Med Surg II Test 4

1. A patient with osteomyelitis is to receive vancomycin (Vancocin) 500 mg IV every 6 hours. The vancomycin is diluted in 100 mL of normal saline and needs to be administered over 1 hour. The nurse should set the IV pump to deliver how many milliliters per minute? (Round to the nearest hundredth.)

ANS: 1.67 To administer 100 mL in 60 minutes, the IV pump will need to provide 1.67 mL/min.

40. Which action should the nurse include in the plan of care for a patient with newly diagnosed ankylosing spondylitis? Have the patient sleep on their back with a flat pillow. Discuss that application of heat may worsen symptoms. Schedule annual laboratory assessment for the HLA-B27 antigen. Assist patient to choose physical activities that involve spinal flexion.

ANS: A Because ankylosing spondylitis results in flexion deformity of the spine, postures that extend the spine (e.g., sleeping on the back and with a flat pillow) are recommended. HLA-B27 antigen is assessed for initial diagnosis but is not needed annually. To counteract the development of flexion deformities, the patient should choose activities that extend the spine, such as swimming. Heat application is used to decrease localized pain.

12. Which action should the nurse take to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the right femur? Assess for hip pain. Check for contractures. Palpate peripheral pulses. Monitor for hip dislocation.

ANS: A Buck's traction is used to reduce painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.

18. What finding should indicate to the nurse that colchicine has been effective for a patient with an acute attack of gout? Reduced joint pain Increased urine output Elevated serum uric acid Increased white blood cells

ANS: A Colchicine reduces joint pain in 24 to 48 hours by decreasing inflammation. The recommended increase in fluid intake of 2 to 3 L/day during acute gout would increase urine output but would not indicate the effectiveness of colchicine. Elevated serum uric acid would result in increased symptoms. The WBC count might decrease with decreased inflammation but would not increase.

38. A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding should the nurse report immediately to the health care provider? The patient has painful hematuria. Acne is noted on the patient's face. Fasting blood glucose is 112 mg/dL. The patient has an increased appetite.

ANS: A Corticosteroid use is associated with an increased risk for infection, so the nurse should report the urinary tract symptoms immediately to the health care provider. The increase in blood glucose, increased appetite, and acne are also adverse effects of corticosteroid use but do not need diagnosis and treatment as rapidly as the probable not need diagnosis and treatment as rapidly as the probable urinary

41. After teaching a 28-yr-old with fibromyalgia about the disease, which patient statement does the nurse determines indicates a good understanding of effective self-management? "I will need to stop drinking so much coffee and soda." "I am going to join a soccer team to get more exercise." "I will call the doctor every time my symptoms get worse." "I should avoid using over-the-counter medications for pain."

ANS: A Dietitians often suggest patients with fibromyalgia limit their intake of caffeine and sugar because these substances are muscle irritants. Mild exercise such as walking is recommended for patients with fibromyalgia, but vigorous exercise is likely to make symptoms worse. Because symptoms may fluctuate from day to day, the patient should be able to adapt the regimen independently rather than calling the provider whenever symptoms get worse. Over-the-counter medications such as ibuprofen and acetaminophen are frequently used for symptom management.

19. Which action should the nurse take when caring for a patient with osteomalacia? Teach about the use of vitamin D supplements. Educate about the need for weight-bearing exercise. Instruct the patient to avoid dairy products in the diet. Discuss the use of medications such as bisphosphonates.

ANS: A Osteomalacia is caused by inadequate intake or absorption of vitamin D. Weight-bearing exercise and bisphosphonate administration may be used for osteoporosis but will not be beneficial for osteomalacia. Because ultraviolet light is needed for the body to synthesize vitamin D, the patient might be taught that 20 minutes a day of sun exposure is beneficial.

13. A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse including in discharge teaching? "Check and clean the pin insertion sites daily." "Remove the external fixator for your shower." "Remain on bed rest until bone healing is complete." "Take prophylactic antibiotics until the fixator is removed."

ANS: A Pin insertion sites should be cleaned daily to decrease risk for infection at the site. An external fixator allows the patient to be out of bed and avoid the risks of prolonged immobility. The device is surgically placed and is not removed until the bone is stable. Prophylactic antibiotics are not routinely given during external fixator use.

33. Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis should the nurse identify as a likely adverse effect of the medication? Blurred vision Joint tenderness Abdominal cramping Elevated blood pressure

ANS: A Plaquenil can cause retinopathy. The medication should be stopped. Other findings are not related to the medication although they will also be reported.

3. What should the occupational health nurse advise a patient whose job involves many hours of typing? Obtain a keyboard pad to support the wrist. Do stretching exercises before starting work. Wrap the wrists with compression bandages every morning. Avoid using nonsteroidal antiinflammatory drugs (NSAIDS).

ANS: A Repetitive strain injuries caused by prolonged work at a keyboard can be prevented by using a pad to keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting work. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to decrease swelling.

28. For a patient who has had right hip arthroplasty, which nursing action can the nurse delegate to experienced unlicensed assistive personnel (UAP)? Reposition the patient every 1 to 2 hours. Assess for skin irritation on the patient's back. Teach the patient quadriceps-setting exercises. Determine the patient's pain intensity and tolerance.

ANS: A Repositioning of orthopedic patients is within the scope of practice of UAP after they have been trained and evaluated in this skill. The other actions should be done by licensed nursing staff members.

36. A patient who had arthroscopic surgery of the right knee 7 days ago is admitted with a red, swollen, hot knee. Which assessment finding should the nurse report immediately to the health care provider? The blood pressure is 86/50 mm Hg. The patient says the knee pain is severe. The white blood cell count is 11,500/μL. The patient is taking ibuprofen (Motrin).

ANS: A The low blood pressure suggests the patient may be developing septicemia as a complication of septic arthritis. Immediate blood cultures and initiation of antibiotic therapy are indicated. The other information is typical of septic arthritis and should be reported to the health care provider, but it does not indicate any immediately life-threatening problems.

14. A patient who has had open reduction and internal fixation (ORIF) of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take? Check the patient's prescribed weight-bearing status. Use a mechanical lift to transfer the patient to the chair. Decrease the pain medication before getting the patient up. Have the unlicensed assistive personnel (UAP) transfer the patient.

ANS: A The nurse should be familiar with the weight-bearing orders for the patient before attempting the transfer. Mechanical lifts are not typically needed after this surgery. Pain medications should be given because the movement is likely to be painful for the patient. The registered nurse (RN) should supervise the patient during the initial transfer to evaluate how well the patient is able to accomplish the transfer.

