NHI Exam #2
A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? A) "I need to avoid getting the cast wet." B) "I will use my fingertips to lift and move the leg." C) "I need to cover the casted leg with warm blankets." D) "I can use a padded coat hanger end to scratch under the cast."
A) "I need to avoid getting the cast wet."
The nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is least likely needed before reduction of the fracture in the casting room? A) Anesthesia consent B) Consent for the procedure C) Administration of an analgesic D) Explanation of the procedure to the client
A) Anesthesia consent
The nurse is discharging a client with a diagnosis of gout. Which best practice guidelines should the nurse teach the client? Select all that apply. A) Drink plenty of fluids. B) Avoid taking diuretics. C) Avoid taking acetaminophen. D) Organ meats are allowed on your diet. E) Avoid excessive physical or emotional stress.
A) Drink plenty of fluids. B) Avoid taking diuretics. E) Avoid excessive physical or emotional stress.
The nurse is reviewing the record of a client who has been prescribed baclofen. Which disorder should alert the nurse to contact the health care provider? A. Seizure disorders B. Hyperthyroidism C. Diabetes mellitus D. Coronary artery disease
A. Seizure disorders
A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further instructions are needed about skin care if the client makes which statement? A) "I will soak the skin and then wash it gently." B) "I need to scrub the skin vigorously with soap and water." C) "I need to apply an emollient lotion to enhance softening." D) "I need to use a sunscreen on the skin if it will be directly exposed to the sun."
B) "I need to scrub the skin vigorously with soap and water."
A client with possible rib fracture has never had a chest x-ray. The nurse should tell the client which statement about the procedure? A) "The x-ray stimulates a small amount of pain." B) "It is necessary to remove jewelry and any other metal objects." C) "The client will be asked to breathe in and out during the x-ray." D) "The x-ray technologist will stand next to the client during the x-ray."
B) "It is necessary to remove jewelry and any other metal objects."
The nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which teaching points in discussion with the client? A) The brace should be applied directly next to the skin. B) The device is applied before getting out of bed in the morning. C) The Velcro closures should be fairly loose to avoid constriction. D) Areas of skin redness at the edges of the brace indicate a good, snug fit.
B) The device is applied before getting out of bed in the morning.
The nurse is reinforcing discharge instructions to a client receiving baclofen. Which should the nurse include in the instructions? A. Restrict fluid intake. B. Avoid the use of alcohol. C. Stop the medication if diarrhea occurs. D. Notify the health care provider if fatigue occurs.
B. Avoid the use of alcohol.
The 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. How should the nurse explain compartment syndrome? A) A bone fragment has injured the nerve supply in the area. B) An injured artery causes impaired arterial perfusion through the compartment. C) Bleeding and swelling cause increased pressure in an area that cannot expand. D) The fascia expands with injury, causing pressure on underlying nerves and muscles.
C) Bleeding and swelling cause increased pressure in an area that cannot expand.
The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium (Dantrium). Which laboratory test(s) would identify an adverse effect associated with the administration of this medication? A. Creatinine B. Liver function tests C. Blood urea nitrogen D. Hematological function tests
B. Liver function tests
The client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, it is most important for the nurse to collect which data? A. The injection site for itching and edema B. The white blood cell counts and platelet counts C. A metallic taste in the mouth, with a loss of appetite D. Whether the client is experiencing fatigue and joint pain
B. The white blood cell counts and platelet counts
A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor determines that the student needs further teaching if the student states that which is an associated risk factor? A) Postmenopausal age B) Family history of osteoporosis C) High-calcium diet consumption D) Long-term use of corticosteroids
C) High-calcium diet consumption
The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? A) Take a set of vitals B) Call the radiology department C) Immobilize the leg before moving the client D) Reassure the client that everything will be fine.
C) Immobilize the leg before moving the client
A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? A) Infection under the cast B) The anxiety of the client C) Impaired tissue perfusion D) The newness of the fracture
C) Impaired tissue perfusion
A client receives a prescription for methocarbamol (Robaxin), and the nurse reinforces instructions to the client regarding the medication. Which client statement should indicate a need for further teaching? A. "My urine may turn brown or green." B. "This medication is prescribed to help relieve my muscle spasms." C. "If my vision becomes blurred, I don't need to be concerned about it." D. "I need to call my doctor if I experience nasal congestion from this medication."
