Chapter 4 exam
The emergency room nurse is assisting with a client that needs an emergency fasciotomy of the left arm. The nurse knows that which of the following should be completed first? a) Prepare the arm. b) Identify the client. c) Administer pain medications. d) Place IV in right arm.
Identify the client.
After a client sprained their ankle, the nurse is educating the client on how to care for the sprained ankle at home. Which of the following statements by the nurse is correct? a) "You should elevate your ankle when possible." b) "You should alternate heat and ice." c) "You should try to walk on your ankle every hour for 10 minutes." d) "You should wear your knee immobilizer to remind you to not use your ankle."
"You should elevate your ankle when possible."
Mark is to receive Rocephin IV bid. He weighs 15 lbs. The PDR states the recommended dose is 30 mg/kg/day. Mark is to receive how much daily? How many mg per dose? a) 240 mg/day, 120 mg/dose b) 450 mg/day, 225 mg/dose c) 204 mg/day, 102 mg/dose d) 990 mg/day 495 mg/dose
204 mg/day, 102 mg/dose
Calculate the total intake: 2 oz soda, 3 teaspoon (tsp) water, 4 1/2 oz milk, 30 ml of Jell-o. a) 240 ml b) 200 ml c) 300 ml d) 135 ml
240 ml
Order: infuse 1 liter of NS @100ml/hr. Drop factor is 15 gtt/min. what is the drip rate? a) 1.66 ml/min b) 20 gtt/min c) 25 gtt/min d) 2 gtt/min
25 gtt/min
Gentamycin is ordered for a 20 lb child. The PDR recommends 3.6 mg/kg/day IV q8h. The recommended dosage for this child is ________ per dose. a) 10.9 mg b) 11 mg c) 32.7 mg d) 10 mg
32.7 mg
Calculate the drip rate for 2 liters of IV fluids to be given over 10 hours. The drop factor is 10 drops/ml. a) 3.33 gtt/min b) 33 gtt/min c) 25 gtt/min d) 35 gtt/min
33 gtt/min
The female patient was in a car accident and reports pain over the pelvic region with difficulty raising her legs in a supine position. The nurse notes ecchymosis over the pelvic region. Which laboratory test is the primary concern in the immediate phase of care? a) Stool for occult blood. b) Hemoglobin and hematocrit c) Urinalysis d) Blood type and Rh
Hemoglobin and hematocrit
A client experiences a muscle sprain of the ankle. When assessing the injury. The nurse discovers a developing hematoma and edema. The client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include application of what? a) Ice pack b) Binder c) Warm compress d) Elastic bandage
Ice pack
When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain what? a) Adduction b) Abduction c) Elevation d) Traction
Abduction
What is the first priority nursing intervention for an impending fat embolism? a) Administer oxygen in a respiratory emergency. b) Increase intravenous fluids. c) Position in flat position to ease decreased blood pressure. d) Cover with warm blanket.
Administer oxygen in a respiratory emergency.
A patient, age 68, has suffered an intertrochanteric fracture of the right hip. before surgery to provide support and comfort an immobilizing device of a ___________ is applied. a) Thomas splint b) Bryant traction c) Russell traction d) Buck traction
Buck traction
A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed on a long leg cast. The assessments by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds and small 1 cm area of blood on cast. What should the nurse do? a) Notify charge nurse of impending compartment syndrome. b) Document that all assessments are within normal limits. c) Inform charge nurse about probable hemorrhage. d) Place warm compresses on left foot.
Document that all assessments are within normal limits.
The emergency department nurse assesses the two cardinal signs of a hip fracture in a newly admitted patient, what are the shortening of the injured leg and the ___________ rotation of that same leg. a) internal b) abduction c) adduction d) external
External
Which of the following are the main purposes of traction? Select all that apply. a) Promote bed rest. b) Prevent deformities. c) Relieve muscle spasms. d) Align and stabilize a fracture.
Promote bed rest. Prevent deformities. Align and stabilize a fracture.
A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for high-protein diet is to do what? a) promote gluconeogenesis. b) decrease pain medication requirements. c) promote cell growth and bone union. d) produce an anti-inflammatory effect.
Promote cell growth and bone union.
Which individual is most at risk for developing carpel tunnel syndrome? a) Housekeeper b) Software engineer c) Healthcare worker d) Professional athlete
Software engineer
The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions the nurse should plan to tell the client to place the crutches in which position? a) 6 inches outside of the client's toes. b) 3 inches to the front and side of the client's toes. c) 15 inches to the front and side of the client's toes. d) 20 inches to the front and side of the client's toes.
