Med surg test
During a routine physical examination on an older female client, a nurse notes that the client is 5 feet, 3/8 inches (1.6 (m) tall. The client states, "How is that possible? I was always 5 feet and 1/2? (1.7 m) tall." Which statement is the best response by the nurse?
"After menopause, the body's bone density declines, resulting in a gradual loss of height."
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
"I floss my teeth every morning."
The nurse instructs a client receiving chemotherapy on actions to prevent the development of stomatitis. Which client statement indicates to the nurse that teaching has been effective?
"I will brush my teeth after every meal."
A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the client's injury when documenting? Fill in the blank with a number.
36
The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside?
A tourniquet
A client has been admitted to the hospital for the treatment of gout. Which is not an appropriate nursing care activity for a gout client?
Apply heat for pain.
Which nursing intervention is appropriate for monitoring the client for the development of Volkmann's contracture?
Assess the radial pulse.
A client who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge?
Client can demonstrate safe use of assistive devices.
The nurse manager is orienting a new nurse to the oncology unit. When reviewing the safe administration of antineoplastic agents, which action should the nurse manager emphasize?
Dispose of the antineoplastic wastes in the hazardous waste receptacle.
The primary nursing intervention that will control swelling while treating a musculoskeletal injury is:
Elevate the affected area.
A high school student who was injured in a football game presents with knee pain with internal rotation of the foot. Which interventions are appropriate nursing actions? Select all that apply.
Elevate the affected leg. Apply ice packs to the affected knee. Apply a knee brace or wrap the affected knee.
A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement?
Ill make sure to monitor my body temperature on a regular basis.
When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?
Ineffective airway clearance related to edema of the respiratory passages
A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?
Lund and Browder method
The nurse is caring for a client who has just been told that stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the client the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer?
Palliative
A woman with a family history of breast cancer received a positive result on a breast tumor marking test and is requesting a bilateral mastectomy. This surgery is an example of which type of oncologic surgery?
Prophylactic surgery
With fractures of the femoral neck, the leg is
Shortened, adducted, and externally rotated
Which zone consists of the area where the injury is most severe and deepest?
coagulation
An oncologist advises a client with an extensive family history of breast cancer to consider a mastectomy. What type of surgery would the nurse include in teaching?
prophylactic
A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?
"Are the burns associated with chemicals used in the plant?"
A client with a history of gout experiences an attack every 2 to 3 months despite losing weight and stopping all alcohol intake. Which question will the nurse ask when assessing this client?
"Are you taking the medication as prescribed?"
A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse?
"Describe the pain and rate it on the pain scale."
An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the client of the diagnosis or to keep it quiet. Which is the best response from the nurse?
"In my experience, clients who know are more likely to be involved with their plan of care."
A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make?
"It reduces the risk of complications from an infection."
A client with fibromyalgia asks why physical therapy has been prescribed. Which response will the nurse make?
"It will help with the overall deconditioning that has occurred."
An older adult with rheumatoid arthritis limits going out with others because of the need to use a cane. Which response will the nurse make to this client?
"Look at the cane as maintaining your independence."
A client is cared for in a burn unit after suffering partial-thickness burns. The dient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply.
"This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal."
A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?
"Tumor removal will promote comfort."
A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is
"You will need to practice birth control measures."
A nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching?
"You will receive IV antibiotics for 3 to 6 weeks."
A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what actions? Select all that apply.
-Regular bone density testing -A high-calcium diet -Use of falls prevention precautions -Weight-bearing exercise
The nurse is caring for a patient after arthroscopic surgery for a rotator cuff tear. The nurse informs the patient that full activity can usually resume after what period of time?
6 to 12 months
A client is to undergo surgery to repair a ruptured Achilles tendon and application of a brace. The client demonstrates understanding of activity limitations when stating that a brace must be worn for which length of time?
6-8 weeks
A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury?
A second-degree strain
The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care?
Acute
A patient with a diagnosis of renal cell carcinoma is being treated with chemotherapy. During a previous round of chemotherapy, the patient's tumor responded well to treatment but the chemotherapy caused intense nausea and vomiting. How should the patient's potential nausea and vomiting be addressed during this current round of treatment?
Administer antiemetics in anticipation of the patient's nausea.
An older adult client slipped on an area rug at home and fractured the left hip. The client is unable to have surgery immediately and is having severe pain. What interventions should the nurse provide for the patient to minimize energy loss in response to pain?
Administer prescribed analgesics around-the-clock.
What special elements of care should be incorporated into the care of a client in traction? Select all that apply.
All of the answers are true (When traction is discontinued, prepare the client for further treatment, such as casting, and for the appearance of the affected area---skin and muscles. Point out activities that are allowed or contraindicated. Provide simple and direct explanations about the traction and its purpose.)
Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis?
An older adult client with an infected pressure ulcer in the sacral area
A client has presented to the emergency department with an injury to the wrist. The client is diagnosed with a third-degree strain. Why would the health care provider prescribe an x-ray of the wrist?
Avulsion fractures are associated with third-degree strains.
A patient has stepped in a hole in the yard, causing an ankle injury. The ankle is edematous and painful to palpation. How long should the nurse inform the patient that the acute inflammatory stage will last?
Between 24 and 48 hours
Which of the following is the first-line medication that would be used to treat and prevent osteoporosis?
Bisphosphonates
A client has experienced a fracture. Place in the correct order the steps in bone healing that the nurse will explain to the client to prepare her for what to expect
Blood seeps into the area and a hematoma forms.
The hospice nurse has just admitted a new client to the program. What principle guides hospice care?
Care addresses the needs of the client as well as the needs of the family.
A client comes to the emergency department complaining of localized pain and swelling of the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. Which of the following would the nurse suspect as most likely?