C. "If my vision becomes blurred, I don't need to be concerned about it."
The nurse is monitoring a client receiving baclofen for side effects related to the medication. Which should indicate that the client is experiencing a side effect? A. Polyuria B. Diarrhea C. Drowsiness D. Muscular excitability
C. Drowsiness
The nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further teaching if the client verbalizes which action should be done? A) Increase fiber and fluids in the diet. B) Bend at the knees to pick up objects. C) Strengthen the back muscles by swimming or walking. D) Get out of bed by sitting straight up and swinging the legs over the side of the bed.
D) Get out of bed by sitting straight up and swinging the legs over the side of the bed.
A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which action should be included in the postoperative plan of care? A) Ensure the client receives the daily tablet of enoxaparin. B) Assist the client in keeping the legs as close together as possible. C) Remind the client to use a handrail when lowering the hips into a 120-degree flexion. D) Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription.
D) Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively; check surgeon's prescription.
The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? A) Pulling up on the trapeze B) Flexing and extending the feet C) Doing quadriceps-setting and gluteal-setting exercises D) Performing active range of motion (ROM) to the right ankle and knee
D) Performing active range of motion (ROM) to the right ankle and knee
Colcrys (colchicine) is prescribed for a client with a diagnosis of gout. The nurse reviews the client's medical history in the health record, knowing that the medication would be contraindicated in which disorder? A. Myxedema B. Renal failure C. Hypothyroidism D. Diabetes mellitus
D. Diabetes mellitus
Alendronate (Fosamax) is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse reinforce? A. Take the medication at bedtime. B. Take the medication in the morning with breakfast. C. Lie down for 30 minutes after taking the medication. D. Take the medication with a full glass of water after rising in the morning.
D. Take the medication with a full glass of water after rising in the morning.
Which of the following guidelines should a nurse include in the teaching plan for a patient who has osteoarthritis? a) achieve ideal body weight b) increase daily calcium intake to 1500 mg c) maintain a high fiber diet d) sleep at least 10 hours each day
a) achieve ideal body weight
How do you position a client with left hip fracture in Buck's traction? a) head of bed raised at 45 degree angle b) left calf on pillow from knee to ankle c) position the left on affected side with pillows between legs d) position the left in the center of the bed with the leg extended
b) left calf on pillow from knee to ankle
The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the post-anesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply. A) Ensure that the machine is well padded. B) Assess the client's response to the machine. C) When the machine is not in use, store it on the floor. D) Check the cycle and range-of-motion settings once a day. E) Turn off the machine while the client is having a meal in bed. F) Make sure that the joint being moved is properly positioned on the machine.
A) Ensure that the machine is well padded. B) Assess the client's response to the machine. E) Turn off the machine while the client is having a meal in bed. F) Make sure that the joint being moved is properly positioned on the machine.
The nurse is caring for a client diagnosed with Paget's disease. The nurse plans care knowing that this condition usually affects which bones? Select all that apply. A) Femur B) Skull C) Tibia D) Sternum E) Shoulder F) Vertebrae
A) Femur B) Skull C) Tibia F) Vertebrae
The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? A) Dependent edema B) Diminished distal pulse C) Presence of a "hot spot" on the cast D) Coolness and pallor of the extremity
C) Presence of a "hot spot" on the cast
The nurse is caring for a client admitted with fat embolism syndrome (FES). Which are some of the early manifestations of this syndrome? Select all that apply. A) Fever B) Dyspnea C) Petechiae D) Hypoxemia E) Tachypnea F) Decreased level of consciousness
B) Dyspnea D) Hypoxemia E) Tachypnea
The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? A) Keep the leg in a level position. B) Elevate the leg for 3 hours, and put it flat for 1 hour. C) Keep the leg level for 3 hours, and elevate it for 1 hour. D) Elevate the leg on pillows continuously for 24 to 48 hours.
D) Elevate the leg on pillows continuously for 24 to 48 hours.
