Ch. 11 Final
17) When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to the nurse that the patient needs additional teaching? 1. "I take my ibuprofen every morning as soon as I get up." 2. "My daughter removed all of the throw rugs in my home." 3. "My husband helps me every afternoon with range-of-motion exercises." 4. "I rest in my reclining chair every day for at least an hour."
1. "I take my ibuprofen every morning as soon as I get up." Rationale:Ibuprofen can cause abdominal discomfort or pain and ulceration of the gastrointestinal tract. In such cases, it should be taken with meals or milk. Removal of throw rugs helps prevent falls. Range-of-motion exercises and rest are important strategies for coping with osteoporosis.
23) A patient with a right above-the-knee amputation asks the nurse why he has phantom limb pain.What is the nurse's best response? 1. "Phantom limb pain is not explained or predicted by any one theory." 2. "Phantom limb pain occurs because your body thinks your leg is still present." 3. "Phantom limb pain will not interfere with your activities of daily living." 4. "Phantom limb pain is not real pain but is remembered pain."
1. "Phantom limb pain is not explained or predicted by any one theory." Rationale:Three theories are being researched with regard to phantom limb pain. The peripheral nervous system theory holds that sensations remain as a result of the severing of peripheral nerves during the amputation. The central nervous system theory states that phantom limb pain results from a loss of inhibitory signals that were generated through afferent impulses from the amputated limb. The psychological theory helps predict and explain phantom limb pain because stress, anxiety, and depression often trigger or worsen a pain episode.
21) The nurse is supervising a new graduate RN caring for a patient with a fracture of the right ankle who is at risk for complications of immobility. For which action should the supervising nurse intervene? 1. Encouraging the patient to go from a lying to a standing position 2. Administering pain medication before the patient begins exercises 3. Explaining to the patient and family the purpose of the exercise program 4. Reminding the patient about the correct use of crutches
1. Encouraging the patient to go from a lying to a standing position Rationale:Moving directly from a lying to a standing position does not allow the patient to establish balance. The supervising nurse should instruct the new graduate RN about moving the patient from a lying position first, then to a sitting position, and finally to a standing position, which will allow the patient to establish balance before standing. Administering pain medication before the patient begins exercising decreases pain with exercise. Explanations about the purpose of the exercise program and proper use of crutches are appropriate interventions with this patient.
26) A patient who underwent a right above-the-knee amputation 4 days ago also has a diagnosis of depression. Which order would the nurse clarify with the health care provider? 1. Give fluoxetine 40 mg once a day. 2. Administer acetaminophen with codeine 1 or 2 tablets every 4 hours as needed. 3. Assist the patient to the bedside chair every shift. 4. Reinforce the dressing to the right residual limb as needed.
1. Give fluoxetine 40 mg once a day. Rationale:Doses of fluoxetine, a drug used to treat depression, that are greater than 20 mg should be given in two divided doses, not once a day. The other three orders are appropriate for a patient who underwent amputation 4 days earlier.
12) A patient is scheduled for endoscopic carpal tunnel release surgery in the morning. What would the nurse be sure to teach the patient? 1. Pain and numbness are expected to be experienced for several days to weeks. 2. Immediately after surgery, the patient will no longer need assistance. 3. After surgery, the dressing will be large, and there will be lots of drainage 4. The patient's pain and paresthesia will no longer be present.
1. Pain and numbness are expected to be experienced for several days to weeks. Rationale:Postoperative pain and numbness occur for a longer period of time with endoscopic carpal tunnel release than with an open procedure. Patients often need assistance postoperatively, even after they are discharged. The dressing from the endoscopic procedure is usually very small, and there should not be a lot of drainage.
8) The nurse delegates the measurement of vital signs to an experienced unlicensed assistive personnel (UAP). Osteomyelitis has been diagnosed in a patient. Which vital sign value would the nurse instruct the UAP to report immediately for this patient? 1. Temperature of 101°F (38.3°C) 2. Blood pressure of 136/80 mm Hg 3. Heart rate of 96 beats/min 4. Respiratory rate of 24 breaths/min
1. Temperature of 101°F (38.3°C) Rationale:An elevated temperature indicates infection and inflammation. This patient needs IV antibiotic therapy. The other vital sign values are normal or high normal.