6 inches outside of the client's toes.
The nurse is assigned to care for a client who is in skeletal traction. The nurse needs to avoid which action when caring for the client? a) Placing the best linens on the traction rope. b) Keeping the weights hanging freely. c) Ensuring that the ropes are in the pulleys. d) Ensuring that the weights are out of the clients reach.
Placing the best linens on the traction rope.
When providing care to a patient in skeletal traction, what action would be included in the nurse's plan of care? a) Cleanse pin sites and observes for signs of infection. b) Encourage patient to sit in a straight, firm, chair for no longer than 20 minutes each time. c) Place patient on drainage and secretion precautions. d) Provide cast care.
Cleanse pin sites and observes for signs of infection.
After a fracture of the forearm or tibia, complaints of sharp, deep unrelenting pain in the hand or foot unrelieved by analgesics or elevation of the extremity indicates which complication? a) Cast syndrome. b) Compartment syndrome c) Fat embolism d) Gas gangrene
Compartment syndrome
Which of the following is not included in the seven "Ps" of orthopedic assessment? a) Polar temperature b) Pain c) Paresthesia d) Polydipsia
Polydipsia
A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses a capillary refill of 5 seconds and cold fingers of the right hand. Which intervention should the nurse deploy? a) Elevate the right hand to heart level to maintain arterial pressure. b) Notify the charge nurse of a probable compartment syndrome. c) Cut the cast of to release constriction. d) Apply warm compress to the fingers to relieve swelling.
Elevate the right hand to heart level to maintain arterial pressure.
The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? a) Placing the leg in a slightly dependent position and applying ice. b) Keeping the leg horizontal and applying ice to the affected leg. c) Elevating the limb and applying ice to the affected leg. d) Elevating the limb and covering with bath blankets.
Elevating the limb and applying ice to the affected leg.
Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse assessed a pulse of 110, respirations at 25, and labored crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of a(n): a) impending pneumonia. b) atelectasis. c) fat embolism. d) anxiety attack.
Fat embolism
A 4-year-old child was brought to the emergency department with a fractured tibia. Which type of fracture is most common in children of this age? a) compound b) comminuted c) greenstick d) transverse
Greenstick
The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? a) Inflammation b) Pain at a pin site c) Purulent drainage d) Serous drainage
Serous drainage
What Clinical manifestation of compartment syndrome? a) Restlessness. b) Toxic delirium. c) Tophi around the rim of the ear. d) Sharp pain that increases with passive movement.
Sharp pain that increases with passive movement.
A nurse is caring for a 10-year-old boy who sustained a fractured cervical vertebra while playing football. When he is placed in a cervical traction, the nurse teaches him that the traction will do what? a) Flex the head to prevent stretching of the neck muscles. b) Align the body to allow for cerebrospinal fluid to encircle the spinal cord. c) Hyperextend the neck to maintain an open airway. d) Immobilize the area to minimize injury to the spinal cord.
Immobilize the area to minimize injury to the spinal cord.
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? a) The newness of the fracture b) The anxiety of the client c) Infection under the cast d) Impaired tissue perfusion
Impaired tissue perfusion
The nurse is providing care to a client who has suspected pelvic fracture as the result of a motor vehicle accident. Which is the priority nursing action? a) Logrolling for transfers b) Preparing for pelvic examination c) Administering prescribed pain medication d) Inspecting the genitalia
Inspecting the genitalia
A client is receiving warfarin (Coumadin). Which test results should the nurse use to determine if the daily dose of this anticoagulant is therapeutic? a) Erythrocyte Sedimentation Rate (ESR) b) International Normalized Ration (INR) c) Accelerated Partial Thromboplastin Time (APTT) d) Bleeding time
International Normalized Ration (INR)
A client undergoes a below-the-knee amputation (BKA). What nursing explanation is correct when the client asks why the stump is re-wrapped with elastic bandages several times a day? a) It maintains joint flexibility. b) It shrinks and shapes the stump. c) It lengthens and tones the muscles. d) It absorbs blood and drainage.
It shrinks and shapes the stump.
A client who had an open reduction and internal fixation of a fractured ankle is being discharged. Which behavior indicates the need for further information about the use of crutches? a) Moving the crutches before the unaffected leg when descending stairs. b) Leaning axillae on the crutches to support the body's weight. c) Advancing both crutches with the weaker leg. d) Transferring the crutches into one hand when sitting in a chair.
Leaning axillae on the crutches to support the body's weight.