The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? A) Elevating the limb and applying ice to the affected leg B) Elevating the limb and covering it with bath blankets C) Keeping the leg horizontal and applying ice to the affected leg D) Placing the leg in a slightly dependent position and applying ice
A) Elevating the limb and applying ice to the affected leg
The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches? A) Crutches and then both legs simultaneously B) Crutches and the right leg, then advance the left leg C) Crutches and the left leg, then advance the right leg D)Left leg and right crutch, then right leg and left crutch
B) Crutches and the right leg, then advance the left leg
The nurse is caring for a client who has a cast applied to the left lower leg. On data collection, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate? A) Contact the primary health care provider. B) Petal the cast edges with adhesive tape. C) Massage the skin at the edges of the cast. D) Place a small face cloth in the cast around the edges of the cast
B) Petal the cast edges with adhesive tape.
The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. A) Keep the cast and extremity elevated. B) The cast needs to be kept clean and dry. C) Allow the wet cast 24 to 72 hours to dry. D) Expect tingling and numbness in the extremity. E) Use a hair dryer set on a warm to hot setting to dry the cast. F) Use a soft-padded object that will fit under the cast to scratch the skin under the cast.
A) Keep the cast and extremity elevated. B) The cast needs to be kept clean and dry. C) Allow the wet cast 24 to 72 hours to dry.
A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? A) Massaging the skin at the rim of the cast B) Petaling the cast edges with adhesive tape C) Using a rough file to smooth the cast edges D) Applying lotion to the skin at the rim of the cast
B) Petaling the cast edges with adhesive tape
The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first? A) Provide pin care. B) Check the client's alignment in bed. C) Medicate the client with an analgesic. D) Call the primary health care provider (PHCP).
D) Call the primary health care provider (PHCP).
The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? A) Pork B) Seafood C) Sardines D) Plain yogurt
A) Pork
Cyclobenzaprine (Flexeril) is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which disorder would indicate a need to contact the health care provider regarding the administration of this medication? A. Glaucoma B. Emphysema C. Hyperthyroidism D. Diabetes mellitus
A. Glaucoma
A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How does the nurse correctly interpret the client's statement? A) "It is a normal response and indicates the presence of phantom limb pain." B) "It is a normal response and indicates the presence of phantom limb sensation." C) "It is an abnormal response and indicates that the client is in denial about the limb loss." D) "It is an abnormal response and indicates that the client needs more psychological support."
B) "It is a normal response and indicates the presence of phantom limb sensation."
The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action A) Holds the cane on the right side B) Moves the cane when the right leg is moved C) Leans on the cane when the right leg swings through D) Keeps the cane 6 inches out to the side of the right foot
B) Moves the cane when the right leg is moved
A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The licensed practical nurse (LPN) should take which action? A) Administer an analgesic. B) Notify the registered nurse. C) Check the circulation again in 30 minutes. D) Provide range-of-motion exercises to the fingers of the left hand.
B) Notify the registered nurse.
The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. How should the nurse plan to position the client? A) Trochanter roll to prevent abduction while turning B) Pillow to keep the right leg abducted during turning C) Pillow to keep the right leg adducted during turning D) Trochanter roll to prevent external rotation while turning
B) Pillow to keep the right leg abducted during turning
The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? A)Inflammation B) Serous drainage C) Pain at a pin site D) Purulent drainage
B) Serous drainage
The nurse is providing care for a client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? A) Elevating the limb for 24 hours B) Monitoring vital signs every 4 hours C) Administering intramuscular opioid analgesics D) Monitoring the site for swelling, bleeding, hematoma
C) Administering intramuscular opioid analgesics
The nurse is reinforcing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further teaching? A) "I should elevate my arm to reduce the swelling." B) "I should use a sling to limit movement and keep my arm elevated." C) "I should return to the primary health care provider in about 10 days to have the sutures removed." D) "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."
D) "I should perform pronation and supination exercises of my wrist starting 24 hours after surgery."
The nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the early signs of this complication by checking which criteria? Select all that apply. A) The client's renal system B) The client's mental status C) The client's mobility status D) The client's respiratory function E) The client's cardiovascular system
B) The client's mental status D) The client's respiratory function
A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which area as a high-risk area for pressure and breakdown? A) Scapulae B) Left heel C) Right heel D) Back of the head
B) Left heel
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 which action is noted? A) The client holds the walker using the handgrips. B) The client advances the walker with reciprocal motion. C) The client leans forward slightly when advancing the walker. D) The client supports body weight on the hands while advancing the weaker leg
B) The client advances the walker with reciprocal motion.
