MS Mastery

A client is admitted for closed spine surgery to repair a herniated disk. The nurse is discussing the surgery with the client. Which instruction should the nurse reinforce in the preoperative education?

"An endoscope is used to perform the surgery."

The nurse is caring for a client on the orthopedic unit. Which discharge instructions should be reinforced for a client after surgical repair of a hip fracture?

"Do not flex the hip more than 90°, do not cross your legs, and get help putting on your shoes."

The nurse is caring for a client on the orthopedic unit. When preparing the client for discharge, which instructions should the nurse reinforce after surgical repair of a hip fracture?

"Do not flex the hip more than 90°, do not cross your legs, and get help putting on your shoes." Explanation: Discharge instructions should include not flexing the hip more than 90°, not crossing the legs, and getting help to put on shoes. These restrictions prevent dislocation of the new prosthesis.

A nurse reinforces preoperative instructions for a client who is scheduled for a left above-the-knee amputation. Which statement made by the client indicates an understanding of the instructions?

"Isometric exercise will help me to maintain the muscle tone of my remaining limb." Explanation: Isometric exercise (static contraction of a muscle without any visible movement in the angle of the joint) is necessary to maintain muscle tone of the remaining limb. The exercises should begin the day after an above-the-knee amputation. Immediately after surgery, the client usually is not alert enough to get out of bed, even with assistance. Physical therapy begins in the hospital setting and continues in the rehabilitation or outpatient/community setting after discharge. A continuous passive motion machine is used to provide passive-range-of motion for the knee.

The X-rays of a client who was brought to the emergency department after falling on ice reveal a leg fracture. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs? "Place both crutches on the first step and swing both legs upward to this step." "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." "Place the crutches and injured leg on the first step, followed by the unaffected leg." "Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side follow."

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." Explanation: When climbing stairs with crutches, the client should lead with the unaffected leg, followed by the crutches and injured leg moving together. Any other method is incorrect and could increase the client's risk of falling.

A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?

"You may experience progressive deterioration in all voluntary muscles."

The client calls the nurse in the clinic and states that the cast feels very rough around the edges and is scratching the skin. What is the best response by the nurse? Apply moleskin or pink tape around the edges. Elevate the limb above the level of the heart. Break off the rough area and file it down. Distribute pressure evenly.

Apply moleskin or pink tape around the edges.

The nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrity

The nurse is instructing unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of his left fibula. Which observation indicates that the education was effective? You Selected:

Correct response: The weights are allowed to hang freely over the end of the bed.

A client who was involved in a motor vehicle accident has a fractured femur and reports severe pain. Which nursing interventions are appropriate? Select all that apply.

Determine the client's perception of pain. Ask the client about methods used previously to alleviate pain.

A nurse in the emergency department is caring for a client with an ankle injury that occurred while playing football. Which nursing action takes priority?

Inspect for visible deformity.

Which finding should alert a nurse to a potential complication in a client with a cast following fracture of the radius?

Pain occurs over a bony prominence.

A nurse is caring for a confused client with a fractured hip who is trying to get out of bed. Which action should the nurse take first?

Reorient the client to the surroundings

A nurse is caring for a confused client with a fractured hip who is trying to get out of bed. Which action should the nurse take first? Obtain a prescription for wrist restraints. Review the facility's restraint policy. Move the client closer to the nurse's station. Reorient the client to the surroundings.

Reorient the client to the surroundings.

The nurse is caring for a client with a long leg cast. Which nursing intervention can best prevent foot drop? Encourage bed rest. Support the foot with 45 degrees of flexion. Support the foot with 90 degrees of flexion. Place a stocking on the foot to provide warmth.

Support the foot with 90 degrees of flexion. Explanation: To prevent foot drop in a casted leg, the foot should be supported with 90 degrees of flexion. Bed rest can cause foot drop. Keeping the extremity warm won't prevent foot drop.

The nurse is caring for a client with a long leg cast. Which nursing intervention can best prevent foot drop? Encourage bed rest. Support the foot with 45 degrees of flexion. Support the foot with 90 degrees of flexion. Place a stocking on the foot to provide warmth.

Support the foot with 90 degrees of flexion. Explanation: To prevent foot drop in a casted leg, the foot should be supported with 90 degrees of flexion. Bed rest can cause foot drop. Keeping the extremity warm won't prevent foot drop.

Which observation by the nurse indicates that the parent of a neonate with developmental dysplasia of the hip understands the discharge education?

The infant is wearing three diapers. Explanation: Placing several diapers on the infant will keep the hips abducted. A pillow placed outside of the legs will not help abduct the hips. Swaddling the infant tightly straightens the legs and doesn't allow the hips to abduct. Placing the infant in a prone position won't keep the hips abducted and isn't recommended due to the increased risk of sudden infant death syndrome.

When observing a newly hired nurse change a wet-to-dry dressing, which action by the nurse would indicate to the nurse mentor that further teaching is needed? The nurse loosens the wet-to-dry dressing with normal saline. The nurse discards the drape that became wet when normal saline was poured. The nurse disposes of the used dressing in a red biohazard bag. The nurse keeps the hands between the waist and nipple level.

The nurse loosens the wet-to-dry dressing with normal saline. Explanation: Loosening the wet-to-dry dressing with any solution defeats the purpose - to debride. The drape should be discarded once wet because it is considered contaminated. Used dressings are to be disposed in a red biohazard bag due to bodily contaminated secretions. Areas above the nipple and below the waist are considered contaminated.

The nurse is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct? Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. To avoid fractures, the client should avoid strenuous exercise. The recommended daily allowance of calcium may be found in a wide variety of foods. Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.

