Saunders MS practice questions

Alendronate is prescribed for a client with osteoporosis, and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide? 1.Take the medication at bedtime. 2.Take the medication in the morning with breakfast. 3.Lie down for 30 minutes after taking the medication. 4.Take the medication with a full glass of water after rising in the morning.

4.Take the medication with a full glass of water after rising in the morning. Rationale:Precautions need to be taken with the administration of alendronate to prevent gastrointestinal adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication

A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter?

pao2 Rationale:A significant feature of fat embolism is a significant degree of hypoxemia, with a Pao2 often less than 60 mm Hg (60 mm Hg). The data in the question indicate that the items in the remaining options are normal blood gas results

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?

supine, with limb elevated with pillows ** ask professor witherspoon about this . For the first 24 hours you elevate the limb

The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply. 1.Use night-lights. 2.Remove scatter rugs. 3.Use staircase railings. 4.Remove wall-to-wall carpeting. 5.Place hand rails in the bathroom

1.Use night-lights. 2.Remove scatter rugs. 3.Use staircase railings. 5.Place hand rails in the bathroom Rationale:Home modifications to reduce the risk for falls include using railings on all staircases, providing ample lighting, removing scatter rugs, and placing hand rails in the bathroom. Removing wall-to-wall carpeting is not necessary as long as it is in good condition

An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? 1.Anemia 2.Fractures 3.Infection 4.Muscle sprains

2. Fractures Rationale:The client is most at risk for fractures as a result of osteoporosis. Although other complications can occur, fracture is the greatest concern. Anemia and infection can occur with bone marrow disorders, and muscle sprains are unrelated to osteoporosis

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan 1.Ensure that the knots are at the pulleys. 2.Check the weights to ensure that they are off of the floor. 3.Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4.Monitor the weights to ensure that they are resting on a firm surface.

2.Check the weights to ensure that they are off of the floor. Rationale:To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights should not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? 1.A fall and further injury 2.Injury to the brachial plexus nerves 3.Skin breakdown in the area of the axilla 4.Impaired range of motion while the client ambulates

2.Injury to the brachial plexus nerves Rationale:Crutches are measured so that the tops are 2 to 3 fingerwidths from the axillae. This ensures that the client's axillae are not resting on the crutch or bearing the weight of the crutch, which could result in injury to the nerves of the brachial plexus. Although the conditions in options 1, 3, and 4 can occur, they are not the most likely result from resting the axilla directly on the crutches.

The nurse has conducted teaching with 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 that he or she should report which early symptom of compartment syndrome? 1.Cold, bluish-colored fingers 2.Numbness and tingling in the fingers 3.Pain that increases when the arm is dependent 4.Pain that is out of proportion to the severity of the fracture

2.Numbness and tingling in the fingers Rationale:The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along with other symptoms associated with the pain, is not an early manifestation

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client 1.Calcium level of 9.0 mg/dL (2.25 mmol/L) 2.Uric acid level of 9.0 mg/dL (540 mcmol/L) 3.Potassium level of 4.1 mEq/L (4.1 mmol/L) 4.Phosphorus level of 3.1 mg/dL (1.0 mmol/L

2.Uric acid level of 9.0 mg/dL (540 mcmol/L)

The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1.Hypotension 2.Weak pedal pulses 3.Redness at the pin sites 4.Drainage at the pin site

2.Weak pedal pulses Rationale:Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage used to secure the traction system. This type of traction does not use pins; rather, elastic bandages or a prefabricated boot is worn by the client. Therefore, redness and/or drainage at the pin sites are incorrect. Hypotension is not directly associated with the use of this type of traction

The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? 1."Changes in the shape of the knee are expected." 2."Fever, redness, and increased pain are expected." 3."All caregivers should be told about the metal implant." 4."Bleeding gums or black stools may occur, but this is normal."

3."All caregivers should be told about the metal implant." Rationale:A TJR is also known as a total joint arthroplasty (TJA). The client must inform other caregivers of the presence of the metal implant because certain tests and procedures will need to be avoided. After total knee replacement, the client should report signs and symptoms of infection and any changes in the shape of the knee. These could indicate developing complications. With a metal implant, the client may be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from a variety of sources, and the client will need antibiotic prophylaxis for invasive procedures

A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? 1."When I have pain, I will take ibuprofen." 2."I should perform low-impact exercises regularly." 3."Because I have no symptoms, my disease is not progressing." 4."I must notify my primary health care provider if I experience any hearing loss

3."Because I have no symptoms, my disease is not progressing." Rationale:Paget's disease is characterized by skeletal deformities caused by abnormal bone resorption followed by abnormal regeneration. It is a chronic disease, and most persons who are affected by it are asymptomatic. Even though there may be no symptoms, excessive bone loss may have occurred. Over-the-counter nonsteroidal anti-inflammatory drugs may be used for pain, and low-impact exercises may reduce pain and increase mobility. Bones in the ear may be affected, and pressure from an enlarged temporal bone may cause hearing loss. If hearing loss occurs, the primary health care provider is notified.