In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which findings should the nurse interpret as acceptable responses? Select all that apply. A. Symptom control during periods of emotional stress B. Normal white blood cell, platelet, and neutrophil counts C. Radiological findings that show nonprogression of joint degeneration D. An increased range of motion in the affected joints 3 months into therapy E. Inflammation and irritation at the injection site 3 days after injection is given F. A low-grade temperature upon rising in the morning that remains throughout the day
A. Symptom control during periods of emotional stress B. Normal white blood cell, platelet, and neutrophil counts C. Radiological findings that show nonprogression of joint degeneration D. An increased range of motion in the affected joints 3 months into therapy
The nurse is teaching a client about crutch walking. Which comment by the client indicates a need for further teaching? A) "I know I need strong arm muscles to walk with crutches." B) "My crutches must rest up underneath my arm for extra support." C) "I need to make sure that there are rubber tips on the ends of my crutches so I won't slip." D) "I'm going to use the three-point gait, because it allows little weight bearing on my affected leg."
B) "My crutches must rest up underneath my arm for extra support."
A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm? A) Heat B) Cold C) Analgesics D) Prescribed intermittent traction
B) Cold
A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse should make which appropriate response to the client? A. "You should never stop the medication." B. "It is best that you taper the dose if you intend to stop the medication." C. "It is okay to stop the medication if you think that you can tolerate the muscle spasms." D. "Weakness and fatigue commonly occur and will diminish with continued medication use."
D. "Weakness and fatigue commonly occur and will diminish with continued medication use."
The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? A) 3 inches to the front and side of the client's toes B) 8 inches to the front and side of the client's toes C) 15 inches to the front and side of the client's toes D) 20 inches to the front and side of the client's toes
B) 8 inches to the front and side of the client's toes
A client is complaining of pain underneath a cast in the area of a bony prominence. Which should the nurse anticipate? A) The cast will be bivalved. B) A window will be cut in the cast. C) The cast will be replaced with an air splint. D) Extra padding will be put over this area of the cast.
B) A window will be cut in the cast.
A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse should be most useful in trying to provide good skin care to the client? A) Having another nurse tilt the client to the side B) Asking the client to pull up on a trapeze to lift the hips off the bed C) Pushing down on the mattress of the bed while administering care D) Asking the client to lift up by digging into the mattress with the unaffected leg
B) Asking the client to pull up on a trapeze to lift the hips off the bed
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 with which action? A) Applying heat B) Bending or lifting C) Taking ibuprofen D) Maintaining bed rest
B) Bending or lifting
The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. The nurse assesses which factors that can put this client at risk for amputation? Select all that apply. A)Psoriasis B) Bony deformity C) Limited joint mobility D) Peripheral neuropathy E) Peripheral vascular disease F) History of skin ulcers or previous amputation
B) Bony deformity C) Limited joint mobility D) Peripheral neuropathy E) Peripheral vascular disease F) History of skin ulcers or previous amputation
The nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which outcome is noted? A) Intact skin surfaces B) Bowel movement every 5 days C) Equal calf measurements bilaterally D) Active range of motion (ROM) of uninvolved joints
B) Bowel movement every 5 days
The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicate to the nurse a favorable resolution of the fat embolus? A) Minimal dyspnea B) Clear chest x-ray C) Oxygen saturation 85% D Arterial oxygen level of 78 mm Hg
B) Clear chest x-ray
The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? Select all that apply. A) Ensure the client doesn't bend the hips beyond 120 degrees. B) Ensure the client doesn't sit or stand for long periods of time. C) Ensure the client engages in rigorous exercise to maintain strength. D) Ensure the client doesn't cross the legs past the midline of the body. E) Ensure the client uses assistive/adaptive devices with activities of daily living.
B) Ensure the client doesn't sit or stand for long periods of time. D) Ensure the client doesn't cross the legs past the midline of the body. E) Ensure the client uses assistive/adaptive devices with activities of daily living.