The recommended daily allowance of calcium may be found in a wide variety of foods. Explanation: Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day. In most cases, it's possible to get the recommended daily requirement in the foods we eat. Supplements are available but not always necessary. Osteoporosis doesn't show up on ordinary X-rays until 30% of the bone loss has occurred. Bone densitometry can detect bone loss of 3% or less. This test is sometimes recommended routinely for women older than age 35 who are at risk. Strenuous exercise won't cause fractures.

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation shown, which laboratory result is the priority for the nurse to report to the health care provider? rheumatoid factor blood culture alkaline phosphatase ESR

blood culture

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation shown, which laboratory result is the priority for the nurse to report to the health care provider? rheumatoid factor blood culture alkaline phosphatase ESR

blood culture Explanation: Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture should be reported immediately to the health care provider so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L is within the normal range, and an ESR of 10 mm/hour is also within the normal range.

A nurse is caring for a child with severe scoliosis. For which complication should the nurse closely monitor the child? increased vital capacity increased oxygen uptake diminished vital capacity decreased residual volume

diminished vital capacity Explanation: Scoliosis of greater then 60 degrees can shift organs and decrease ability of the ribs to expand, thus decreasing vital capacity. An increase in vital capacity or oxygen uptake wouldn't occur secondary to a decrease in chest expansion. Residual volume would increase secondary to decreased ability of the lungs to expel a

A nurse is caring for a child with severe scoliosis. For which complication should the nurse closely monitor the child? increased vital capacity increased oxygen uptake diminished vital capacity decreased residual volume

diminished vital capacity Explanation: Scoliosis of greater then 60 degrees can shift organs and decrease ability of the ribs to expand, thus decreasing vital capacity. An increase in vital capacity or oxygen uptake wouldn't occur secondary to a decrease in chest expansion. Residual volume would increase secondary to decreased ability of the lungs to expel air.

A client reports low back pain that radiates down the right leg, with numbness and weakness of the right leg. The nurse recognizes these symptoms as related to which disorder?

herniated nucleus pulposus (HNP)

A client with a recent fracture is suspected of having compartment syndrome. Which findings does the nurse recognize correlate with this diagnosis?

inability to perform active movement; pain with passive movement

The parents of a neonate diagnosed with clubfoot ask the nurse to explain talipes varus. The nurse would describe this as which condition? inversion of the foot eversion of the foot plantar flexion dorsiflexion

inversion of the foot

Which response by the nurse provides an accurate definition?

lateral curves in the spinal column described as right or left convexities

Which strategy does the nurse reinforce education regarding, that would be the first choice in attempting to maximize function in a child with muscular dystrophy? long leg braces motorized wheelchair manual wheelchair walker

long leg braces Explanation: Long leg braces are functional assistive devices that provide increased independence and increased use of upper and lower body strength. Wheelchairs, both motorized and manual, provide less independence and less use of upper and lower body strength. Walkers are functional assistive devices that provide less independence than braces.

The nurse is caring for a child with suspected muscular dystrophy. For which diagnostic test will the nurse prepare the child?

muscle biopsy Explanation: A muscle biopsy shows the degeneration of muscle fibers and infiltration of fatty tissue. It's used for diagnostic confirmation of muscular dystrophy. X-ray is best for identifying an osseous deformity. Ambulation assessment alone wouldn't diagnose this child's disorder. EEG wouldn't be appropriate in this case.

The nurse is reinforcing instruction for a client on a 3-point gait using crutches. The client demonstrates an understanding when placing weight on what part of the body? feet axillary areas palms of the hands palms and axillary areas

palms of the hands Explanation: To avoid damage to the brachial plexus nerves in the axilla, the palms of the hands should bear the client's weight. Minimal weight should be placed on the affected leg.

The nurse is reinforcing instruction for a client on a 3-point gait using crutches. The client demonstrates an understanding when placing weight on what part of the body? feet axillary areas palms of the hands palms and axillary areas

palms of the hands To avoid damage to the brachial plexus nerves in the axilla, the palms of the hands should bear the client's weight. Minimal weight should be placed on the affected le

A child is having increased difficulty getting out of the chair at school. Which recommendation may the nurse make to assist the child?

seat cushion

The nurse is caring for a female client with osteoarthritis who is being discharge to home. Which items would the nurse reinforce the use of in order to assist the client to dress independently at home? Select all that apply. tennis shoes that tie skirts with elastic waists blouse with rear buttons jackets with Velcro closures bras with front closure

skirts with elastic waists jackets with Velcro closures bras with front closure

A client is reporting severe pain in the right upper arm. Which x-ray finding would indicate to the nurse that further investigation is required? longitudinal fracture oblique fracture spiral fracture transverse fracture

spiral fracture

The parents of a child newly diagnosed with developmental dysplasia of the hip (DDH) ask the nurse how their child developed this condition. The nurse explains that the greatest number of cases are caused by which condition? dislocation subluxation acetabular dysplasia dislocation with fracture

subluxation

The nurse would expect to see which activity level prescribed for a client immediately after a spinal fusion?

supine bed rest

A client presents with pain and warmth in his big toe and reduced urine output. The health care provider suspects gouty arthritis. The nurse can expect the health care provider to confirm this diagnosis by ordering which diagnostic tests? synovial fluid analysis and serum uric acid level great toe and chest x-rays blood gas analysis and platelet count serum protein and bilirubin levels

synovial fluid analysis and serum uric acid level Explanation: Gouty arthritis results in the formation of urate crystals in synovial fluid and increases serum uric acid level, so the nurse can expect these diagnostic tests to be ordered. Toe and chest x-rays are not diagnostic for this complaint. Blood gas analysis detects respiratory disorders, and platelet count checks for clotting disorders. Serum protein and bilirubin levels help diagnose liver dysfunction.