25) During assessment of a patient with fractures of the medial ulna and radius, the nurse finds all of these data. Which assessment finding should the nurse report to the health care provider immediately? 1. The patient reports pressure and pain. 2. The cast is in place and is dry and intact. 3. The skin is pink and warm to the touch. 4. The patient can move all the fingers and the thumb.
1. The patient reports pressure and pain. Rationale:Pressure and pain may be caused by increased compartment pressure and can indicate the serious complication of acute compartment syndrome. This situation is urgent. If it is not treated, cyanosis, tingling, numbness, paresis, and severe pain can occur. The other findings are normal and should be documented in the patient's chart.
14) The nurse is preparing a patient who had carpal tunnel release surgery for discharge. Which information is important to provide for this patient? 1. The surgical procedure is a cure for carpal tunnel syndrome (CTS). 2. Do not lift any heavy objects. 3. Frequent doses of pain medication will no longer be necessary. 4. The health care provider should be notified immediately if there is any pain or discomfort.
2. Do not lift any heavy objects. Rationale:Hand movements, including heavy lifting, may be restricted for 4 to 6 weeks after surgery. Patients experience discomfort for weeks to months after surgery. The surgery is not always a cure; in some cases, CTS may recur months to years after surgery.
28) The emergency department (ED) nurse should question which health care provider order when providing care for an older adult with a fracture of the left ulna? 1. Get x-rays of left forearm. 2. Give meperidine IM for pain. 3. Monitor vital signs every hour. 4. Elevate left arm on pillows.
2. Give meperidine IM for pain. Rationale:Meperidine should not be used because of its toxic metabolites that can cause seizures and other adverse drug events, especially in the older adult population. X-rays are used to confirm the diagnosis. Vital signs and elevation are common actions for a patient in the ED, and elevation can decrease the swelling in the affected extremity.
5) The nurse's assessment reveals all of these data when a patient with Paget disease is admitted to the acute care unit. Which finding should the nurse notify the health care provider about first? 1. There is a bowing of both legs, and the knees are asymmetrical. 2. The base of the skull is invaginated (platybasia). 3. The patient is only 5 feet tall and weighs 120 lb. 4. The skull is soft, thick, and larger than normal.
2. The base of the skull is invaginated (platybasia). Rationale:Platybasia (basilar skull invagination) causes brainstem manifestations that threaten life. Patients with Paget disease are usually short and often have bowing of the long bones that results in asymmetrical knees or elbow deformities. The skull is typically soft, thick, and enlarged.
18) A patient has a fractured femur. Which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient reports pain. 2. The patient appears confused. 3. The patient's blood pressure is 136/88 mm Hg. 4. The patient voided using the bedpan.
2. The patient appears confused. Rationale:Fat embolism syndrome is a serious complication that often results from fractures of long bones. Its earliest manifestation is altered mental status caused by a low arterial oxygen level. The nurse would want to know about and treat the pain, but it is not life threatening. The nurse would also want to know about the blood pressure and the patient's voiding; however, this information is not urgent to report.
22) The charge nurse is assigning the nursing care of a patient who had a left below-the-knee amputation 1 day ago to an experienced LPN/LVN, who will function under an RN's supervision. What will the RN tell the LPN/LVN is the major focus for the patient's care today? 1. To attain pain control over phantom pain 2. To monitor for signs of sufficient tissue perfusion 3. To assist the patient to ambulate as soon as possible 4. To elevate the residual limb when the patient is supine
2. To monitor for signs of sufficient tissue perfusion Rationale:Monitoring for sufficient tissue perfusion is the priority at this time. Phantom pain is a concern but is more common in patients with above-the-knee amputations. Early ambulation is a goal, but at this time, the patient is more likely to be engaged in muscle-strengthening exercises. Elevating the residual limb on a pillow is controversial because it may promote knee flexion contracture.
32) The RN is receiving a patient with peripheral vascular disease from the postanesthesia care unit (PACU) after a Syme amputation of the right lower extremity. At which level on the diagram would the RN expect to find the amputation? 1. A 2. B 3. C 4. D
3. C Rationale:When a patient has a Syme amputation, most of the foot is removed but the ankle remains. Advantages of this surgery over below the knee include that the patient can still be weight bearing (with a prosthesis) and there is less pain.
