrome (CRPS), the client is at risk for developing CRPS, a chronic debilitating complication of traumatic injury.

The nurse is assessing an older adult client who has severe kyphosis. What psychosocial client problem would the nurse anticipate? Dementia Bipolar disorder Psychosis Depression

Depression Clients who have severe kyphosis often have poor self-esteem and body image. Many clients are afraid to go out of their homes and socially interact and are concerned about possible falls. As a result, depression can occur.

What will the nurse recommend as the most appropriate way to decrease the risk for osteoporosis in a client who has just been determined to be at high risk for the disease? Increase nutritional intake of phosphorus. Walk for 30 minutes three times a week. Increase nutritional intake of calcium. Engage in high-impact exercise, such as running.

Walk for 30 minutes three times a week. Walking for 30 minutes three to five times a week is the best and single most effective exercise for osteoporosis prevention. Osteoporosis occurs most often in older, lean-built Euro-American and Asian women, particularly those who do not exercise regularly. Walking is a safe way to promote weight bearing and muscle strength.A variety of nutrients are needed to maintain bone health, so the promotion of a single nutrient will not prevent or treat osteoporosis. High-impact exercise and overtraining, such as running, may cause vertebral compression fractures and should be avoided. Calcium loss occurs at a more rapid rate when intake of phosphorus is high; people who drink large amounts of carbonated beverages each day (over 40 ounces [1.2 L]) are at high risk for calcium loss and subsequent osteoporosis, regardless of age or gender.

A client with a family history of colorectal cancer (CRC) regularly sees a primary health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client? Decrease in liver function test results Elevated carcinoembryonic antigen Negative test for occult blood Elevated hemoglobin levels

Elevated carcinoembryonic antigen Carcinoembryonic antigen may be elevated in many patients diagnosed with CRC. Liver involvement may or may not occur in CRC. Hemoglobin will likely be decreased with CRC, not increased. An occult blood test is not reliable to affirm or rule out CRC.

The nurse recognizes that a client who has persistent pain may have difficulty with pain management after a total joint arthroplasty. What collaborative interventions are needed to help the client manage postoperative pain? (Select all that apply.) Establish trust and explain the postoperative pain management plan. Consult the pain management team if needed and available. Plan continuing pain management after discharge. Use multimodal and alternative pain management modalities. Identify at-risk clients preoperatively using a comprehensive assessment.

Establish trust and explain the postoperative pain management plan. Consult the pain management team. Plan continuing pain management. Multimodal and alternative pain management. Identify at risk clients. All of these interventions are needed to successfully manage pain for clients who have persistent (chronic) pain.

The nurse is assessing a client who is suspected of having early gastric cancer. What signs and symptoms would the nurse expect? (Select all that apply.) Fatigue Feeling of fullness Dyspepsia Weakness Weight loss Nausea and vomiting

Feeling of fullness Dyspepsia The client who has early gastric cancer usually has no or few signs and symptoms, but may have dyspepsia and a feeling of fullness. More distressing changes are manifested when the cancer becomes more advanced.

The nurse is caring for a client immediately after a vertebroplasty. In what position would the nurse most likely place the client? Prone for the first 1 to 2 hours High-Fowler for the first hour Side-lying for the first 2 hours Flat supine for the first 1 to 2 hours

Flat supine for the first 1 to 2 hours The flat supine position provides support for the percutaneous or minimally invasive surgical procedure.

The nurse is recovering a client who had an esophagogastroduodenoscopy (EGD). What assessment would the nurse perform before determining if the client can have fluids to drink? Bowel sounds Orientation Presence of bruit Gag reflex

Gag reflex The nurse would check for the return of the client's gag reflex before allowing the client to drink or eat to prevent aspiration.

The nurse is caring for a client with an inflamed, reddened, and severely painful first metatarsal joint. With what type of arthritis are these signs and symptoms associated? Rheumatoid arthritis Infectious arthritis Gouty arthritis Osteoarthritis

Gouty arthritis Clients who have gout (also called gouty arthritis) experience severe inflammation in small joints, especially the metatarsal of the great (first) toe. Gout results when urate crystals created by errors in purine metabolism deposit in small synovial joints.