A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane? a) Stronger hand b) Right hand c) Dominant hand d) Left hand
Left hand
What is the appropriate nursing intervention for a patient suffering from a fractured hip with bipolar hip repair? Select all that apply. a) Maintain abduction of the affected extremity. b) Maintain adduction of the affected extremity. c) Release traction weight q4-6hours. d) Ensure the head of the bed is not elevated more than 445 degrees.
Maintain abduction of the affected extremity
After undergoing an amputation of the lower left leg. The client complains of pain in his left leg and foot. He requests pain medication for the sensation. The nurse's best course of action will be to: a) Explain to the client the discomfort he is reporting is not possible since his limb is missing. b) Medicate the client for the complaints of pain. c) Contact the health care provider concerning a possible consult with a psychologist. d) Attempt to distract the client from the situation.
Medicate the client for the complaints of pain.
The nurse is performing a neurovascular check on a hospitalized client who had a cast applied to the lower leg. The client complains of tingling in the toes distal to the fracture site. Which action should the nurse take? a) Ambulate the client with crutches. b) Elevate the extremity. c) Document as normal. d) Notify the physician.
Notify the physician.
The nurse would expect the client with a lumbar herniated intervertebral disk to report which additional symptom? a) Diminished sensation in one or both knees b) Brief periods when the toes feel quite cold. c) Tenderness over one or both iliac crests. d) Pain radiating into the buttocks and leg.
Pain radiating into the buttocks and leg.
What does prolonged bed rest put the older adults at risk for? a) pathologic fractures b) osteomyelitis c) gout d) ankylosing spondylitis
Pathologic fractures
A client has a compound fracture of the femur. The nurse should assess the client for the typical signs and symptoms of a fat embolus. In comparison to thromboembolism, which clinical indicator is unique to a fat embolus? a) Anxiety b) restlessness c) pinpoint red spots on the chest d) decreased arterial oxygen level
Pinpoint red spots on the chest
When the nurse assesses the characteristics of pain in a client with a herniated disk, what activity would the nurse most likely expect to intensify the pain? a) Urinating b) Eating c) Sneezing d) Sleeping
Sneezing
To prevent footdrop in a client with a leg cast, what should the nurse do? a) Encourage complete bed rest to promote healing of the foot. b) Support the foot with 90 degrees of flexion. c) Place an elastic stocking on the foot to provide support. d) Place the foot in traction.
Support the foot with 90 degrees of flexion.
A client sustains a fractured right femur in a fall on the ice and is admitted to the hospital's emergency department. How should the nurse assess this client for signs of circulatory impairment? a) Ask the client to cough and deep breathe. b) Take the clients pedal pulse in the affected extremity. c) Turn the client to the side lying position. d) Instruct the client to wiggle the toes of the right foot.
Take the clients pedal pulse in the affected extremity.
An X-ray film of a client's arm reveals a comminuted fracture of the radial bone. When determining an appropriate plan of care, the nurse recalls that with a comminuted fracture what happens? a) The bone has broken into several fragments and the skin is intact. b) The bone is broken into two parts and the skin may or may not be broken. c) Bone protrudes through a break in the skin. d) Splinting has occurred on one side of the bone and bending on the other side.
The bone has broken into several fragments and the skin is intact.
A client who sustained a fractured arm requires range-of-motion exercises to promote circulation. The nurse educates the client about performing active range of motion. Which of the following best described how this motion is performed? a) The nurse and the client perform the exercise together. b) The nurse performs the exercise for the client. c) The client performs the exercise without assistance. d) The client wears an electronical device that performs range of motion.
The client performs the exercise without assistance.
The practitioner prescribes no weight bearing on a leg that has been casted because of a fracture of the femur. How should the nurse determine the appropriate length of the crutches for this client? Select all that apply. a) The crutches tip should rest 6 inches outside the feet. B) here should be a snug fit under the axillae when the client walks. c) Elbows slightly flexed, no more than 30 degrees, and the shoulders straight. d) The crutches should reach 2 inches below the axillae.
The crutches tip should rest 6 inches outside the feet. Elbows slightly flexed, no more than 30 degrees, and the shoulders straight. The crutches should reach 2 inches below the axillae.
What should the nurse expect the healthcare provider to prescribe if a client exhibits clinical indicators of warfarin overdose? a) Iron dextran b) Vitamin K c) Protamine Sulfate d) Heparin
Vitamin K
A nurse explains to a client that stimulation of calcium deposition in the bone after a distal femoral fracture is achieved best by what? a) Resting the extremity b) Weight-bearing activity c) Ingesting foods high in calcium d) Normal aging processes
Weight-bearing activity