The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. 1.Capillary refill less than 3 seconds 2.Pulses present and with swollen, pink fingers 3.Client report of severe, deep, unrelenting pain 4.Client report of pain as nurse assesses finger movement 5.Client report of numbness and tingling sensation in the fingers

3.Client report of severe, deep, unrelenting pain 4.Client report of pain as nurse assesses finger movement 5.Client report of numbness and tingling sensation in the fingers Rationale:The pressure in compartment syndrome, if unrelieved, will cause permanent damage to nerve and muscle tissue distal to the pressure. Circulatory damage may result in necrosis. Nerve and muscle damage may result in permanent contractures, deformity of the extremity, and functional impairment. Normal capillary refill time is 3 seconds or less. Pink appearance and a pulse indicate adequate blood flow; swelling is expected after a fracture. Client report of severe, deep, unrelenting pain; client report of numbness and tingling sensation; and client report of pain as the nurse assesses finger movement are indicative of development of compartment syndrome

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 elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1.Infection under the cast 2.The anxiety of the client 3.Impaired tissue perfusion 4.The recent occurrence of the fracture

3.Impaired tissue perfusion Rationale:Most pain associated with fractures can be minimized with rest, elevation, application of cold, and administration of analgesics. Pain that is not relieved by these measures should be reported to the primary health care provider because pain unrelieved by medications and other measures may indicate neurovascular compromise. Because this is a new closed fracture and cast, infection would not have had time to set in. Intense pain after casting is normally not associated with anxiety or the recent occurrence of the injury. Treatment following the fracture should assist in relieving the pain associated with the injury.

A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? 1.Lack of control 2.Lack of physical mobility 3.Inability to entertain self 4.Inability to maintain health

3.Inability to entertain self Rationale:A manifestation of the inability to entertain self is expression of boredom by the client. The question does not identify difficulties with coordination, range of motion, or muscle strength, which would indicate lack of physical mobility. The question also does not relate to client feelings of inability to take responsibility for meeting basic health practices (inability to maintain health) or to lack of control

The nurse is analyzing the laboratory studies on a client receiving dantrolene to treat muscle spasms from an injury. Which laboratory test would identify an adverse effect associated with the administration of this medication? 1.Platelet count 2.Creatinine level 3.Liver function tests 4.Blood urea nitrogen level

3.Liver function tests Rationale:Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, liver function tests should be performed before treatment and throughout the treatment interval. Dantrolene is administered at the lowest effective dosage for the shortest time necessary

A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? 1.Sprained left ankle 2.Decreased calcium intake 3.Open trauma to the left leg 4.Starting to smoke cigarettes

3.Open trauma to the left leg Rationale:Osteomyelitis is a bone infection and may be caused by direct contamination of bone through an open wound. Bacteria invade the bone tissue and produce inflammation. Ischemia and necrosis of the bone tissue may follow if not treated. The remaining options are unrelated to the cause of osteomyelitis.

The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? 1.Contact the primary health care provider. 2.Massage the skin at the edges of the cast. 3.Petal the cast edges with appropriate material. 4.Place a small facecloth in the cast around the edges of the cast

3.Petal the cast edges with appropriate material. Rationale:If a client with a cast has skin irritation from the edges of the cast, the nurse would petal the edges of the cast with tape to minimize the irritation. It is not necessary to contact the primary health care provider unless skin breakdown is noted. Massaging the skin will not eliminate the problem. Placing a small facecloth in the cast around the edges of the cast is not appropriate

The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self-positioning in bed? 1.Use the assistance of four nurses to reposition the client. 2.Place a draw sheet on the mattress for pulling the client up in bed. 3.Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. 4.Encourage the client to push with the unaffected leg on the bed mattress to help with repositioning.

3.Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed.