The nurse is caring for a client who has a gastric ulcer. For which potentially life-threatening complication would the nurse monitor for this client? Hypokalemia Hemorrhage Nausea and vomiting Infection

Hemorrhage Clients who have gastric ulcers are particularly at risk for upper GI bleeding, or hemorrhage. They may also experience nausea and vomiting causing dehydration. However, hemorrhage is most serious.

Which risk factors are shared by male clients who have osteoporosis or osteomalcia? (Select all that apply.) High alcohol intake Homelessness Low BMI A history of smoking Inadequate exposure to sunlight

High alcohol intake A history of smoking Inadequate exposure to sunlight Homlessness High alcohol intake is a risk factor for both osteoporosis and osteomalacia. A history of smoking is a risk factor for osteoporosis only. Inadequate exposure to sunlight and homelessness are risk factors for osteomalacia. A high BMI is a risk factor for both.

The nurse is developing a health teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? Take up knitting to slow down joint degeneration. Eat at least 2 yogurts every day. Wear supportive shoes at all times. Begin a jogging or running program.

Wear supportive shoes at all times. Wearing supportive shoes will help prevent falls and damage to foot joints, especially metatarsal joints. Running and running promotes stress on joints and should be avoided. Repetitive stress activities such as knitting or typing should be avoided for prolonged periods. No single food can cure OA; a well-balanced diet should be recommended.

A middle-age female client has osteoporosis and is at risk for developing vertebral fractures. She asks the nurse about exercises to help minimize this risk. Which exercise will the nurse recommend? Cycling Running Walking Yoga

Yoga Yoga helps to strengthen abdominal and back muscles which improves posture and support for the spine. Cycling, running, and walking help to develop range of motion and muscle strengthening but do not have specific effects on posture and spinal stability.

The nurse is caring for a client with osteoarthritis who reports severe pain in both knees. What nonpharmacologic intervention is the most appropriate for the nurse to recommend for this client? Massage and hypnosis. Hot compresses or moist heating pad. Glucosamine and chondroitin combination. Ice packs used every 3 to 4 hours during the day.

Hot compresses or moist heating pad. Heat sources such as compresses and heating pads cause vasodilation which promotes healing in the affected joints. Ice is best for inflamed joints rather than those that are degenerative. Glucosamine and chondroitin are integrative therapies that help some clients but their effectiveness has not been validated. Massage would be painful and hypnosis may or may not be helpful, depending on the client.

Which of the drugs or supplements taken daily taken by a client who is newly diagnosed with drug-induced systemic lupus erythematosus (SLE) does the nurse suspect is most likely to have caused this problem?

Hydralazine Hydralazine is a blood pressure medication that has been found to cause drug-induced SLE. None of the other drugs are associated with drug-induced SLE, although lisinopril, an angiotensin-converting enzyme inhibitor, is associated with development of angioedema.

The nurse is caring for a client with peptic ulcer disease who has been vomiting profusely at home before coming to the emergency department. For which vital sign change will the nurse expect for this client? Hypotension Tachypnea Oxygen desaturation Bradycardia

Hypotension The client who is vomiting profusely is losing fluids from the body causing dehydration. A client who is dehydrated has hypovolemia resulting in hypotension and tachycardia.

The nurse is caring for a client who has an external fixator for an open fracture of the tibia and fibula. What is the nurse's priority for care related to the fixator? Inspect the pins to monitor for infection and do not remove crusts. Make sure that the wound is managed using a moist wound healing method. Keep the leg covered to keep the extremity warm to promote circulation. Keep the extremity elevated to three pillows while in bed or in a chair.

Inspect the pins to monitor for infection and do not remove crusts. An external fixator is a series of pins attached to a metal frame to hold the bone ends in place while the wound can be managed. The nurse would frequently monitor the pin insertion sites for signs and symptoms of infection. Crusting that occurs at the sites should not be removed because it helps seal the open pin site areas to prevent infection. Leg elevation is important but the client would not necessarily need three pillows.