19) After the nurse receives change-of-shift report, which patient should be assessed first? 1. A 42-year-old patient with carpal tunnel syndrome who reports pain 2. A 64-year-old patient with osteoporosis awaiting discharge 3. A 28-year-old patient with a fracture who reports that the cast is tight 4. A 56-year-old patient with a left leg amputation who reports phantom pain
3. A 28-year-old patient with a fracture who reports that the cast is tight Rationale:The patient with the tight cast is at risk for circulation impairment and peripheral nerve damage. Although all of the other patients' concerns are important and the nurse will want to see them as soon as possible, none of their complaints is urgent, but the patient with the tight cast may have risk for injury to a limb.
6) The charge nurse observes an LPN/LVN assigned to provide all of these interventions for a patient with Paget disease. Which action requires that the charge nurse intervene? 1. Administering 600 mg of ibuprofen to the patient 2. Encouraging the patient to perform exercises recommended by a physical therapist 3. Applying ice and gentle massage to the patient's lower extremities 4. Reminding the patient to drink milk and eat cottage cheese
3. Applying ice and gentle massage to the patient's lower extremities Rationale: Applying heat, not ice, is the appropriate measure to help reduce the patient's pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by a physical therapist would be nonimpact in nature and provide strengthening for the patient. A diet rich in calcium promotes bone health.
10) The nurse is caring for a patient with carpal tunnel syndrome (CTS) who has been admitted for surgery. Which intervention should be delegated to the unlicensed assistive personnel (UAP)? 1. Initiating placement of a splint for immobilization during the day 2. Assessing the patient's wrist and hand for discoloration and brittle nails 3. Assisting the patient with daily self-care measures such as bathing and eating 4. Testing the patient for painful tingling in the four digits of the hand
3. Assisting the patient with daily self-care measures such as bathing and eating Rationale:Helping with activities of daily living (e.g. bathing, feeding) is within the scope of practice of UAPs. Placing a splint for the first time is appropriate to the scope of practice of physical therapists. Assessing and testing for paresthesia are not within the scope of practice of UAPs and is appropriate for professional nurses.
15) The nurse is providing care for a patient with a rotator cuff tear. What treatment does the nurse expect the health care provider will prescribe first for this patient? 1. Arthroscopic repair of the rotator cuff tear 2. Elimination of movements in the affected shoulder 3. Conservative therapies such as nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy 4. Pendulum exercises that start slow and progress over 2 weeks
3. Conservative therapies such as nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy Rationale:For the patient with a torn rotator cuff, the health care provider usually treats the patient conservatively with NSAIDs, intermittent steroid injections, physical therapy, and activity limitations while the tear heals. Physical therapy treatments may include ultrasound, electrical stimulation, ice, and heat.
31) The nurse is teaching an older patient about risks for fractures and osteoporosis. Which diagnostic test should the nurse teach about when the goal is to establish the patient's bone strength and determine if osteoporosis is present? 1. Computed tomography (CT) scan 2. Magnetic resonance imaging (MRI) scan 3. Dual-energy x-ray absorptiometry (DXA or DEXA) scan 4. Joint x-rays
3. Dual-energy x-ray absorptiometry (DXA or DEXA) scan Rationale:Testing bone density (how strong the bones are) is the only way to know for sure if a patient has osteoporosis. A diagnostic test commonly prescribed by health care providers is DXA or DEXA. This type of scan focuses on two main areas, the hip and the spine. However, the forearm can be tested if the hip or spine cannot be tested. The other tests may be prescribed but are not as commonly used to test bone strength.
11) The nurse observes the unlicensed assistive personnel (UAP) performing all of these interventions for a patient with carpal tunnel syndrome (CTS). Which action requires that the nurse intervene immediately? 1. Arranging the patient's lunch tray and cutting his meat 2. Providing warm water and assisting the patient with his bath 3. Replacing the patient's splint in hyperextension position 4. Reminding the patient not to lift very heavy objects
3. Replacing the patient's splint in hyperextension position Rationale:When a patient with CTS has a splint to immobilize the wrist, the wrist is placed either in the neutral position or in slight extension, not hyperextension. The other interventions are correct and are within the scope of practice of a UAP. UAPs may remind patients about elements of their care plans such as avoiding heavy lifting.