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection 1.Dependent edema 2.Diminished distal pulse 3.Presence of a "hot spot" on the cast 4.Coolness and pallor of the extremity

3.Presence of a "hot spot" on the cast Rationale:Signs of infection under a casted area include odor or purulent drainage from the cast or the presence of "hot spots," which are areas of the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Signs of impaired circulation in the distal limb include coolness and pallor of the skin, diminished distal pulse, and edema

A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? 1.Using a footboard 2.Providing an overhead trapeze 3.Slightly elevating the foot of the bed 4.Slightly elevating the head of the bed

3.Slightly elevating the foot of the bed Rationale:The part of the bed under an area in traction usually is elevated to aid in countertraction. For the client in Buck's extension traction (which is applied to a leg), the foot of the bed is elevated. The remaining options are incorrect

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? 1.Redness around the pin sites 2.Pain on palpation at the pin sites 3.Thick, yellow drainage from the pin sites 4.Clear, watery drainage from the pin sites

3.Thick, yellow drainage from the pin sites Rationale:The nurse should monitor for signs of infection such as inflammation, purulent (thick white or yellow) drainage, and pain at the pin site. However, some degree of inflammation, pain at the pin site, and serous drainage would be expected; the nurse should correlate assessment findings with other clinical findings, such as fever, elevated white blood cell count, and changes in vital signs. Additionally, the nurse should compare any findings to baseline findings to determine if there were any changes. Test-Taking Strategy(ies):Note the strategic word, most. Determine if an abnormality exists. Recall that purulent drainage is indicative of infection, and that some degree of pain, inflammation, and serous drainage should be expected.

The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response? 1.Allergic 2.Metabolic 3.Endocrine 4.Autoimmune

4. Autoimmune Rationale:The most likely cause for rheumatoid arthritis is activation of an autoimmune response. This is thought to trigger antigen-antibody responses and release of lysosomes from phagocytic cells, which ultimately attack the cartilage and synovia, with resultant synovitis. Other theories related to the cause of rheumatoid arthritis have been proposed, but the most likely cause is an autoimmune reaction

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? 1."I can resume regular exercise tomorrow." 2."I can't eat food for the remainder of the day." 3."I need to stay off the leg entirely for the rest of the day." 4."I need to report a fever or swelling to my orthopedic surgeon."

4."I need to report a fever or swelling to my orthopedic surgeon." Rationale:After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the orthopedic surgeon

The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction 1."I should slide objects rather than lifting them." 2."I should try not to remain in the same position for a long period of time." 3."I should use large joints instead of small joints when performing activities." 4."Pain or fatigue is expected, and I should try to continue with the activity if this occurs."

4."Pain or fatigue is expected, and I should try to continue with the activity if this occurs." Rationale:The client should be instructed to use pain or fatigue as an indicator and guide to increase, maintain, or decrease an activity level. If pain or fatigue is experienced, the client should rest. The client should learn to slide objects rather than lifting them and not remain in the same position for a long time. Whenever possible, the client should use large joints instead of small joints for activities and should use the joints in their most natural position.

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery 1.Hemorrhage 2.Edema of the residual limb 3.Slight redness of the incision 4.Separation of the wound edges

4.Separation of the wound edges Rationale:Clients with diabetes mellitus are more prone to wound infection, wound separation, and delayed wound healing because of the disease. Postoperative hemorrhage and edema of the residual limb are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as the incision is dry and intact

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? 1.Try to reduce the fracture manually. 2.Assist the victim to get up and walk to the sidewalk. 3.Leave the victim for a few moments to call an ambulance. 4.Stay with the victim and encourage him or her to remain still

4.Stay with the victim and encourage him or her to remain still. Rationale:With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before the victim is moved, the site of fracture is immobilized to prevent further injury.

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast 1."I need to avoid getting the cast wet." 2."I need to cover the casted leg with warm blankets." 3."I need to use my fingertips to lift and move my leg." 4."I need to use something like a padded coat hanger end to scratch under the cast if it itches."

1."I need to avoid getting the cast wet." Rationale:A plaster cast must remain dry to keep its strength. The cast should be handled with the palms of the hands, not the fingertips, until fully dry; using the fingertips results in indentations in the cast and skin pressure under the cast. Air should circulate freely around the cast to help it dry; the cast also gives off heat as it dries. The client should never scratch under the cast because of the risk of altered skin integrity; the client may use a hair dryer on the cool setting to relieve an itch.

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply. 1."I should not use someone else's crutches." 2."I need to remove any scatter rugs at home." 3."I can use crutch tips even when they are wet." 4."I need to have spare crutches and tips available." 5."When I'm using the crutches, my arms need to be completely straight."