35. A patient undergoes left above-the-knee amputation with an immediate prosthetic fitting. What should the nurse do when the patient arrives on the orthopedic unit after surgery? Assess the surgical site for hemorrhage. Remove the prosthesis and wrap the site. Place the patient in a side-lying position. Keep the residual limb elevated on a pillow.

ANS: A The nurse should monitor for postoperative hemorrhage. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. Unless contraindicated, the patient will be placed in a prone position for 30 minutes several times a day to prevent hip flexion contracture.

22. A 25-yr-old female patient with systemic lupus erythematosus (SLE) has a facial rash and alopecia. She tells the nurse, "I never leave my house because I hate the way I look." Which patient problem should the nurse plan to address? Social isolation Activity intolerance Impaired skin integrity Impaired social interaction

ANS: A The patient's statement about not going anywhere because of hating the way he or she looks expresses social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.

1. During assessment of the patient with fibromyalgia, the nurse should expect the patient to report which of the following? (Select all that apply.) Sleep disturbances Multiple tender points Cardiac palpitations and dizziness Multijoint inflammation and swelling Widespread bilateral, burning musculoskeletal pain

ANS: A, B, E These symptoms are commonly described by patients with fibromyalgia. Cardiac involvement and joint inflammation are not typical of fibromyalgia.

1. Which actions should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur? (Select all that apply.) Monitor serum calcium. Teach about the need for strict bed rest. Explain the use of sustained-release opioids. Support the left leg when repositioning the patient. Assist family and patient as they discuss the prognosis.

ANS: A, C, D, E The nurse will monitor for hypercalcemia caused by bone decalcification. Support of the leg helps reduce the risk for pathologic fractures. Although the patient may be reluctant to exercise, activity is important to maintain function and avoid complications associated with immobility. Adequate pain medication, including sustained-release and rapid-acting opioids, is needed for the severe pain often associated with bone cancer. The prognosis for metastatic bone cancer is poor, so the patient and family need to be supported as they deal with the reality of the situation.

10. A patient who had open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch. Which action should the nurse take next? Notify the health care provider. Assess the incision for redness. Reposition the left leg on pillows. Check the patient's blood pressure.

ANS: AThe patient's clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.

42. Which information should the nurse include when teaching a patient with newly diagnosed systemic exertion intolerance disease (SEID) about self-management? Symptoms usually progress as patients become older. A gradual increase in daily exercise may help decrease fatigue. Avoid use of over-the-counter antihistamines or decongestants. A low-residue, low-fiber diet will reduce any abdominal distention.

ANS: B A graduated exercise program is recommended to avoid fatigue while encouraging ongoing activity. Because many patients with SEID syndrome have allergies, antihistamines and decongestants are used to treat allergy symptoms. A high-fiber diet is recommended. SEID usually does not progress.

38. Which action should the urgent care nurse take for a patient with a possible knee meniscus injury? Encourage bed rest for 24 to 48 hours. Apply an immobilizer to the affected leg. Avoid palpation or movement of the knee. Administer intravenous opioids for pain management.

ANS: B A knee immobilizer may be used for several days after a meniscus injury to stabilize the knee and minimize pain. Patients are encouraged to ambulate with crutches. The knee is assessed by flexing, internally rotating, and extending the knee (McMurray's test). The pain associated with a meniscus injury will not typically require IV opioid administration. Nonsteroidal antiinflammatory drugs (NSAIDs) are recommended for pain management.

32. A 60-yr-old patient had open reduction and internal fixation (ORIF) for an open, displaced tibial fracture, What should the nurse identify as the priority patient problem? Acute pain Risk for infection Activity intolerance Risk for constipation

ANS: B A patient having ORIF is at risk for problems such as wound infection and osteomyelitis. After ORIF, patients typically are mobilized starting the first postoperative day, so the problems caused by immobility are not as likely. Pain management is important, but the most important action is to prevent infection.

17. The day after a having a right below-the-knee amputation, a patient reports pain in the missing right foot. Which action is most important for the nurse to take? Explain the reasons for the pain. Administer prescribed analgesics. Reposition the patient to assure good alignment. Tell the patient that the pain will diminish over time.

ANS: B Acute phantom limb sensation is treated as any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. Alignment is important but is unlikely to relieve the pain. Although the pain may decrease over time, it currently requires treatment.

6. Which action should the nurse include in the plan of care for a patient with a new diagnosis of rheumatoid arthritis (RA)? Instruct the patient to purchase a soft mattress. Encourage the patient to take a nap in the afternoon. Teach the patient to use lukewarm water when bathing. Suggest exercise with light weights several times daily.

ANS: B Adequate rest helps decrease the fatigue and pain associated with RA. Patients are taught to avoid stressing joints, use warm baths to relieve stiffness, and use a firm mattress. When the disease is stabilized, a physical therapist usually develops a therapeutic exercise program that includes exercises that improve flexibility and strength of affected joints, as well as the patient's general endurance.

12. Anakinra (Kineret) is prescribed for a patient with rheumatoid arthritis (RA). What information should the nurse include in teaching the patient about this drug? Avoiding aspirin use. Giving subcutaneous injections. Taking the medication with water. Recognizing gastrointestinal bleeding.

ANS: B Anakinra is administered by subcutaneous injection. GI bleeding is not a side effect of this medication. Because the medication is injected, instructions to take it with fluid would not be appropriate. The patient is likely to be concurrently taking aspirin or nonsteroidal antiinflammatory drugs (NSAIDs), and these should not be discontinued.

44. A patient with psoriatic arthritis and back pain is receiving etanercept (Enbrel). Which finding is most important for the nurse to report to the health care provider? Red, scaly patches are noted on the arms. Crackles are auscultated in the lung bases. Hemoglobin is 11.1g/dL, and hematocrit is 35%. Patient has continued pain after first week of therapy.

ANS: B Because heart failure is a possible adverse effect of etanercept, the medication may need to be discontinued. The other information will also be reported to the health care provider but does not indicate a need for a change in treatment. Red, scaly patches of skin and mild anemia are commonly seen with psoriatic arthritis. Treatment with biologic therapies requires time to improve symptoms.

27. The nurse should determine additional instruction is needed when a patient diagnosed with scleroderma makes which statement? "Paraffin baths can be used to help my hands." "I should lie down for an hour after each meal." "Lotions will help if I rub them in for a long time." "I should perform range-of-motion exercises daily."

ANS: B Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate teaching has been effective.

5. A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action should the nurse include in the plan of care? Logroll the patient every 2 hours. Assist the patient with ambulation. Discuss the need for genetic testing with the patient. Teach the patient about the muscle biopsy procedure.

ANS: B Because the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing because the patient already knows the diagnosis.