20) A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately? 1. The patient wants to change position in bed. 2. There is a small amount of clear fluid at the pin sites. 3. The traction weights are resting on the floor. 4. The patient reports pain and muscle spasm.
3. The traction weights are resting on the floor. Rationale:When the weights are resting on the floor, they are not exerting pulling force to provide reduction and alignment or to prevent muscle spasm. The weights should always hang freely. Attending to the weights may reduce the patient's pain and spasm. With skeletal pins, a small amount of clear fluid drainage is expected. It is important to inspect the traction system after a patient changes position because position changes may alter the traction.
24) During morning care, a patient with a below-the-knee amputation asks the unlicensed assistive personnel (UAP) about prostheses. How will the nurse instruct the UAP to respond? 1. "You should get a prosthesis so that you can walk again." 2. "Wait and ask your doctor that question the next time he comes in." 3. "It's too soon to be worrying about getting a prosthesis." 4. "I'll ask the nurse to come in and discuss this with you."
4. "I'll ask the nurse to come in and discuss this with you." Rationale:The patient is indicating an interest in learning about prostheses. The experienced nurse can initiate discussion and begin educating the patient. Certainly, the health care provider can also discuss prostheses with the patient, but the patient's wish to learn should receive a quick response. The nurse can then notify the health care provider about the patient's request.
7) The charge nurse is making assignments for the day shift. Which patient should be assigned to the nurse who was floated from the postanesthesia care unit (PACU) for the day? 1. A 35-year-old patient with osteomyelitis who needs teaching before hyperbaric oxygen therapy 2. A 62-year-old patient with osteomalacia who is being discharged to a long-term care facility 3. A 68-year-old patient with osteoporosis given a new orthotic device whose knowledge of its use must be assessed 4. A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement
4. A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement Rationale:The PACU nurse is very familiar with the assessment skills necessary to monitor a patient who just underwent surgery. For the other patients, nurses familiar with musculoskeletal system-related nursing care are needed to provide teaching and assessment and prepare a report to the long-term care facility.
3) The nurse is caring for a patient with osteoporosis who is at increased risk for falls. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Identifying environmental factors that increase risk for falls 2. Monitoring gait, balance, and fatigue level with ambulation 3. Collaborating with the physical therapist to provide the patient with a walker 4. Assisting the patient with ambulation to the bathroom and in the halls
4. Assisting the patient with ambulation to the bathroom and in the halls Rationale:Assisting with activities of daily living, including assisting with ambulation to the bathroom, is within the scope of the UAP's practice. The other three interventions require additional educational preparation and are within the scope of practice of licensed nurses.
30) The nurse is preparing a patient for magnetic resonance imaging (MRI). Which action can the nurse delegate to the experienced unlicensed assistive personnel (UAP)? 1. Teach the patient what to expect during the test. 2. Instruct the patient to remove metal objects including zippers. 3. Witness that the patient has signed the consent form. 4. Check and record preprocedure vital signs.
4. Check and record preprocedure vital signs. Rationale:The UAP's scope of practice includes checking and recording patient vital signs. Teaching and instructing, as well as witnessing consent forms, is appropriate to the professional RN's scope of practice. The UAP could remind the patient about removal of metal objects after the patient receives instructions.
29) The RN is mentoring a student nurse who is caring for a patient with carpal tunnel syndrome of the right hand with neurovascular check ordered every 2 hours. For which action by the student nurse must the RN intervene? 1. Student nurse checks the patient's radial pulse every 2 hours. 2. Student nurse checks for sensation in the patient's right hand. 3. Student nurse assesses color, temperature, and pain in right wrist and hand. 4. Student nurse instructs the patient to avoid movement because of the pain.
4. Student nurse instructs the patient to avoid movement because of the pain. Rationale:Performing complete neurovascular assessment (also called a "circ check") includes palpation of pulses in the extremities below the level of injury and assessment of sensation, movement, color, temperature, and pain in the injured part. If pulses are not palpable, use of a Doppler helps find pulses in the extremities. After surgery, the patient should be given pain medication and encouraged to move the fingers frequently. Some hand movements such as lifting heavy objects may be restricted for 4 to 6 weeks after surgery.