FINAL NCLEX Challenge Summer 2020
discussing ageism with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the concept?
"Ageism refers to the stereotype that older adults are not able to understand new information." Ageism refers to stereotypes about older adults based solely on age. The belief that older adults are unable to learn and understand new information is a myth of ageing.
stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?
A reddened area over the sacrum A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.
client who is 24 hr post op following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of acute compartment syndrome (ACS)?
Dyspnea Dyspnea is an early manifestation of ACS that occurs due to hypoxemia.
client who has impaired mobility. which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?
Footboard Plantar flexion contractures, or foot drop, develop when a client's unsupported feet are constantly in plantar flexion. The nurse should place the soles of the client's feet against a footboard, a flat wooden or plastic panel perpendicular to the bed, to keep them dorsiflexed and, therefore, prevent foot drop.
following the application of a leg cast for the treatment of a fracture. IF the cast is too tight, which of the following findings should the nurse expect to observe first?
Pallor of the toes. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.
caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia.
Perform a neurovascular assessment. The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check."
post op following an ORIF of a fractured femur. which of the following actions id the most important for the nurse to complete in the post op period?
Perform neurovascular checks of the extremities. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.
assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication?
Pitting edema around the stump dressing If the elastic bandage is properly applied, it should prevent edema. The nurse should remove the bandage and rewrap the stump.
client who has limited hand mvmd. Which of the following actions should the nurse take to assist the client with feeding?
Provide an adaptive feeding device for the client. Adaptive devices, such as utensils with bent or angled handles, wide handles, or foam handles, are helpful for clients whose hand mobility is limited because these devices promote independence.
fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms.
Realign the clients position The greatest risk to this client is injury form circulatory compromise and tissue damage; therefore, the first action the nurse should take is to realign the client's position.
caring for a client who is experiencing dysphagia. the nurse should recommend a referral to which of the following members of the healthcare team?
Speech therapist A speech therapist assesses and makes recommendations for clients experiencing speech, language, and swallowing difficulties.
sustained a femur fracture in an automobile accident and is placed into a 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. Traction weights, which are to hang freely at all times, are never to be removed without a specific provider prescription unless there is a life-threatening situation.
providing teaching for a client who is post op following below-the-knee amputation. The nurse should instruct the client that which of the following nutrients is necessary for wound healing?
Vitamin C Vitamin C promotes collagen synthesis, which is essential for wound healing.
teaching an older client who has osteoporosis about beginning a program of regular physical activity.
Walking briskly Weight-bearing exercises are essential for maintaining bone mass. Walking is an appropriate activity for an older client to promote weight bearing and to maintain bone mass.
1 day post op following hip open reduction with internal fixation. The client is scheduled to being PT in 30 mins.
offer to administer analgesia The nurse should offer to premedicate the client prior to painful procedures, such as physical therapy, to help keep pain under control.
Experienced a femur fracture 8hr ago and now reports sudden onset dyspnea and severe chest pain.
provide high-flow oxygen The first action the nurse should take when using the airway, breathing, circulation approach to client care is to provide the client with high-flow oxygen. The client is experiencing fat embolism syndrome as a complication of a long bone fracture. The lungs are affected first, causing a drop in the level of arterial oxygen, and the client can require mechanical ventilation.
total knee arthroplasty about self-administering morphine via a PCA infusion device. client statements indicates an understanding of the teaching?
"I should tell the nurse if I can't control my pain with this device." PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self-administer pain medication on an as-needed basis The client should notify the nurse if pain control is not achieved. The nurse can initiate a re-evaluation of the client's pain management plan.
ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?
"I'll apply ice to my ankle today and tomorrow." The RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation. The client should apply ice for the first 24 to 48 hr after the injury.
client about crutch walking using the three-point gait. which statement should be included in the teaching?
"Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches." The nurse should instruct the client to use this method of crutch walking for a three-point gait.
planning to discharge a client who has quadriplegia to his home, The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide?
"Respite care allows the primary caregiver time away from day-to-day care responsibilities." A client who has quadriplegia requires support for many activities of daily living. Primary caregivers need time to meet their own personal needs as well. Respite care allows primary caregivers time away from their day-to-day care responsibilities for the client.
post op 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." The client should rest and elevate the foot to help reduce discomfort and prevent edema.
teaching a client who is to starting to take alendronate effervescent tablets to treat osteoporosis.