6. The nurse should instruct a patient with a nondisplaced fractured left radius that the cast will need to remain in place for what amount of time? Two weeks At least six weeks Until swelling of the wrist has resolved Until x-rays show complete bony union

ANS: B Bone healing starts immediately after the injury, but because ossification does not begin until 3 weeks after injury, the cast will need to be worn for at least 3 weeks. Complete union may take up to 1 year. Resolution of swelling does not indicate bone healing.

9. Which laboratory result should the nurse monitor to determine if prednisone has been effective for a patient who has an acute exacerbation of rheumatoid arthritis? Blood glucose C-reactive protein Serum electrolytes Liver function tests

ANS: B C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.

42. After change-of-shift report, which patient should the nurse assess first? Patient with a repaired mandibular fracture who is reporting facial pain. Patient with repaired right femoral shaft fracture who reports tightness in the calf. Patient with an unrepaired Colles' fracture who has right wrist swelling and deformity. Patient with an unrepaired intracapsular left hip fracture whose leg is externally rotated.

ANS: B Calf swelling after a femoral shaft fracture suggests possible DVT or compartment syndrome. The nurse should assess the patient rapidly and then notify the health care provider. The other patients have symptoms that are typical for their injuries but do not require immediate intervention.

40. Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the health care provider? Patient declines to be turned due to back pain. Patient has been incontinent of urine and stool. Patient reports lumbar area tenderness to palpation. Patient frequently uses oral corticosteroids to treat asthma.

ANS: B Changes in bowel or bladder function indicate possible spinal cord compression and should be reported immediately because surgical intervention may be needed. The other findings are also pertinent but are consistent with the patient's diagnosis and do not require immediate intervention.

8. Which information should the nurse include when preparing teaching materials for a patient who has an exacerbation of rheumatoid arthritis? Affected joints should not be exercised when pain is present Applying cold packs before exercise may decrease joint pain Exercises should be performed passively by someone other than the patient Walking may substitute for range-of-motion (ROM) exercises on some days

ANS: B Cold application is helpful in reducing pain during periods of exacerbation of RA. Because the joint pain is chronic, patients are instructed to exercise even when joints are painful. ROM exercises are intended to strengthen joints and improve flexibility, so passive ROM alone is not sufficient. Recreational exercise is encouraged but is not a replacement for ROM exercises.

2. The nurse is assessing a patient with osteoarthritis who uses naproxen (Naproxyn) for pain management. Which assessment finding should the nurse recognize as likely to require a change in medication? a. The patient has gained 3 pounds. b. The patient has dark-colored stools. c. The patient's pain affects multiple joints. d. The patient uses capsaicin cream (Zostrix).

ANS: B Dark-colored stools may indicate the patient is experiencing gastrointestinal bleeding caused by the naproxen. The patient's ongoing pain and weight gain will also be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.

14. Which information should the nurse include when teaching a patient with newly diagnosed ankylosing spondylitis (AS) about managing the condition? Exercise by taking long walks. Do daily deep-breathing exercises. Sleep on the side with hips flexed. Take frequent naps during the day

ANS: B Deep-breathing exercises are used to decrease the risk for pulmonary complications that may result from reduced chest expansion that can occur with AS. Patients should sleep on the back and avoid flexed positions. Prolonged standing and walking should be avoided. There is no need for frequent naps.

32. Which result for a patient with systemic lupus erythematosus (SLE) should the nurse identify as most important to communicate to the health care provider? Decreased C-reactive protein (CRP) Elevated blood urea nitrogen (BUN) Positive antinuclear antibodies (ANA) Positive lupus erythematosus cell prep

ANS: B Elevated BUN and serum creatinine indicate possible lupus nephritis and a need for a change in therapy to avoid further renal damage. The positive lupus erythematosus cell prep and ANA would be expected in a patient with SLE. A drop in CRP shows decreased inflammation.

7. A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective? "I will keep my back straight when I lift above than my waist." "I will begin doing exercises to strengthen and support my back." "I will tell my boss I need a job where I can stay seated at a desk." "I can sleep with my hips and knees extended to prevent back strain."

ANS: B Exercises can help strengthen the muscles that support the back. Flexion of the hips and knees places less strain on the back than keeping these joints extended. Sitting for prolonged periods can aggravate back pain. Modification in the way the patient lifts boxes is needed, but the patient should not lift above the level of the elbows.

1. A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention should the nurse include in the initial plan of care? Quadriceps-setting exercises Immobilization of the left leg Positioning the left leg in flexion Assisted weight-bearing ambulation

ANS: B Immobilization of the affected leg helps to decrease pain and reduce the risk for pathologic fracture. Weight-bearing exercise increases the risk for pathologic fractures. Flexion of the affected limb is avoided to prevent contractures.

1. Which finding should the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee? Presence of Heberden's nodules Discomfort with joint movement Redness and swelling of the knee joint Stiffness that increases with movement

ANS: B Initial symptoms of OA include pain with joint movement. Heberden's nodules occur on the fingers. Redness of the joint is associated with inflammatory arthritis such as rheumatoid arthritis. Stiffness in OA is worse right after the patient rests and decreases with joint movement.

26. A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action should the nurse include in the plan of care? Avoid use of capsaicin cream on hands. Keep the environment warm and draft free. Obtain capillary blood glucose before meals. Assist to bathroom every 2 hours while awake.

ANS: B Keeping the room warm will decrease the incidence of Raynaud's phenomenon, one aspect of the CREST syndrome. Capsaicin cream may be used to improve circulation and decrease pain. There is no need to obtain blood glucose or to assist the patient to the bathroom every 2 hours.

25. The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order should the nurse question? Draw anti-DNA blood titer. Administer varicella vaccine. Naproxen 200 mg twice daily. Famotidine (Pepcid) 20 mg daily.

ANS: B Live virus vaccines, such as varicella, are contraindicated in a patient taking immunosuppressive drugs. The other orders are appropriate for the patient.

19. A patient with gout has a new prescription for losartan (Cozaar). What should the nurse plan to monitor? Blood glucose Blood pressure Erythrocyte count Lymphocyte count

ANS: B Losartan may be effective for treating older patients with gout and hypertension. Losartan promotes urate excretion and may normalize serum urate. Losartan, an angiotensin II receptor antagonist, should lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.

34. A 29-yr-old woman is taking methotrexate to treat rheumatoid arthritis. Considering this treatment, which information should the nurse report to the health care provider? The patient had a history of infectious mononucleosis as a teenager. The patient is trying to get pregnant before her disease becomes more severe. The patient has a family history of age-related macular degeneration of the retina. The patient has been using large doses of vitamins and health foods to treat the RA.

