Final NCLEX Challenge
A nurse is caring for a client who has a severe gangrenous infection of the right lower extremity. The nurse should plan preoperative teaching based on the possibility of which of the following amputation procedures?
"Your pain will gradually become less severe"
A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? (Select all that apply).
- Sedentary lifestyle -Aging - Caffeine intake - Secondhand smoke
A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply)
-Monitor peripheral pulses in the affected extremity - Examine the skin under the traction splint - Assess the temperature of the affected extremity
A nurse is teaching a newly licensed nurse about the difference between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?
A synthetic cast is weighs less
A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority?
Administer antibiotics to the client
A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet?
Broccoli
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
Check the tubing for kinks
A nurse is caring for a client who has a cast in place for a fractured tibia. Which of the following nursing actions is the priority immediately after the provider has applied the cast?
Checking capillary refill distal to the cast
A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?
Decreased muscle mass
A nurse is caring for a group of clients. She plans to delegate obtaining morning vital signs to an assistive personnel (AP) on her team. Which of the following actions should the nurse plan to take?
Determine the time frame the AP should report the results
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?
Difficulty starting the flow of urine
A nurse is assessing a client who is in a body cast. Which of the following manifestations should the nurse identify as a possible cast syndrome?
Dilated pupils
A nurse is caring for a client who has a metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take?
Discuss initiating hospice care with the client and family
A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching?
Dry the prosthesis socket completely before applying it to the limb
A nurse at a rehabilitation center is planning care for a client who has a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
Establish the ability to communicate effectively
A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include?
Examine the testicles after a bath or shower
A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?
Explain that the provider will see him and determine a course of action
A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following is a trigger for the formation of vitamin D in the body?
Exposure to sunlight
A nurse is caring for an older client who had a femoral facture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?
Fat embolism
A nurse is caring for a client who is 3 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take?
Have the client lie prone several times per day
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
Hemorrhage
A nurse is caring for a client who has a new short-leg cast on his lower leg to treat an ankle fracture. Which of the following findings required immediate notification of the provider?
Inability to flex the toes of the casted foot
During the assessment of a client who has a cast on his right leg, the nurse located an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect?
Infection
A nurse is caring for a male client who has a new diagnosis of genital herpes (HSV 2). Which of the following findings should the nurse expect?
Influenza-like symptoms
A nurse is planning an educational program on a sildenafil to a group of older male clients. Which of the following information should the nurse include in the educational program?
Ingestion of the medication with nitrates causes hypotension
A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders?
Kyphosis
A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis?
Localized erythema
A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
Output of burgundy colored urine
A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?
Pale pink
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?
Perform neurovascular checks of the extremities.
A nurse is assessing the elastic bandage on the stump of a client who has a right-below-the-knee amputation. Which of the following findings should the nurse identify as a complication?
Pitting edema around the stump dressing
A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome?
Positive Phalen's sign
A nurse on a medical-surgical unit is caring for a client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Potential condition: Obstructed urinary catheter Actions to take: - Irrigate the urinary catheter - Medicate the client for bladder spasms Parameters to monitor: -Urine output - Hgb and Hct
A nurse is assessing a client who is postoperative following a right below-the-knee amputation. Which of the following findings should the nurse identify as a possible complication?
Presence edema above the stump dressing
A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
Provide high-flow oxygen
A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?
Tachypnea
A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?
The client develops a life-threatening situation
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?
This service began with the client's admission to the hospital
A nurse is reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis?
Thyroid hormones
A nurse is teaching an older adult client who has osteoporosis about beginning a program or regular physical activity. Which of the following recommendations should the nurse make?
Walking briskly
A nurse is caring for a client who is postoperative following a below-the-knee-amputation and will soon undergo fitting for a leg prosthesis. Which of the following is an appropriate nursing intervention for this client at this time?
Wrap the residual limb with an elastic bandage in a figure-eight configuration
A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?
fever
A nurse is providing postoperative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching?
"Rest frequently with your foot elevated"
A coworker puts an arm around a nurse and says, "I bet you are a great lover." Which of the following is an appropriate response by the nurse?
"Speaking to me like that makes me uncomfortable"
A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications?
Fat embolism syndrome
A nurse is caring for a client who has a fractured right femur and is in balances suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?
Realign the client's position
A nurse is talking to a client who is taking a calcium supplement for osteoporosis. The client tells the nurse she is experiencing flank pain. Which of the following adverse effects should the nurse suspect?
Renal stones
A nurse is providing discharge teaching to a client who has a Plaster of Paris walking cast on his left lower leg. Which of the following instructions should the nurse include?
Report any numbness or pain in your toes
A nurse is discussing Russell's traction with a newly licensed nurse. Which of the following statements about this form of traction should the nurse include in the teaching?
Russell's traction uses a sling under the knee to treat a fracture of the femur
A nurse is reviewing the medical record of a client who has moderate Alzheimer' disease. Drag words from the choices below to fill in each blank in the following sentence. To effectively manage the provider prescriptions, which of the following tasks should the nurse assign to an assistive personnel?
The nurse should plan to assign CONTINUE BOWEL TRAINING PROGRAM and RECORD STRICT NUTRITIONAL CONTENT to the AP.
A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker? (Select all that apply).
- A client who requires placement in an assisted living facility - a client who requests to secure an emergency notification system in the home - a client who requests to get school assignments while hospitalized on a pediatric unit
A nurse is assessing a client who has Paget's disease of the bone. Which of the following findings should the nurse expect? (Select all that apply).
- cranial enlargement -skeletal pain - waddling gait
A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil?
Isosorbide
A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make?
"Normal bone growth can be affected"
A nurse is caring for a client in the emergency department (ED). Select the 4 assessment findings on day 2 that require immediate follow-up.
- heart rate - edema - urine color - pedal pulses
A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?
Acute compartment syndrome
A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following adverse effects should the nurse instruct the client to report to the provider? (Select all that apply).
- Jaw pain - blurred vision - dysphagia
A nurse is caring for a client who has had an open radical prostatectomy. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client
- Place the client in the sitting position while in bed: Contraindicated - Administer an antispasmodic medication: Anticipated - Teach the client how to use a leg bag: Anticipated - Apply ice to the scrotum and penis: Anticipated - Administer a docusate sodium suppository: Contraindicated
An occupational health nurse is instructing workers at an industrial facility about emergency procedures to take in the event of a traumatic amputation of a finger. Which of the following guidelines should the nurse include for preserving an amputated part for surgical reattachment? (Select all that apply).
- Wrap the amputated finger in dry, sterile gauze - Put the amputated finger in a sealed, waterproof plastic bag - Prevent the amputated finger from contacting water
An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse include for emergency care? (Select all that apply).
- Wrap the part in dry sterile gauze - Put the severed part in a dry, waterproof plastic bag - Evaluate the extremity - Prevent contact of the severed part with water
A nurse is prepping a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
Wrap the stump with an elastic bandage in a figure-eight configuration