A client is in skeletal traction for a complex femoral fracture. Which nursing intervention ensures proper care of this client? Ensure that weights are placed on the floor. Remove the traction weights only for bathing. Ensure that pins are not loose and tighten as needed. Inspect the skin at least every 8 hours.

Inspect the skin at least every 8 hours. The client's skin should be inspected at least every 8 hours for signs of irritation, inflammation, or actual skin breakdown. Weights must never rest on the floor because they will not be effective. They must hang freely at all times. Pin sites would be checked for signs and symptoms of infection and for security in their position to the fixation and the client's extremity. However, the nurse does not adjust the pins. Any loose pin site or alteration must be reported to the health care provider. Traction weights are not removed for bathing.

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? Keep the client's heels off the bed at all times. Reposition the client every 3 to 4 hours. Avoid the use of antiembolism stockings. Administer pain medication before deep-breathing exercises.

Keep the client's heels off the bed at all times. Because the client is an older adult and is more at risk for skin breakdown because of impaired circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant pressure on this sensitive area. Repositioning the older adult client must be done every 2 hours, not every 3 to 4 hours, to prevent skin breakdown and to inspect the skin for any signs of breakdown. Pain medication would not be administered for deep-breathing exercises because this client typically would not experience pain upon breathing. Antiembolic stockings or sequential compression devices are used for older adults to help prevent venous thromboembolism (VTE).

After a client is hospitalized for an anaphylactic reaction to a bee sting, a nurse is teaching the client about the use of an epinephrine autoinjector. Which instruction/ instructions should be included in client education? (Select all that apply.)

Keep the device with you at all times. After administering the device, hospital monitoring is necessary. Use the device before calling 911. If the drug becomes discolored, order a replacement device. Instruct the client to utilize the device at the first symptom of anaphylactic reaction before calling 911. Hospital monitoring is always necessary after utilizing epinephrine for anaphylaxis. The device should be available at all times, as allergens can be encountered in all life situations. For client safety if the drug becomes discolored, it needs to be replaced.The device CAN be given through a thin layer of clothing. The ideal injection site for an epinephrine automatic injector is in the upper thigh.

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse would instruct the client to notify the primary health care provider immediately if which change occurs?

Large amount of serosanguineous or bloody drainage A large amount of serosanguineous or bloody drainage may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention.Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this client. Absence of erythema and tenderness of the surgical site would also be normal findings for this client. The client would be able to flex and extend the right knee (limb) after surgery.

The nurse is caring for a client with peptic ulcer disease who has been vomiting profusely at home before coming to the emergency department. For which acid-base imbalance will the nurse expect for this client? Respiratory acidosis Respiratory alkalosis Metabolic alkalosis Metabolic acidosis

Metabolic alkalosis Gastric contents are rich in acid (hydrogen and chloride ions). When this fluid is lost through vomiting, the client has less acid causing an alkalotic state.

The nurse is caring for a client who was recently diagnosed with Helicobacter. pylori infection. Which drugs does the nurse and anticipate would be used for this client to manage the infection? (Select all that apply.) Metronidazole Lansoprazole Azithromycin Tetracycline Hydroxychloroquine

Metronidazole Lansoprazole Tetracycline Most clients who have this type of infection are prescribed to take a proton pump inhibitor, such as lansoprazole, and two antimicrobial drugs, such as metronidazole and tetracycline. Clarithromycin and amoxicillin may be used as alternative antibiotics.

A client sustains a fracture of one arm and the primary health care provider applies a synthetic cast to the extremity. What will the nurse teach the client to do during the first 24 hours after discharge from the emergency department? Monitor neuromuscular status for decreased circulation and sensation in the extremity. Check the fit of the cast by inserting a tongue blade between the cast and the skin. Apply a heating pad for 15 to 20 minutes four times daily to help with pain. Keep the cast covered with a soft towel to help it to dry quickly.