ANS: B Methotrexate is teratogenic, and the patient should be taking contraceptives during methotrexate therapy. The other information will not impact the choice of methotrexate as therapy.

45. Which action for the care of a patient who has scleroderma can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? Monitor for difficulty in breathing. Document the patient's oral intake. Check finger strength and movement. Apply capsaicin (Zostrix) cream to hands.

ANS: B Monitoring and documenting patient's oral intake is included in UAP education and scope of practice. Assessments for changes in physical status and administration of medications require more education and scope of practice and should be done by RNs.

9. A patient who is to have no weight bearing on the left leg is learning to use crutches. Which observation by the nurse indicates the patient can safely ambulate independently? The patient moves the right crutch with the right leg and then the left crutch with the left leg. The patient advances the left leg and both crutches together and then advances the right leg. The patient uses the bedside chair to assist in balance as needed when ambulating in the room. The patient keeps the padded area of the crutch firmly in the axillary area when ambulating.

ANS: B Patients are usually taught to move the crutches and the injured leg forward at the same time and then to move the unaffected leg. If the 2- or 4-point gait is to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid brachial plexus damage.

5. A tennis player has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. Which information will the nurse include in postoperative teaching? "You will not be able to serve a tennis ball again." "You will begin work with a physical therapist tomorrow." "Keep the shoulder immobilizer on for the first 4 days to minimize pain." "The surgeon will use the drop arm test to determine the success of surgery."

ANS: B Physical therapy after a rotator cuff repair begins on the first postoperative day to prevent "frozen shoulder." A shoulder immobilizer is used immediately after the surgery, but leaving the arm immobilized for several days would lead to loss of range of motion. The drop arm test is used to test for rotator cuff injury but not after surgery. The patient may be able to return to tennis after rehabilitation.

21. Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient understands the nurse's teaching about the condition? "I will exercise even if I am tired." "I will use sunscreen when I am outside." "I should avoid nonsteroidal antiinflammatory drugs." "I should take birth control pills to avoid getting pregnant."

ANS: B Severe skin reactions can occur in patients with SLE who are exposed to the sun. Patients should avoid fatigue by balancing exercise with rest periods as needed. Oral contraceptives can exacerbate lupus. Aspirin and nonsteroidal antiinflammatory drugs are used to treat the musculoskeletal manifestations of SLE.

11. How should the nurse suggest that a patient recently diagnosed with rheumatoid arthritis (RA) plan to start each day? A brief routine of isometric exercises A warm bath followed by a short rest Active range-of-motion (ROM) exercises Stretching exercises to relieve joint stiffness

ANS: B Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

29. A patient who arrives at the emergency department with severe left knee pain is diagnosed with a patellar dislocation. What should be the nurse's initial focus for patient teaching? Use of a knee immobilizer Monitored anesthesia care Physical activity restrictions Performance of gentle knee flexion

ANS: B The first goal of interprofessional management is realignment of the knee to its original anatomic position, which will require anesthesia or monitored anesthesia care, formerly called conscious sedation. Immobilization, gentle range-of-motion exercises, and discussion about activity restrictions will be implemented after the patella is realigned.

3. A patient has recently been diagnosed with rheumatoid arthritis (RA) The patient, who has two school-age children, tells the nurse that home life is very stressful. Which initial response should the nurse make? "You need to see a family therapist for some help with stress." "Tell me more about the situations that are causing you stress." "Perhaps it would be helpful for your family to be in a support group." "Your family should understand the impact of your rheumatoid arthritis."

ANS: B The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

15. Which information should the nurse include in discharge teaching for a patient who has had a repair of a fractured mandible? Administration of nasogastric tube feedings How and when to cut the immobilizing wires The importance of high-fiber foods in the diet The use of sterile technique for dressing changes

ANS: B The jaw will be wired for stabilization, and the patient should know what emergency situations require the wires to be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge, the patient will swallow liquid through a straw.

20. Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain? Provide information about therapeutic neck exercises. Ask about numbness or tingling of the hands and arms. Suggest the patient alternate the use of heat and cold to the neck. Teach about the use of nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: B The nurse's initial action should be further assessment of related symptoms because cervical nerve root compression will require different treatment than musculoskeletal neck pain. The other actions may also be appropriate, depending on the assessment findings.

18. Which statement by a patient who has had an above-the-knee amputation indicates the nurse's discharge teaching has been effective? "I should elevate my residual limb on a pillow 2 or 3 times a day." "I should lie flat on my abdomen for 30 minutes 3 or 4 times a day." "I should change the limb sock when it becomes soiled or each week." "I should use lotion on the stump to prevent skin drying and cracking."

ANS: B The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage hip flexion contracture.

36. Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take? Observe output from the surgical drain. Administer prescribed pain medication. Instruct the patient about benefits of early ambulation. Change the dressing and document the wound appearance.

ANS: B The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not affect ambulation.

2. A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information should the nurse include in the discharge teaching? How to apply warm packs to the leg to reduce pain How to monitor and care for a long-term IV catheter The need for daily aerobic exercise to help maintain muscle strength The reason for taking oral antibiotics for 7 to 10 days after discharge

ANS: B The patient will be taking IV antibiotics for several months. The patient will need to recognize signs of infection at the IV site and know how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.

25. After being hospitalized for 3 days with a right femur fracture, a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? Stay with the patient and offer reassurance. Administer prescribed PRN O2 at 4 L/min. Check the patient's legs for swelling or tenderness. Notify the health care provider about the symptoms.

ANS: B The patient's clinical manifestations and history are consistent with a pulmonary embolism, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient but meeting the physiologic need for O2 is a higher priority. The health care provider should be notified after the O2 is started and pulse oximetry obtained concerning suspected fat embolism or venous thromboembolism.

37. A patient hospitalized with polymyositis has joint pain; erythematous facial rash; eyelid edema; and a weak, hoarse voice. What safety priority should the nurse identify for this patient? Acute pain Risk for aspiration Impaired tissue integrity Disturbed visual perception

ANS: B The patient's vocal weakness and hoarseness indicate weakness of the pharyngeal muscles and a high risk for aspiration. The other concerns are also appropriate but are not as high a priority as the maintenance of the patient's airway.

8. Which action should the nurse take when repositioning the patient who has just had a laminectomy and discectomy? Instruct the patient to move the legs before turning the rest of the body. Place a pillow between the patient's legs and turn the entire body as a unit. Have the patient turn by grasping the side rails and pulling the shoulders over. Turn the patient's head and shoulders first, followed by the hips, legs, and feet.

ANS: B The spine should be kept in correct alignment after laminectomy. The other positions will create misalignment of the spine.