"Sit upright or stand for at least 30 minutes after taking this medication." The nurse should instruct the client to sit or stand for 30 minutes after administration of this medication to reduce prolonged contact of the medication with the esophageal mucosa that can cause esophagitis.
metastatic osteosarcoma. while the parents are away, the adolescent asks the nurse if she is going to die. Which of the following responses should the nurse make?
"Tell me more about what you are thinking." This response by the nurse facilitates therapeutic communication, and encourages the adolescent to explore her feelings further while in a safe environment.
instructing a class of AP about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?
"When the client moves, he should move the cane forward first." When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.
client who is preparing for a below the knee amputation. which of the following statements is true regarding the post op placement of a prosthesis?
"You will do special exercises in advance of getting your prosthesis." The physical therapist will teach muscle strengthening exercises to prepare the client for prosthesis use.
scheduled for a dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. which instruction should the nurse include in the teaching?
"You will need to remove all jewelry before the test." The nurse should instruct the client to remove all jewelry or metal objects that can interfere with the test. A DXA scan is the mostly commonly used screening and diagnostic tool for measuring bone mineral density.
severe gangrenous infection of the right lower extremity. the nurse should plan prep teaching based on the possibility of which of the following amputation procedures?
"Your pain will gradually become less severe." Phantom leg pain usually diminishes over time, and often is intermittent in response to a trigger.
caring for a group of clients. which of the following clients should the nurse refer to a social worker?
A client who requires placement in an assisted living facility is correct. A social worker can assist in placing a client in an assisted living facility. A client who requests to secure an emergency notification system in the home is correct. It is within the scope of the social worker's expertise to identify community resources to meet client needs after discharge. A client who requests to get school assignments while hospitalized on a pediatric unit is correct. It is within the scope of the social worker's expertise to coordinate with school systems to meet the educational needs of children who are hospitalized.
right leg is in buck's traction. which of the following interventions should the nurse implement to promote the clients mobility?
Active range-of-motion exercises of the left leg Active range-of-motion exercises help preserve joint function and mobility in an extremity that has limited mobility. The goals of active range-of-motion exercises include prevention of contractures, prevention of thrombus formation, and maintenance of some muscle mass and strength. Buck's traction is a form of skin traction. The primary purpose of skin traction is to decrease painful muscle spasms. This contraindicates active range of motion of the right leg.
increasing edema in the calf of a client who has multiple fractures of the leg, Increasing edema is a manifestation of which of the following complications?
Acute compartment syndrome. Increasing edema is a manifestation of acute compartment syndrome, which is a complication that occurs when excessive pressure reduces circulation.
caring for a client who has acute osteomyelitis. which of the following interventions is the nurse's priority?
Administer antibiotics to the client. The greatest risk to this client is bacteremia caused by the infection which can lead to septic shock; therefore, the priority intervention is antibiotic therapy. The client might require multiple antibiotics for an extended time.
new diagnosis of Paget's disease. The nurse anticipates the provider will prescribe which of the following medications for this client?
Alendronate Alendronate, a bisphosphonate, decreases bone resorption and minimizes loss of bone density.
conducting a fall risk assessment for four clients. the nurse should identify that which of the following clients is the greatest risk for a fall?
An older adult client who is confused and has urinary frequency An older adult client who is confused and has urinary frequency is at the greatest risk for a fall because this client might attempt to go to the bathroom without assistance. The nurse should implement interventions to prevent a fall, such as using a bed alarm, and placing the client close to the nurses' station.
the nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
Apply ice to the affected area. Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint. Applying ice to the affected area in the immediate postoperative period (first 24 hr) reduces pain and swelling.
community presentation about repetitive motion injuries. which of the following occupations should the nurse identify as increasing a clients risk for carpal tunnel syndrome?
Assembly line worker Occupations that require continuous wrist movement, such as working on a factory assembly line, increase the risk for developing carpal tunnel syndrome.
Teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?
Bend at the knees when picking up an object. Bending at the knees can help the client maintain her center of gravity. Then when she lifts the object, she should use her leg muscles, not her back muscles, to lift it.
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 Broccoli is high in calcium. Most vegetables contain considerably less calcium, except for kale, collard greens with stems, and turnip greens, which are also good sources of calcium.
post op following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the clients affected extremity?
Color Temperature Sensation Clients who have sustained trauma to an extremity, such as a fracture, are at increased risk for neurovascular compromise. The nurse should check the color of the client's affected extremity as part of this assessment. The nurse should identify pallor or cyanosis of the extremity as an indication of peripheral neurovascular dysfunction and should notify the provider.