Monitor neuromuscular status for decreased circulation and sensation in the extremity. The most important intervention the nurse teaches the client is to monitor the neurovascular status during the first 24 hours after ED discharge. The client should apply ice for discomfort, not heat. The client should not place anything between the cast and the skin. In assessing fit, one finger should easily fit between the cast and the skin. The cast dries quickly because it is made of synthetic materials.

A client in the emergency department receives moderate sedation while having a closed reduction of a fractured ankle. What is the nurse's priority assessment during this procedure? Check the client's blood pressure frequently. Monitor the client's pain level. Monitor the client's respiratory rate. Perform circulation checks before and after the procedure.

Monitor the client's respiratory rate. The drugs used for moderate sedation can suppress respiratory rate which requires constant monitoring during the procedure. The client should not feel any pain.

What is the most important action to prevent harm for the nurse to perform after a client's oral and facial swelling from an angiotensin-converting enzyme inhibitor (ACEI) have resolved?

Monitoring the client for return of symptoms for at least the next 2 to 4 hours All actions are important, although phlebitis is not likely to occur from IV therapy for angioedema. The ACEI class of drugs have a longer half-life and remain in the body longer than does the corticosteroid infusion used to treat the angioedema. As a result, symptoms can recur after first resolving when corticosteroid therapy is stopped. The client remains at risk and must be monitored for at least 2 to 4 hours for return of angioedema.

A client is admitted to the same-day surgical center PACU after a bunionectomy. After assessing the client's ABCs, what is the priority assessment for the client? Muscle strength assessment Joint assessment Neurovascular assessment Neurologic assessment

Neurovascular assessment The client had foot surgery and would have a bulky surgical dressing placed on the area to prevent bleeding. The nurse would want to frequently assess the neurovascular status of the operative foot as the priority.

The nurse is caring for a client who reports stomach pain and heartburn. Which assessment finding is most significant suggesting the client's ulcer is duodenal and not gastric? Pain occurs 1½ to 3 hours after a meal, usually at night. The client is a man older than 50 years. Pain is worsened by the ingestion of food. The client has a malnourished appearance.

Pain occurs 1½ to 3 hours after a meal, usually at night. A key symptom of duodenal ulcers is that pain usually awakens the client between 1:00 a.m. and 2:00 a.m. (0100 and 0200) and occurs 1½ to 3 hours after a meal. Pain that is worsened with ingestion of food and a malnourished appearance are key features of gastric ulcers. A male over 50 years is a finding that could apply to either type of ulcer.

The nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? (Select all that apply.) Select all that apply. Yoga Acupuncture Peppermint oil capsules Decreasing physical activities Meditation

Possible treatment modalities the nurse suggests for a client with IBS include: acupuncture, meditation, peppermint oil capsules, and yoga. Acupuncture is recommended as a complementary therapy for IBS. Meditation, yoga, and other relaxation techniques help many patients manage stress and their IBS symptoms. Research has shown that peppermint oil capsules may be effective in reducing symptoms of IBS. Regular exercise is important for managing stress and promoting bowel elimination.

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. After a complete assessment, what action would the nurse plan implement at this time? Change the nasogastric suction level from "intermittent" to "continuous." Administer medication for pain based on the client's pain level. Position the client in a semi- or high-Fowler position. Prepare the client for emergency surgery in collaboration with the health team.

Prepare the client for emergency surgery in collaboration with the health team. The appropriate nursing action for a client with intestinal obstruction whose pain changes from "colicky" intermittent type to constant discomfort is to prepare surgery because this change is most likely indicative of perforation or peritonitis and will require immediate surgical intervention. Pain medication may mask the client's symptoms but will not address the root cause. A change in the nasogastric suction rate will not resolve the cause of the client's pain and could be particularly ineffective if a nonvented tube is in use.