Dantrolene sodium (Dantrium) is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds knowing that which is the therapeutic action of this medication? A. Depresses spinal reflexes B. Acts directly on the skeletal muscle to relieve spasticity C. Acts within the spinal cord to suppress hyperactive reflexes D. Acts on the central nervous system (CNS) to suppress spasms
B. Acts directly on the skeletal muscle to relieve spasticity
The client has been on treatment for rheumatoid arthritis for 3 weeks. Which is most important for the nurse to check during the administration of etanercept (Enbrel)? A. The injection site for itching and edema B. The white blood cell counts and platelet counts C. A metallic taste in the mouth and a loss of appetite D. Whether the client is experiencing fatigue and joint pain
B. The white blood cell counts and platelet counts
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 determines that the client is experiencing which problem? A) Feelings of isolation B) Inability to tolerate activity C) Concerns about body image D) Inability to physically move about
C) Concerns about body image
A client has undergone fasciotomy to treat compartment syndrome of the leg. Which type of wound care should the nurse anticipate will be prescribed for the fasciotomy site? A) Dry, sterile dressings B) Hydrocolloid dressings C) Moist, sterile saline dressings D) Half-strength providone-iodine dressings
C) Moist, sterile saline dressing
A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide counter-traction? A) Using a footboard B) Providing an overhead trapeze C) Slightly elevating the foot of the bed D) Slightly elevating the head of the bed
C) Slightly elevating the foot of the bed
The nurse is discharging a client who had conventional open back surgery. Which comment by the client indicates a need for further teaching? A) "I plan to restrict or limit my driving." B) "I will avoid bending and twisting at the waist." C) "I'll go for a walk every day, but I won't take the dog." D) "I'll be careful not to lift anything heavier than 20 pounds."
D) "I'll be careful not to lift anything heavier than 20 pounds."
The nurse has reinforced instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client makes which statement? A) "I can resume regular exercise tomorrow." B) "I will stay off of the leg entirely for the rest of the day." C) "I need to refrain from eating food for the remainder of the day." D) "I'll report fever or site inflammation to the primary health care provider."
D) "I'll report fever or site inflammation to the primary health care provider."
The nurse has given a client instructions on how to do active range-of-motion exercises on her contracted right hand. The nurse determines that the client understands the rationale for this procedure when the client makes which statement? A) "I'm doing this, so I can go home soon." B) "It hurts, but things always have to hurt at my age." C) "If I don't do this, that therapist gets really angry at me." D) "I'm doing these exercises so I can begin to fasten my buttons and dress myself again."
D) "I'm doing these exercises so I can begin to fasten my buttons and dress myself again."
The nurse is teaching a male client with osteomalacia about this disorder. Which comment by the client indicates a need for further teaching? A) "I need to take high doses of vitamin D." B) "Calcification does not occur to harden my bones." C) "Vitamin D helps calcium to be absorbed in my small intestines." D) "This condition is primarily due to my lack of calcium and testosterone."
D) "This condition is primarily due to my lack of calcium and testosterone."
The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which to protect the knee joint? A) Obtain a walker to minimize weight bearing by the client on the affected leg. B) Apply an Ace wrap around the dressing, and put ice on the knee while sitting. C) Lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. D) Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting.
D) Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting.
The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. Which is the initial nursing action? A) Elevate the casted leg. B) Contact the primary health care provider. C) Administer another dose of pain medication. D) Check the neurovascular status of the toes on the casted leg
D) Check the neurovascular status of the toes on the casted leg
A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? A) Allows bony healing to begin before surgery B) Provides rigid immobilization of the fracture site C) Lengthens the fractured leg to prevent severing of blood vessels D) Provides comfort by reducing muscle spasms and provides fracture immobilization
D) Provides comfort by reducing muscle spasms and provides fracture immobilization
The 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 should immediately perform which action? A) Apply ice to the site. B) Call the primary health care provider. C) Apply a dry sterile dressing and elevates it on one pillow. D) Rewrap the residual limb with an elastic compression bandage.
D) Rewrap the residual limb with an elastic compression bandage.
A nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse would plan to: A)Try to manually reduce the fracture. B)Assist the person to get up and walk to the sidewalk. C) Leave the person for a few moments to call an ambulance. D) Stay with the person and encourage the person to remain still.
D) Stay with the person and encourage the person to remain still.
Mr. Davis asks the nurse, "What is osteoarthritis?" Which response from the nurse is correct? a) your bones are inflamed b) your weight bearing joints are inflamed c) you have inflammation in your joints d) there is shortening of your long bones
b) your weight bearing joints are inflamed
