N-CLEX Silvestri 41-80

A nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast care at home. The nurse determines that the client needs further instructions if the client makes which statement?

"If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

A client is being transferred to the nursing unit from the postanesthesia care unit following spinal fusion with rod insertion. The nurse would prepare to teansfer the client from the stretcher to the bed by using:

A slider board and the assistance of four people

A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. The nurse should:

Administer an analgesic

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if the client:

Advances the walker with reciprocal motion

A nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse would be especially concerned with which of the following findings?

An oral temperature of 101 degrees fahrenheit orally

A nurse has an order to get tue client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which of the following to protect the knee joint?

Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting

A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. The nurse's response is based on the understanding that the device should be used:

As much as the client can tolerate

A client in skeletal leg traction with an overload frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client?

Asking the client to pull on a trapeze to lift the hips off the bed

A nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affect which bones?

Axial skeleton including the vertebrae

A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated by:

Bending or lifting

A nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that:

Bleeding and swelling cause increased pressure in an area that cannot expand.

A nurse is giving the client with a left leg cast crutch walking instructions using the three point gait. The client is allowed touch down of the affected leg. The nurse tells the client to advances the:

Crutches and the left leg, then advance the right leg

A nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, which of the following would the nurse avoid to minimize the chance for further injury.

Delays in responding to call light

A nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which of the following data obtained by the nurse would not place the client at increased risk for disturbed thought process?

Hearing aid available and in working order

A nurse has an order to place a client with herniated lumbar intervertebral disk on bedrest to minimize the pain. The nurse plans to put the bed:

In semi-Fowler's position with the knee gatch slighty raised

A client being measured for crutches asks the nurses why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could result in:

Injury to the brachial plexus nerves

A client has Buck's extension traction applied to the right leg. The nurse would plan which intervention to prevent complications of the device?

Inspecting the skin on the right leg at least once every 8 hours

A client with right sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the:

Left hand, and 6 inches lateral to the left foot

A nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which of the following is a primary prevention measure?

Maintaining body weight at or above minimum recommended levels

A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse would expect that which type of wound care will be prescribed for the fasciotomy site?

Moist, sterile saline dressings

A client with herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of:

Muscle spasm in the area of the herniated disk

A nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome?

Numbness and tingling in the fingers

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse would avoid which of the following to maintain client safety after this procedure?

Overhead trapeze

A nurse is caring for a client with osteoarthritis. The nurse monitors the client, knowing that which of the following is a clinical manifestation associated with the disorder?

Pain that increases with activity and is relieved by rest

A nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse plans to use a:

Pillow to keep the right leg abducted during turning

A client who has experienced a brain attack(stroke) has partial hemiplegia of the left leg. The straight leg cane formerly use by the client is not sufficient any longer. The nurse determines that the client could benefit from the somewhat greater support and stability provided by a:

Quad cane

An older client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse would expect to note which of the following on inspection of the client's leg?

Shortening, adduction, and external rotation

A client is fearful about having an arm cast removed. Which of the following actions by the nurse would be the most helpful?

Showing the client the cast cutter and explaining how it works

A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs could best be addressed by referral to the:

Social worker

A client who is learning to use a cane is afraid it will sleep with ambulation, causing a fall. The nurse provides the client with the greatest reassurance by telling the client that:

The cane has a flared tip with concentric rings to provide stability.

A nurse has given the client instructions regarding crutch safety. The nurse determines that the client needs reinforcement of the instructions if the client states:

The crutch tip will not slip, even when wet

A nurse is planning toreinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which of the following teaching points in discussion with the client?

The device is applied before getting out of bed in the morning

A nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client?

Uric acid level of 8 mg/dL

A nurse is caring for a client with a diagnosis of gout. Which of the following laboratory values would the nurse expect to note in the client?

Uric acid level of 8 mg/dL

A nurse is caring for a client being treated for fat embolus after multiple fractures. Which of the following data would the nurse determine as the favorable indication of resolution of the fat embolus?

Clear chest x-ray

A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse suggests which of the following nursing diagnoses for the client?

Disturbed body image

A nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse immediately:

Rewraps the residual limb with an elastic compression bandage

A client has slight weakness in the right leg. Based on this information, the nurse determines that the client would benifit most from the use of a:

Straight leg cane

A client is being discharged to home following spinal fusion with insertion of rods. The nurse would suggest a consultation with the continuing care nurse regarding the need for follow-up modification of the home environment if the client states that:

The bedroom and bath are on the second floor of the home

A nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which of the following?

Vitamin D