The nurse is caring for a postoperative client with total hip arthroplasty. What actions would the nurse take to prevent venous thromboembolism (VTE) postoperatively? (Select all that apply.) Select all that apply. Apply pneumatic or sequential compression devices. Administer anticoagulant therapy. Ambulate the client on the day of surgery. Elevate the client's legs. Keep the legs slightly abducted.

Preventive postoperative actions that help prevent VTE include pharmacology (anticoagulants), ambulation, and compression.

A 67-year-old male client with no surgical history reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have? Reducible Strangulated Incarcerated Femoral

Reducible The hernia is reducible because its contents can be pushed back into the abdominal cavity. Femoral hernias tend to occur more frequently in obese and pregnant women. A hernia is considered to be strangulated when the blood supply to the herniated segment of the bowel is cut off. An incarcerated or irreducible hernia cannot be reduced or placed back into the abdominal cavity. Any hernia that is not reducible requires immediate surgical evaluation.

The nurse is caring for a female client who has a right wrist ganglion which is interfering with her ability to do her job as an administrative assistant. What collaborative treatment would the nurse anticipate for this client? Physical therapy Occupational therapy Removal of the ganglion Intravenous antibiotic therapy

Removal of the ganglion Because the ganglion cyst is interfering with the client's ability to work, the ganglion cyst would likely be removed rather than aspirated. Antibiotics are not appropriate and rehabilitation is not going to help remove her cyst.

The nurse is caring for an older client who has a large bulky lower leg dressing with posterior splint to maintain alignment after closed reduction for an ankle fracture. Which client assessment finding would the nurse report to the primary health care provider or Rapid Response Team immediately? Affected foot slightly cooler than the other foot. Reports pain level is 4 on a 0-10 pain intensity scale. Pedal pulse on affected foot is 1+ and regular. Reports tingling and numbness in affected foot.

Reports tingling and numbness in affected foot. This client is at risk for neurovascular compromise or compartment syndrome from the external dressing. Pain and a slightly cooler foot is to be expected. However, the client should not have tingling and numbness suggesting that arterial blood flow is diminished.

The nurse is caring for a client who is diagnosed with a perforated duodenal ulcer. Which assessment finding would the nurse expect? Positive McBurney point Rigid, board-like and tender abdomen Nausea and profuse vomiting Absent bowel sounds in all four quadrants

Rigid, board-like and tender abdomen Perforation allows intestinal contents to escape into the peritoneal cavity causing peritonitis. The classic assessment finding for a client who has peritonitis is a rigid, board-like abdomen that is tender or painful.

Which precaution is a priority to prevent harm for the nurse to teach a client with systemic lupus erythematosus (SLE) who is newly prescribed to take hydroxychloroquine for disease management?

See your ophthalmologist for visual field testing every 6 months. Hydroxychloroquine has both immunomodulating and anticlotting effects that can be beneficial to clients with SLE. A major complication of this drug is its toxicity to retinal cells causing retinitis that can lead to an irreversible loss of central vision. Clients prescribed hydroxychloroquine are instructed to have frequent eye examinations with visual field testing (before starting the drug and every 6 months thereafter). If retinal toxicity is suspected, the drug is discontinued to preserve the remaining vision.

The nurse is caring for a client who had an anterior-posterior surgical resection for colorectal cancer this morning. What will the nurse anticipate as the client's priority problem at this time? Intestinal obstruction Nausea and vomiting Severe pain Constipation

Severe pain The surgical incisions are in the perineal area and are very painful due to the number of nerves in that region of the body. Pain control is the biggest challenge for the nurse and health care team to promote client comfort.

The nurse suspects that a client may have plantar fasciitis if the client has which assessment finding? Dorsiflexion of any metatarsophalangeal (MTP) joint, with plantar flexion of the adjacent proximal interphalangeal (PIP) joint A small tumor in a digital nerve of the foot Severe pain in the arch of the foot, especially when getting out of bed Lateral deviation of the great toe; first metatarsal head becomes enlarged

Severe pain in the arch of the foot, especially when getting out of bed Severe pain in the arch of the foot, especially when getting out of bed, is an indication of plantar fasciitis. Lateral deviation of the great toe with an enlarged first metatarsal head describes a bunion of the foot. Dorsiflexion of any MTP joint with plantar flexion of the adjacent PIP joint is a description of a hallux valgus and hammertoe of the foot. A small tumor in a digital nerve of the foot describes Morton neuroma of the foot.