17. What action should the nurse complete before administering alendronate (Fosamax) to a patient with osteoporosis? Ask about any leg cramps or hot flashes. Assist the patient to sit up at the bedside. Be sure that the patient has recently eaten. Administer the ordered calcium carbonate.

ANS: B To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.

43. The nurse is caring for a patient who is using Buck's traction after a hip fracture. Which action can the nurse delegate to experienced unlicensed assistive personnel (UAP)? Remove and reapply traction periodically. Ensure the weight for the traction is hanging freely. Monitor the skin under the traction boot for redness. Check for intact sensation and movement in the affected leg.

ANS: B UAP can be responsible for maintaining the integrity of the traction after it has been established. The RN should assess the extremity and assure manual traction is maintained if the traction device has to be removed and reapplied. Assessment of skin integrity and circulation should be done by the registered nurse (RN).

21. A nurse who works on the orthopedic unit has just received change-of-shift report. Which patient should the nurse assess first? Patient who reports foot pain after hammertoe surgery. Patient who has not voided 8 hours after a laminectomy. Patient with low back pain and a positive straight-leg-raise test. Patient with osteomyelitis who has a temperature of 100.5° F (38.1° C).

ANS: B Difficulty in voiding may indicate damage to the spinal nerves and should be assessed and reported to the surgeon immediately. The information about the other patients is consistent with their diagnoses. The nurse will need to assess them as quickly as possible, but the information about them does not indicate a need for immediate intervention.

29. Which assessment information should indicate to the nurse that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone? The patient has joint pain and stiffness. The patient's blood glucose is 165 mg/dL. The patient has experienced a recent 5-pound weight loss. The patient's erythrocyte sedimentation rate (ESR) has increased.

ANS: B Corticosteroids have the potential to cause diabetes. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication.

26. A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding should the nurse identify as most important to communicate to the health care provider? There is bruising at the shoulder area. The patient reports arm and shoulder pain. The right arm appears shorter than the left. There is decreased shoulder range of motion.

ANS: C A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. Bruising, pain, and decreased range of motion should also be reported, but these do not indicate emergent treatment is needed to preserve function.

31. A patient with an acute attack of gout in the right great toe has a new prescription for probenecid. Which information about the patient's home routine should the nurse understand indicates a need for teaching regarding gout management? The patient sleeps 8-10 hours each night. The patient usually eats beef once a week. The patient takes one aspirin a day to prevent angina. The patient usually drinks about 3 quarts water each day.

ANS: C Aspirin interferes with the effectiveness of probenecid and should not be taken when the patient is taking probenecid. The patient's sleep pattern will not affect gout management. Drinking 3 quarts of water and eating beef only once or twice a week are appropriate for the patient with gout.

24. A patient with hypertension and gout has a red, painful right great toe. Which action should the nurse include in the plan of care for this patient? Gently palpate the toe to assess swelling. Use pillows to keep the right foot elevated. Use a footboard to hold bedding away from the toe. Teach the patient to avoid acetaminophen (Tylenol).

ANS: C Because any touch on the area of inflammation may increase pain, bedding should be held away from the toe, and touching the toe should be avoided. Elevation of the foot will not reduce the pain, which is caused by urate crystals. Acetaminophen can be used for pain management.

44. Based on the information in the accompanying figure obtained for a patient in the emergency room, which action should the nurse take first? History: Age 23, Right Lower Leg Injury Physical Assessment: Reports severe RL Leg Pain, Reports feeling short of breath, Bone protruding from right lower leg Diagnostic Exams: CBC (WBC 9400; Hgb 11.6 g/dL), RL X-Ray (Right Tibial Fracture) Administer the prescribed morphine 4 mg IV. Contact the operating room to schedule surgery. Check the patient's O2 saturation using pulse oximetry. Ask the patient the date of the last tetanus immunization.

ANS: C Because fat embolism can occur with tibial fracture, the nurse's first action should be to check the patient's O2 saturation. The other actions are also appropriate but not as important at this time as obtaining the patient's O2 saturation.

35. A patient is taking methotrexate to treat rheumatoid arthritis (RA). Which laboratory result is important for the nurse to communicate to the health care provider? Rheumatoid factor is positive. Fasting blood glucose is 90 mg/dL. The white blood cell count is 1500/μL. The erythrocyte sedimentation rate is increased.

ANS: C Bone marrow suppression is a possible side effect of methotrexate, and the patient's low WBC count places the patient at high risk for infection. The elevated erythrocyte sedimentation rate and positive rheumatoid factor are expected in RA. The blood glucose is normal.

1. What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures? Tack down scatter rugs on the floor in the home. Expect most falls to happen outside the home in the yard. Buy shoes that provide good support and are comfortable to wear. Get instruction in range-of-motion exercises from a physical therapist.

ANS: C Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range-of-motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.

28. When the nurse brings medications to a patient with rheumatoid arthritis, the patient refuses the prescribed methotrexate. The patient tells the nurse, "My arthritis isn't that bad yet. The side effects of methotrexate are worse than the arthritis." What is the most appropriate response by the nurse? "You have the right to refuse to take the methotrexate." "Methotrexate is less expensive than some of the newer drugs." "It is important to start methotrexate early to decrease the extent of joint damage." "Methotrexate is effective and has fewer side effects than some of the other drugs."

ANS: C Disease-modifying antirheumatic drugs (DMARDs) are prescribed early to prevent the joint degeneration that occurs as soon as the first year with RA. The other statements are accurate, but the most important point for the patient to understand is that it is important to start DMARDs as quickly as possible.

20. A patient who takes multiple medications develops acute gout arthritis. Which medication should the nurse discuss with the health care provider before administering a prescribed dose? sertraline (Zoloft). famotidine (Pepcid). hydrochlorothiazide. oxycodone (Roxicodone).

ANS: C Diuretic use increases uric acid levels and can precipitate gout attacks. The other medications are safe to administer.

4. Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle? Keep the ankle loosely wrapped with gauze. Apply a heating pad to reduce muscle spasms. Use pillows to elevate the ankle above the heart. Gently move the ankle through the range of motion.

ANS: C Elevation of the leg will reduce swelling and pain. Compression bandages are used to decrease swelling. For the first 24 to 48 hours, cold packs are used to reduce swelling. The ankle should be rested and kept immobile to prevent further swelling or injury.

3. A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. Which statement by the patient should indicate to the nurse the need for additional teaching related to health maintenance? "I'm frustrated with this endless treatment!" "I will take my oral temperature twice a day." "I think my left foot is starting to droop down." "I use crutches to avoid weight bearing on the left leg."

ANS: C Footdrop is an indication that the foot is not being supported in a neutral position by a splint. Using crutches and monitoring the oral temperature are appropriate self-care activities. Frustration with the length of treatment is not an indicator of ineffective health maintenance of the osteomyelitis.

