Joseph Quiz 2

A nurse is caring for a client who has returned from the surgical suite following a surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? A. Prevent aspiration B. Ensure adequate nutrition C. Promote oral health D. Relieve the client's pain

A. Prevent aspiration

A nurse is caring for client who is 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 client's affected extremity? (Select all that apply) Color Temp Ecchymosis Skin integrity Sensation

Color Temp Sensation

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should a nurse expect? (Select all that apply) Contractures of the extremities Polyuria Diarrhea Crackles in the lungs Pressure ulcers

Contractures of the extremities Crackles in the lungs Pressure ulcers

A nurse is caring for a 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? A. Trochanter roll B. Skeepskin heel pad C. Abduction pillow D. Footboard

D. Footboard

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client recieves home health care and spends most of his day in his reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? A. Increased insulin production B. Decreased RBC production C. Decreased Na excretion D. Increased Ca excretion

D. Increased Ca excretion

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment on the client's neurovascular status: A. Measure the circumference of the thigh B. Palpate the femoral pulse C. Monitor the client's calf for edema D. Instruct the client to wiggle his toes

D. Instruct the client to wiggle his toes

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased RR from 18 to 44/min B. Increased oral temp from 36.6C (97.8) to 37C (98.6F) C. Increased BP from 112/68 to 120/72 D. Increased HR from 68 to 72 bpm

A . Increased RR from 18 to 44/min

A nurse is caring for a toddler who has a fractured right femur and is in bryant traction. When determining that the traction is appropriately assembled, the nurse should observe which of the following? A. Skin straps maintain the leg in an extended positon B. Weights are attached to a pin that is inserted into the femur C. A padded sling is under the knee of the affected leg D. The buttocks is elevated slightly off of the bed

D. The buttocks is elevated slightly off of the bed

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehab goals should the nurse add to the client's plan of care? A. Ability to achieve independent transfer from bed to wheelchair B. Independent control of bowel and bladder function C. Use of a wheelchair with a chin or mouth stick D. Ability to self-feed with the use of adaptive equipment

D. Ability to self-feed with the use of adaptive equipment

A nurse is caring for a child who has a fracture of the forearm. The parent tells the nurse that the provider said it was a greenstick fracture and asks what that means. Which of the following statements should the nurse make? A. "The bones is broken on one side and bent on the other side" B. "Fragments of bone have splintered into the surrounding tissue" C. "The bone ends have been forced toward each other" D. "The sharp edges of the bone has broken through the skin"

A. "The bones is broken on one side and bent on the other side"

A nurse is caring for an adolescent client who has a newly fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? A. Perform a neurovascular assessment B. Explain the discharge instructions to the client and parents C. Provide reassurance to the client and parents D. Apply an ice pack to the casted leg

A. Perform a neurovascular assessment

A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following lab findings should a nurse expect? A. Decreased serum Ca level B. Decreased level of serum lipids C. Decreased erythrocyte sedimentation rate (ESR) D. Increased platelet count

A. Decreased serum Ca level

A nurse is assessing a client who is 24 hour 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)? A. Dyspnea B. Red-brown petechiae C. Headache D. Agitation

A. Dyspnea

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority? A. Maintain immobilization and alignment B. Provide optimal nutrition and hydration C. Promote independence in activities of daily living D. Provide relief from pain and discomfort

A. Maintain immobilization and alignment

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first? A. Test the drainage for glucose B. Suction the nostril C. Notify the physician D. Ask the client to blow his nose

A. Test the drainage for glucose

A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching? A. Use a blow dryer on a moderate heat setting to dry the cast after showering B. Use a cotton swab to relieve itching under the cast C. Report any worsening or unrelieved pain D. Avoid moving the affected leg

C. Report any worsening or unrelieved pain

A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first? A. Place the client in a rigid cervical collar B. Open the client's airway using the jaw thrust maneuver. C. Evaluate the client for other injuries D. Complete a neurological check on the client

B. Open the client's airway using the jaw thrust maneuver.

A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures? A. Diarrhea B. Hematuria C. Increased thirst D. Impaired tast

B. Hematuria

A nurse is planning for a newly admitted client who has a skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan? A. Instruct the client to flec and extend the ankle twice a day. B. Monitor the client's pedal pulses every hour C. Remove the weights every 4 hours D. Evaluate pressure points daily

B. Monitor the client's pedal pulses every hour

A nurse is caring for a client whose right leg is in Buck's traction. Which of the following interventions should nurse implement to promote the client's mobility A. Log rolling every 2 hours B. Isometric exercises of both legs C. Active ROM exercises of the left leg D. Passive range of motion to the right leg

C. Active ROM exercises of the left leg

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splinted into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures? A. Impacted B. Transverse C. Comminuted D. Oblique

C. Comminuted

A client who has a femur fracture states "I can't stay in this bed any longer. I need to get home so I can take care of my family". The nurse responds, "You have talked about your family several times. Can you tell me more about your specific concerns?" Which type of therapeutic communication response is the nurse using? A. Summarizing B. Empathizing C. Focusing D. Clarifying

C. Focusing

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 requires immediate notification of the provider? A. Moderate level of pain B. Dependent edema distal to the cast C. Inability to flex the toes of the casted foot D. Ecchymosis of the distal foot

C. Inability to flex the toes of the casted foot

A nurse is caring for a client who is post-op 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 post-op period? A. Medicate the client for pain B. Instruct the client on use of crutches C. Preform neurovascular checks of the extremities D. Direct the client to perform exercises of the ankle and toes

C. Preform neurovascular checks of the extremities

A nurse is caring for an older adult client who has a femoral head fracture 24 hours 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? A. Pneumonia B. Fat embolism C. Pneumothroax D. Airway obstruction

Fat embolism