The nurse finds a client vomiting coffee-ground emesis. On assessment, the client has a blood pressure of 100/74 mm Hg, is acutely confused, and has a weak and thready pulse. Which intervention is the nurse's first priority? Administer antianxiety medication. Initiate enteral nutrition. Start intravenous (IV) fluids, Administer histamine (H2) antagonist.

Start intravenous (IV) fluids, The nurse's first priority is to administer intravenous (IV) fluids. Administering IV fluids is necessary to treat the hypovolemia caused by acute gastrointestinal (GI) bleeding.

The nurse is providing teaching on ways to promote bowel health and disease prevention. Which statement will the nurse include in this teaching? "You should start colorectal cancer screening when you are over 70 years of age." "You only need to have regular colonoscopies if there is colorectal cancer in your family.' "If you perform fecal occult blood tests every 5 years, you don't need a colonoscopy." "You should have a colonoscopy every 10 years starting at 45 years of age."

you should have a colonoscopy every 10 years starting at age 45 -ACS recommends fecal occult blood testing (FOBT) every year -colonoscopy every 10 years -or flexible sigmoidoscopy or CT colonography every 5 years

The nurse is caring for a client who is diagnosed with osteopenia. Which T-score will the nurse expect to see for this client after a bone mineral density (BMD) test? −2 −3 0 to −1 +1.5

−2 The T-score represents the standard deviations above or below the average BMD for young, healthy adults. A T-score of −1 to −2.5 represents osteopenia. The T-score in a young, healthy adult is 0. A normal T-score is between +1 and −1. A score of +1.5 is not a part of the T-score. A T-score of −3 represents osteoporosis.

What precaution is most important for the nurse to teach the client with systemic lupus erythematosus (SLE) prescribed to take 45 mg of a corticosteroid daily for 2 weeks to manage an SLE flare?

Do not suddenly stop taking the drug when your flare is over. All of the precautions are correct and important. However, the most critical precaution is to not suddenly stop taking the drug, which could lead to acute adrenal insufficiency and even death. This dose of the drug (45 mg daily) would need to be tapered down over a period of weeks to prevent adrenal insufficiency.

The nurse assesses a client diagnosed with Sjögren syndrome. The nurse anticipates that the client will also have which symptom? Excessive production of saliva in the mouth Intermittent episodes of diarrhea Abdominal bloating after eating Dry eyes

Dry eyes Clients with Sjögren syndrome experience dry eyes (keratoconjunctivitis sicca), dry mouth, and if female, dry vagina.

The nurse is teaching a postmenopausal client about the need for bone health and screening. What diagnostic test would the nurse recommend? Serum Vitamin D Dual x-ray absorptiometry (DXA) Serum calcium and phosphorus Vertebral x-rays

Dual x-ray absorptiometry (DXA) The DXA scan screens for bone loss and provides a score to indicate the amount of loss, if any. It is a noninvasive test performed every 2 years to monitor for bone loss as one ages.

A client is admitted to the emergency department following a left severe ankle sprain caused by playing football with friends. What nursing actions will the nurse implement at this time? (Select all that apply.) Elevate the left leg above the level of the heart. Tell the client to keep his left leg still. Apply an elastic wrap or ankle or compression brace. Administer morphine via IV push. Apply heat to promote blood flow and healing.

Elevate the left leg above the level of the heart. Keep leg still. apply a wrap or brace. The nurse follows the RICE approach to emergency care of clients who experience a sports-related injury, which includes rest, ice, compression, and elevation of the affected part. Heat may be used after 24 hours, but ice is needed now to reduce swelling. The client does not need a strong opioid for this injury.