8. Which patient statement indicates understanding of the nurse's teaching about a new short-arm synthetic cast? "I can remove the cast in 4 weeks using industrial scissors." "I should avoid moving my fingers until the cast is removed." "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast."

ANS: C Ice application for the first 24 hours after a fracture will help reduce swelling and can be placed over the cast. The cast is typically removed in the outpatient setting. The patient should be encouraged to move the joints above and below the cast. Patients should not insert objects inside the cast.

22. Which information should the nurse include in discharge instructions for a patient with comminuted left forearm fractures and a long-arm cast? Keep the left shoulder elevated on a pillow or cushion. Avoid nonsteroidal antiinflammatory drugs (NSAIDs). Call the health care provider for numbness of the hand. Keep the hand immobile to prevent soft tissue swelling.

ANS: C Increased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat mild to moderate pain after a fracture.

24. A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse? Using crutches with a swing-to gait Sitting upright on the edge of the bed Leaning over to pull on shoes and socks Bending over the sink while brushing teeth

ANS: C Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.

15. Which information from a patient's health history should the nurse identify as a risk factor for septic arthritis? Recently visited South America Several knee injuries as a teenager Sexually active with several partners Has a parent who has rheumatoid arthritis

ANS: C Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.

3. The nurse teaches a patient with osteoarthritis (OA) of the hip about how to manage the OA. Which patient statement indicates to the nurse a need for additional teaching? "A shower in the morning will help relieve stiffness." "I can exercise every day to help maintain joint mobility." "I will take 1 gram of acetaminophen (Tylenol) every 4 hours." "I can use a cane to decrease the pressure and pain in my hip."

ANS: C No more than 4 g of acetaminophen (1 g every 6 hours) should be taken daily to decrease the risk for liver damage. Regular exercise, moist heat, and supportive equipment are recommended for OA management.

4. The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above-the-knee amputation. Which patient statement indicates to the nurse that additional teaching is needed? "I will need to participate in physical therapy after surgery." "I wish I did not need to have chemotherapy after this surgery." "I did not have this bone cancer until my leg broke a week ago." "I can use the patient-controlled analgesia (PCA) to manage postoperative pain."

ANS: C Osteogenic sarcoma may be diagnosed following a fracture, but it is not caused by the injury. The other statements indicate patient teaching has been effective.

10. What suggestion should the nurse make to a group of women with rheumatoid arthritis (RA) about managing activities of daily living? Protect the knee joints by sleeping with a small pillow under the knees. Strengthen small hand muscles by wringing out sponges or washcloths. Avoid activities requiring repetitive use of the same muscles and joints. Stand rather than sit when performing daily household and yard chores.

ANS: C Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase joint stress. Patients are encouraged to position joints in the extended (neutral) position. Sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee range of motion.

41. When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first? Assess for nasal bleeding and pain. Apply ice to the face to reduce swelling. Use a cervical collar to stabilize the spine. Check the patient's alertness and orientation.

ANS: C Patients who have facial fractures are at risk for cervical spine injury and should be treated as if they have a cervical spine injury until this is ruled out. The other actions are also necessary, but the most important action is to prevent cervical spine injury.

34. A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider? Bruising of the left thigh Reports of severe thigh pain Slow capillary refill of the left foot Outward pointing toes on the left foot

ANS: C Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture.

18. Which action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel (UAP)? Check ability to plantar and dorsiflex the foot. Determine the patient's readiness to ambulate. Log roll the patient from side to side every 2 hours. Ask about pain management with the patient-controlled analgesia (PCA).

ANS: C Repositioning a patient is included in the education and scope of practice of UAP, and experienced UAP will be familiar with how to maintain alignment in the postoperative patient. Evaluation of the effectiveness of pain medications, assessment of neurologic function, and evaluation of a patient's readiness to ambulate after surgery require higher level nursing education and scope of practice.

6. What should the nurse include in the teaching plan for ae patient who has acute low back pain and muscle spasms? Keep both feet flat on the floor when prolonged standing is required. Twist gently from side to side to maintain range of motion in the spine. Keep the head elevated slightly and flex the knees when resting in bed. Avoid the use of cold packs because they will exacerbate the muscle spasms.

ANS: C Resting with the head elevated and knees flexed will reduce the strain on the back and decrease muscle spasms. Twisting from side to side will increase tension on the lumbar area. Prolonged standing will cause strain on the lumbar spine, even with both feet flat on the floor. Alternate application of cold and heat should be used to decrease pain.

5. A patient being seen in the clinic has rheumatoid nodules on the elbows. Which action should the nurse take? Draw blood for rheumatoid factor analysis. Teach the patient about injections for the nodules. Assess the nodules for skin breakdown or infection. Discuss the need for surgical removal of the nodules.

ANS: C Rheumatoid nodules can break down or become infected. They are not associated with changes in rheumatoid factor, and injection is not needed. Rheumatoid nodules are usually not removed surgically because of a high probability of recurrence.

39. Which finding in a patient with a Colles' fracture of the left wrist should the nurse identify as most important to communicate immediately to the health care provider? The patient reports severe pain. Swelling is noted around the wrist. Capillary refill to the fingers is slow. The wrist has a deformed appearance.

ANS: C Swelling, pain, and deformity are common findings with a Colles' fracture. Prolonged capillary refill indicates decreased circulation and risk for ischemia. This is not an expected finding and should be immediately reported.

11. A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding should indicate to the nurse a potential complication of the fracture? The patient states the pelvis feels unstable. The patient reports pelvic pain with palpation. Abdomen is distended, and bowel sounds are absent. Ecchymoses are visible across the abdomen and hips.

ANS: C The abdominal distention and absent bowel sounds may be due to complications of pelvic fractures such as paralytic ileus or hemorrhage or trauma to the bladder, urethra, or colon. Pelvic instability, abdominal pain with palpation, and abdominal bruising would be expected with this type of injury.

23. A new clinic patient with joint swelling and pain is having diagnostic tests. Which test should the nurse identify as specific to systemic lupus erythematosus? Rheumatoid factor (RF) Antinuclear antibody (ANA) Anti-Smith antibody (Anti-Sm) Lupus erythematosus (LE) cell prep

ANS: C The anti-Sm is antibody found almost exclusively in SLE. The other blood tests are also used in screening but are not as specific to SLE.

23. A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a sling. Which intervention should the nurse include in the plan of care? Use surgical net dressing to hang the arm from an IV pole. Immobilize the fingers of the left hand with gauze dressings. Assess the left axilla and change absorbent dressings as needed. Assist the patient in passive range of motion (ROM) for the right arm.

ANS: C The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.