Contusion
Your patient has recently completed her first round of chemotherapy in the treatment of lung cancer. When reviewing this morning's blood work, what findings would be suggestive of myelosuppression?
Decreased platelets and red blood cells
A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest?
Deviation of a great toe laterally
While administering an intravenous chemotherapeutic medication to a client, the nurse assesses swelling at the insertion site. What is the nurse's first action?
Discontinue the intravenous medication
The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk?
Encourage physical activity and range-of-motion exercises.
The nurse is planning an education program for women of childbearing years. What does the nurse recognize as the primary prevention of osteoporosis?
Ensuring adequate calcium and vitamin D intake
A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?
Ensuring adequate exposure to sunlight
A client comes to the orthopedic clinic and reports having pain that radiates down the forearm and being unable to grasp objects firmly. What does the nurse suspect is occurring with the client?
Epicondylitis
A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). Which skin manifestation would the nurse expect to observe on inspection?
Erythematous rash
A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient?
Explain to the patient that she will continue to emit radiation while the implant is in place.
A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication?
Fat embolism syndrome
The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing.
Fat embolism syndrome
A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply.
Fluid loss Fluid shift Hypotension
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?
Homografts
A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug?
I have this ringing in my ears that just wont go away
When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?
Inspect the skin frequently.
A nurse is preparing to discharge a client from the emergency department after receiving treatment for an ankle sprain. While providing discharge education, the nurse should encourage what action?
Keep an elastic compression bandage on the ankle.
A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis?
Low serum calcium and low phosphorus level
The nurse is discussing the new medication that a client will be taking for treatment of rheumatoid arthritis. Which disease-modifying antirheumatic drug (DMARD) will the nurse educate the client about?
Methotrexate
The nurse is caring for a client with ankylosing spondylitis (AS). Which medication will the nurse expect to be prescribed for this client?
Nonsteroidal anti-inflammatory drugs (NSAIDs)
A client with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor location rules out the use of enteral feeding. What intervention will best meet this client's nutritional needs?
Parenteral nutrition given via a peripherally inserted central catheter
The nurse is assisting with an examination of a client suspected of having carpal tunnel syndrome. The physician has the client flex the wrist for 30 seconds and percusses the median nerve. The client complains of pain and numbness when this is done. What does the nurse know this positive sign is documented as?
Phalen sign
A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action?
Place the client in a private room.
Which of the following laboratory findings, would be identified by the nurse as the greatest risk for a cancer client scheduled for implantable port?
Platelet count 98,000/mm3
A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the dient?
Presence of soot around nasal passages
A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions?
Prevention of venous thromboembolism
The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element?
Removal of eschar until the point of pain and bleeding occurs
A dient with rheumatoid arthritis comes to the clinic reporting pain in the joint of his right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize?
Restrict consumption of foods high in purines.
After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority?
Risk for infection
A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. Which of the following risk factors should the educator describe?
Small frame and female sex
A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?
Sodium deficit
A client is taking ibuprofen for the treatment of osteoarthritis. What education will the nurse give the client about the medication?
Take the medication with food to avoid stomach upset.
A client has been treated for migraine headaches for several months and comes to the clinic reporting no improvement. The nurse is talking with the client and hears an audible click when the client is moving the jaw. What does the nurse suspect may be happening?
Temporomandibular disorder
A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood?
The client is likely experiencing a delayed onset of respiratory complications
While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the nurse's technique. How should the nurse best interpret this client's behavior?
The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.
The results of a 22-year-old college student's most recent Papanicolaou (Pap) test are suggestive of cervical cancer. Since learning of this news, the client has asked numerous questions of all members of the health care team about she could have gotten cancer. What client teaching should the nurse at the clinic prioritize in this patient's care?
The relationship between viruses and cervical cancer
A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing the client the nurse notes that the client's right leg is shorter than the left leg; the right hip is noticeably deformed and the client is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms?
Traumatic hip dislocation
The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?
Tumor pressure against normal tissues
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?
Urine output of 20 ml/hour
The nurse is caring for a client with ankylosing spondylitis. Which educational information will the nurse provide to this cient?
Use of analgesics,
Which of the following actions should a nurse perform to help reduce the accumulation of debris within the burn wound?
Use powder-free sterile gloves.
When teaching a client how to prevent low back pain as a result of lifting, the nurse should instruct the client to:
avoid overreaching.
An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis?
bone fracture
A client is admitted to the emergency room after being hit by a car while riding a bicycle. The client sustained a fracture of the left femur, and the bone is protruding through the skin. What type of fracture does the nurse recognize requires emergency intervention?
compound
Which is not one of the general nursing measures employed when caring for the client with a fracture?
cranial nerve assessment
The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply.
dietary substances environmental factors viruses
The nurse is working with a client who has had an allo-hematopoietic stem cell transplant (HSCT). The nurse notices a diffuse rash and diarrhea. The nurse contacts the physician to report that the client has symptoms of
graft-versus-host disease
A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:
pain management
A client with metastatic bone cancer sustained a left hip fracture without injury. What type of fracture does the nurse understand occurs without trauma or fall?
pathologic fracture
The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn?
preexisting conditions
A client was burned in a home accident. The ED physician indicated the client's wound, with proper care, should heal within 2 weeks. How was this client's wound classified?
second degree
A client with a recent history of Gl disturbance has been scheduled for a barium study. The physician ordered this particular test for this client because it will:
show movement of the Gl tract.
The nurse is caring for a client with a benign breast tumor. The tumor may have which characteristic?
slow rate of growth
Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of
stasis.
Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?
zone of stasis
At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply.
• Place the client in a horizontal position. • Roll the client in a blanket to smother the fire.