Assessing a client who has paget's disease of the bone.
Cranial enlargement is correct. When the skull is involved, Paget's disease causes thickening and enlargement of the skull bones and enlargement of the cranium. Skeletal pain is correct. Paget's disease causes pain and tenderness over the affected bones. Abnormal gait is correct. When the legs are involved, Paget's disease causes bowing of the legs and an abnormal gait.
senior center about age related musculoskeletal changes. Which of the following changes should the nurse include in the plan?
Decreased muscle mass A decrease in muscle mass and strength occurs with aging.
laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which laboratory finding should the nurse expect?
Decreased serum calcium level A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown.
transfer a client form a bed to a chair, which action should the nurse take first?
Determine if the client can bear weight. Using the nursing process, the nurse should first determine if the client can bear weight.
just told her she has osteosarcoma. which of the following nonverbal expressions warrants further investigation by the nurse?
Enthusiasm It is unlikely that a client would appear enthusiastic after receiving a grim diagnosis. The nurse should determine the client's understanding of the diagnosis and initiate any appropriate referrals.
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. This response illustrates the therapeutic communication technique of focusing the client on the usual course of action that must precede drawing any conclusions about the cause of the client's pain.
older client who sometimes loses her balance while walking. Devices should the nurse use when helping the client ambulate?
Gait belt The nurse should use a gait belt to help support the client during ambulation. A gait belt helps keep the client's center of gravity stable and helps maintain balance and prevent falls.
caring for a client who is 3 days post op following an above-the-knee amputation. Which of the following actions should the nurse take?
Have the client lie prone several times per day. The nurse should encourage the client to lie prone for 20 to 30 min every 3 to 4 hr to help prevent hip flexion contractures.
teaching a client who has left hemiparesis how to use a cane. which of the following instructions should the nurse include?
Hold the cane on the right side to provide support for the weaker leg. The client should hold the cane with her stronger (right) hand.
who reports numbness and pain in his right palm, index finger, and middle finger. works with keyboard most of the time at work. nurse suspects carpal tunnel syndrome. which of the following tests should the nurse request that the client perform?
Hold the wrist at a 90-degree flexion. Carpal tunnel syndrome is the compression of the median nerve at the wrist. The condition is common in people who perform repetitive motions of the hand and wrist, such as typing. Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand, and bending the wrist at a 90-degree flexion will usually result in numbness, tingling, or weakness.
teaching a client who has constipation about a high-fiber diet. which of the following foods should be included as sources of fiber?
Kidney beans is correct. Kidney beans should be included in the teaching as a source of fiber. Blackberries is correct. Blackberries should be included in the teaching as a source of fiber. Whole wheat bread is correct. Whole wheat bread should be included in the teaching as a source of fiber.
assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?
Kyphosis Kyphosis, a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and increases with aging and vertebral fractures.
client who has a puncture wound on his foot. manifestation of acute osteomyelitis?
Localized erythema Swelling and localized erythema are manifestations of acute osteomyelitis.
rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the health care team?
Occupational therapist An occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding.
providing teaching about modifiable risk factors for osteoporosis. which if the following factors should the nurse include?
Sedentary lifestyle is correct. The nurse should identify prolonged immobility or a sedentary lifestyle as a risk factor for the development of osteoporosis. Weight bearing and muscle activities are necessary for osteoblastic (bone building) activity. Carbonated beverages is correct. The nurse should identify clients who consume more than 40 oz of carbonated beverages daily are at increased risk for calcium loss and the development of osteoporosis. Caffeine intake is correct The nurse should identify caffeine intake as a risk factor for the development of osteoporosis due to excessive losses of calcium in the urine. The body maintains homeostasis when this occurs by pulling calcium from the bones, making them more fragile and causing osteoporosis. Smoking tobacco products is correct. The nurse should identify tobacco use as a risk factor for the development of osteoporosis due to respiratory acidosis that can cause bone loss.
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 Long-term use of a synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss.
instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Guidelines should the nurse include for emergency care?
Wrap the part in dry sterile gauze is correct. The person at the scene should wrap the severed part in dry, sterile gauze or a clean cloth. Put the severed part in a dry, waterproof plastic bag is correct. The person at the scene should place the covered part in a sealed, waterproof plastic bag and then put the bag in ice water. Elevate the extremity is correct. This action reduces blood loss. Prevent contact of the severed part with water is correct. The person at the scene should not allow the severed part to become wet but should keep it dry.