21. A high school teacher with ulnar drift caused by rheumatoid arthritis (RA) is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery? "This procedure will correct the deformities in my fingers." "I will not have to do as many hand exercises after the surgery." "I will be able to use my fingers with more flexibility to grasp things." "My fingers will appear more normal in size and shape after this surgery."

ANS: C The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process. Hand exercises will be prescribed after the surgery.

30. After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action should the nurse take first? Elevate the leg on 2 pillows. Apply a compression bandage. Assess leg pulses and sensation. Place ice packs on the lower leg.

ANS: C The initial action by the nurse will be to assess circulation to the leg and observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.

31. A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take? Elevate the right leg. Splint the lower leg. Assess the pedal pulses. Verify tetanus immunization.

ANS: C The initial nursing action should be assessment of the neurovascular condition of the injured leg. After assessment, the nurse may need to splint and elevate the leg based on the assessment data. Information about tetanus immunizations should be obtained if there is an open wound.

16. After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best? "You are upset, but you may lose the foot anyway." "Many people are able to function with a foot prosthesis." "Tell me what you know about your options for treatment." "If you do not want an amputation, you do not have to have it."

ANS: C The initial nursing action should be to assess the patient's knowledge and feelings about the available options. Discussion of the patient's option to refuse the procedure, seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current knowledge and emotional state.

7. The nurse is caring for a patient who has a pelvic fracture and an external fixation device. How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum? Ask the patient to turn to the side independently. Defer back assessment until the patient is ambulatory. Have the patient lift the back and buttocks using a trapeze. Roll the patient over to the side by pushing on the patient's hips.

ANS: C The patient can lift the back slightly off the bed by using a trapeze. The patient may find it very difficult to turn to the side without assistance while in a fixator device. Delaying assessment and skin care may put the patient at risk for an undetected pressure injury. Pushing on the patient's hips may cause additional injury.

16. The nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the clinic reporting chills and muscle aches. Which action should the nurse take to follow up on that finding? Auscultate the heart sounds. Palpate the abdomen for masses. Ask the patient about recent outdoor activities. Question the patient about immunization history.

ANS: C The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization.

7. A patient with rheumatoid arthritis (RA) tells the clinic nurse about having chronically dry eyes. Which action should the nurse take? Ask the HCP about discontinuing methotrexate. Remind the patient that RA is a chronic health condition. Suggest the patient use over-the-counter (OTC) artificial tears. Teach the patient about adverse effects of the RA medications.

ANS: C The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eyedrops is recommended. Dry eyes are not a side effect of methotrexate. A focus on the prognosis for RA is not helpful. The dry eyes are not caused by RA treatment but by the disease itself.

33. The second day after admission with a fractured pelvis, a patient suddenly develops confusion. Which action should the nurse take first? Take the blood pressure. Check the O2 saturation. Assess patient orientation. Observe for facial asymmetry.

ANS: C The patient's history and clinical manifestations suggest a fat embolism. The most important assessment is oxygenation. The other actions are also appropriate but will be done after the nurse assesses O2 saturation.

16. After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. What action should the nurse take? Elevate the right leg on two pillows. Obtain vital signs for indication of hemorrhage. Review the preoperative assessment data in the health record. Turn the patient to the left to relieve pressure on the right leg.

ANS: C The postoperative movement and sensation of the extremities should be unchanged (or improved) from the preoperative assessment. If the numbness and tingling are new, this information should be immediately reported to the surgeon. Numbness and tingling are not symptoms associated with hemorrhage at the site. Turning the patient or elevating the leg will not relieve the numbness.

2. Which information should the nurse include when teaching a patient with acute low back pain? (Select all that apply.) Sleep in a prone position with the legs extended. Keep the knees straight when leaning forward to pick something up. Expect symptoms of acute low back pain to improve in a few weeks. Avoid activities that require twisting of the back or prolonged sitting. Use ibuprofen (Motrin, Advil) or acetaminophen (Tylenol) to relieve pain.

ANS: C, D, E Acute back pain usually starts to improve within 2 weeks. In the meantime, the patient should use medications such as nonsteroidal antiinflammatory drugs (NSAIDs) or acetaminophen to manage pain and avoid activities that stress the back. Sleeping in a prone position and keeping the knees straight when leaning forward will place stress on the back and should be avoided.

4. The nurse should anticipate the need to teach a patient who has osteoarthritis (OA) about which medication? Prednisone Adalimumab (Humira) Capsaicin cream (Zostrix) Sulfasalazine (Azulfidine)

ANS: CCapsaicin cream blocks the transmission of pain impulses and is helpful for some patients in treating OA. The other medications would be used for patients with rheumatoid arthritis.

20. Which action should the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty? Avoid extension of the right knee beyond 120 degrees. Use a compression bandage to keep the right knee flexed. Teach about the need to avoid weight bearing for 4 weeks. Start progressive knee exercises to obtain 90-degree flexion.

ANS: D After knee arthroplasty, active or passive flexion exercises are used to obtain a 90-degree flexion of the knee. The goal for extension of the knee will be 180 degrees. A compression bandage is used to hold the knee in an extended position after surgery. Protected weight bearing is typically not ordered after this procedure.

15. A patient has had surgical reduction of an open fracture of the right radius. Which assessment findings should the nurse report immediately to the health care provider? Serous wound drainage Right arm muscle spasms Pain with right arm movement Temperature 101.4° F (38.6° C)

ANS: D An elevated temperature suggests possible osteomyelitis. The other clinical manifestations are typical after a repair of an open fracture.

13. What should the nurse assess to evaluate the effectiveness of alendronate (Fosamax) therapy for a patient with Paget's disease? Oral intake Daily weight Grip strength Pain intensity

ANS: D Bone pain is a common early manifestation of Paget's disease, and the nurse should assess the pain intensity to determine if treatment is effective. The other information will be collected by the nurse but will not be used in evaluating the effectiveness of the therapy.

14. Which action should the nurse take before administering gentamicin (Garamycin) to a patient with acute osteomyelitis? Ask the patient about any nausea. Obtain the patient's oral temperature. Change the prescribed wet-to-dry dressings. Review the patient's serum creatinine results.

ANS: D Gentamicin is nephrotoxic and can cause renal failure as reflected in the patient's serum creatinine. Monitoring the patient's temperature before gentamicin administration is not necessary. Nausea is not a common side effect of IV gentamicin. There is no need to change the dressing before gentamicin administration.

27. A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which prescribed action will the nurse implement first? Send the patient for ankle x-rays. Administer naproxen (Naprosyn). Give acetaminophen with codeine. Wrap the ankle and apply an ice pack.

ANS: D Immediate care after a sprain or strain injury includes application of cold and use of compression to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.

39. Which patient seen by the nurse in the outpatient clinic is most likely to need teaching about ways to reduce the risk for osteoarthritis (OA)? A 56-yr-old man who has a sedentary office job A 38-yr-old man who plays on a summer softball team A 38-yr-old woman who is newly diagnosed with diabetes A 56-yr-old woman who works on an automotive assembly line

ANS: D OA is more likely to occur in women as a result of estrogen reduction at menopause and in persons whose work involves repetitive movements and lifting. Moderate exercise, such as softball, reduces the risk for OA. Diabetes is not a risk factor for OA. Sedentary work is not a risk factor for OA.

43. The nurse assesses a 78-yr-old who uses naproxen (Aleve) daily for hand and knee osteoarthritis management. Which information should the nurse discuss with the health care provider for an urgent change in the treatment plan? Knee crepitation is noted with normal knee range of motion. Patient reports embarrassment about having Heberden's nodes. Patient's knee pain while golfing has increased over the last year. Laboratory results indicate blood urea nitrogen (BUN) is elevated.

ANS: D Older patients are at increased risk for renal toxicity caused by nonsteroidal antiinflammatory drugs (NSAIDs) such as naproxen. The other information will be reported to the health care provider but is consistent with the patient's diagnosis of osteoarthritis and will not require an immediate change in the patient's treatment plan.

11. A 54-yr-old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia. Which information should the nurse explain to the patient? With a family history of osteoporosis, there is no way to prevent or slow bone resorption. Estrogen replacement therapy must be started to prevent rapid progression to osteoporosis. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. Calcium loss from bones can be slowed by increasing calcium intake and weight-bearing exercise.

ANS: D Progression of osteoporosis can be slowed by increasing calcium intake and weight-bearing exercise. Estrogen replacement therapy is no longer routinely given to prevent osteoporosis because of increased risk of heart disease as well as breast and uterine cancer. Corticosteroid therapy increases the risk for osteoporosis.

17. A patient reporting painful urination and knee pain is diagnosed with reactive arthritis. What long-term therapy should the nurse plan to explain to the patient? methotrexate anakinra (Kineret) etanercept (Enbrel) doxycycline (Vibramycin)

ANS: D Reactive arthritis associated with urethritis is usually caused by infection with Chlamydia trachomatis and requires 3 months of treatment with doxycycline. The other medications are used for chronic inflammatory problems such as rheumatoid arthritis.

12. Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective? Pancakes with syrup and bacon Whole wheat toast and fresh fruit Egg-white omelet and a half grapefruit Oatmeal with skim milk and fruit yogurt

ANS: D Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.

46. When reviewing the health record for a new patient with rheumatoid arthritis, the nurse reads that the patient has swan neck deformities. Which deformity should the nurse expect to observe when assessing the patient? a. A b. B c. C d. D

ANS: D Swan neck deformity involves distal interphalangeal joint hyperflexion and proximal interphalangeal joint hyperextension of the hands. The other deformities are also associated with rheumatoid arthritis: ulnar drift, boutonniere deformity, and hallux vagus.

37. A patient has possible right carpal tunnel syndrome. What symptom should the nurse expect with a positive Tinel's sign? Weakness in the right little finger Burning in the right elbow and forearm Tremor when gripping with the right hand Tingling in the right thumb and index finger

ANS: D Testing for Tinel's sign will cause tingling in the thumb and first three fingers of the affected hand in patients who have carpal tunnel syndrome. The median nerve does not innervate the right little finger or elbow and forearm. Tremor is not associated with carpal tunnel syndrome. DIF: Cognitive Level: Understand (comprehension)

30. The home health nurse is making a follow-up visit to a patient recently diagnosed with rheumatoid arthritis (RA). Which finding indicates to the nurse that additional patient teaching is needed? The patient takes a 2-hour nap each day. The patient has been taking 16 aspirins each day. The patient sits on a stool while preparing meals. The patient sleeps with two pillows under the head.

ANS: D The joints should be maintained in an extended position to avoid contractures, so patients should use a small, flat pillow for sleeping. Rest, aspirin, and energy management are appropriate for a patient with RA and indicate teaching has been effective.

9. Which statement by a patient with discomfort from a bunion indicates to the nurse that more teaching is needed? "I will give away my high-heeled shoes." "I can take ibuprofen (Motrin) if I need it." "I will use the bunion pad to cushion the area." "I can only wear sandals, no closed-toe shoes."

ANS: D The patient can wear shoes that have a wide forefoot (toe box). The other patient statements indicate the teaching has been effective.

19. A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which patient statement to the nurse indicates that additional teaching is needed? "I should not cross my legs while sitting." "I will use a toilet elevator on the toilet seat." "I will have someone else put on my shoes and socks." "I can sleep in any position that is comfortable for me."

ANS: D The patient needs to sleep in a position that prevents excessive internal rotation or flexion of the hip. The other patient statements indicate the patient has understood the teaching.

2. A factory line worker has repetitive strain syndrome in the left elbow. What topic should the nurse plan to include in patient teaching? Surgical options Elbow injections Wearing a left wrist splint Modifying arm movements

ANS: D Treatment for repetitive strain syndrome includes changing the ergonomics of the activity. Elbow injections and surgery are not initial options for this type of injury. A wrist splint might be used for hand or wrist pain.

1. In which order should the nurse implement interventions prescribed for a patient admitted with acute osteomyelitis who has a temperature of 101.2° F? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain blood cultures from two sites. b. Administer dose of gentamicin 60 mg IV. c. Send to radiology for computed tomography (CT) scan of right leg. d. Administer acetaminophen (Tylenol) now and every 4 hours PRN for fever.

ANS:A, B, D, C The highest treatment priority for osteomyelitis is initiation of antibiotic therapy, but cultures should be obtained before administration of antibiotics. Addressing the discomfort of the fever is the next highest priority. Because the purpose of the CT scan is to determine the extent of the infection, it can be done last.

1. In which order should the nurse complete actions when caring for a patient in the emergency department who has a right leg fracture? (Put a comma and a space between each answer choice [A, B, C, D, E, F].) a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis

ANS:C, D, B, E, A, F The initial actions should be to ensure adequate airway, breathing, and circulation. This should be followed by checking the neurovascular condition of the leg (before and after splint application). Application of a splint to immobilize the leg should be done before sending the patient for x-ray examination. The tetanus prophylaxis is the least urgent of the actions.

10. Which assessment finding for a 55-yr-old patient should alert the nurse to the presence of osteoporosis? Bowed legs Loss of height Report of frequent falls Aversion to dairy products

NS: B Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia and osteoarthritis. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.