1."I should not use someone else's crutches." 2."I need to remove any scatter rugs at home." 4."I need to have spare crutches and tips available." Rationale:The client should use only crutches measured for the client. When assessing for home safety, the nurse ensures that the client knows to remove any scatter rugs and does not walk on highly waxed floors. The tips should be inspected for wear, and spare crutches and tips should be available if needed. Crutch tips should remain dry. If crutch tips get wet, the client should dry them with a cloth or paper towel. When walking with crutches, both elbows need to be flexed not more than 30 degrees when the palms are on the handle.

The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction? 1."I should sit in my recliner when I get home." 2."I need to keep my legs apart while sitting or lying." 3."I should try to obtain an elevated toilet seat for use at home." 4."I should contact the primary health care provider if the incision becomes red or irritated or if I note any drainage.

1."I should sit in my recliner when I get home." Rationale:After total hip replacement, the client should be instructed to sit on a high, firm chair. The client should be instructed to keep the legs apart while sitting or lying to prevent disruption of the hip replacement; this may be accomplished by placing a blanket or a pillow between the legs. The use of an elevated toilet seat will prevent discomfort and pressure at the operative site. The primary health care provider should be notified if the client notes the development of any redness, irritation, or drainage at the incision site.

The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information should the nurse include? 1."You will use full weight bearing by discharge." 2."You will use partial weight bearing by discharge." 3."You will use toe-touch weight bearing by discharge." 4."You will need to remain on bed rest even after discharge."

1."You will use full weight bearing by discharge." Rationale:After total knee arthroplasty, there is an emphasis on physical therapy as part of the plan of care. By discharge, the client should be using full weight bearing after working with therapy. The other options are incorrect.

The nurse is talking to a client who had a below-the-knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? 1.Altered body image 2.Inability to care for self 3.Disruption in coping ability 4.Difficulty maintaining health

1.Altered body image Rationale:Altered body image is characterized by negative verbalizations or feelings about a body part. This is a common response after amputation. The nurse supports the client and assists the client to work through these feelings. The client also may have the other problems as listed in the remaining options, but altered body image is the client problem that correlates best with the client's statement.

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus 1.Clear mentation 2.Minimal dyspnea 3.Oxygen saturation of 85% 4.Arterial oxygen level of 78 mm Hg

1.Clear mentation Rationale:An altered mental state is an early indication of fat emboli; therefore, clear mentation is a good indicator that a fat embolus is resolving. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%.

In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? Select all that apply. 1.Control of symptoms during periods of emotional stress 2.Normal white blood cell, platelet, and neutrophil counts 3.Radiological findings that show no progression of joint degeneration 4.An increased range of motion in the affected joints 3 months into therapy 5.Inflammation and irritation at the injection site 3 days after the injection is given 6.A low-grade temperature on rising in the morning that remains throughout the day

1.Control of symptoms during periods of emotional stress 2.Normal white blood cell, platelet, and neutrophil counts 3.Radiological findings that show no progression of joint degeneration 4.An increased range of motion in the affected joints 3 months into therapy

The nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which nursing action would be appropriate? 1.Document the findings. 2.Notify the primary health care provider (PHCP). 3.Remove 2 lb (0.9 kg) of weight from the traction. 4.Lift the weights and place them on the bed so that the PHCP can assess the client.

1.Document the findings. Rationale:A small amount of serous oozing is expected at the pin insertion site. The nurse would document the findings. It is not necessary to notify the PHCP. The nurse would not add or remove any weight from the client's traction setup because this would disrupt the alignment of the fracture.

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide? 1.Drink 3000 mL of fluid a day. 2.Take the medication on an empty stomach. 3.The effect of the medication will occur immediately. 4.Any swelling of the lips is a normal expected response

1.Drink 3000 mL of fluid a day.

Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the primary health care provider about the administration of this medication? 1.Glaucoma 2.Emphysema 3.Hypothyroidism 4.Diabetes mellitus

1.Glaucoma Rationale:Because cyclobenzaprine has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short time (2 to 3 weeks). The conditions in options 2, 3, and 4 are not a concern with this medication

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1.Keep the cast clean and dry. 2.Allow the cast 24 to 72 hours to dry. 3.Keep the cast and extremity elevated. 4.Expect tingling and numbness in the extremity. 5.Use a hair dryer set on a warm to hot setting to dry the cast. 6.Use a soft, padded object that will fit under the cast to scratch the skin under the cast.

1.Keep the cast clean and dry. 2.Allow the cast 24 to 72 hours to dry. 3.Keep the cast and extremity elevated. Rationale:A plaster cast takes 24 to 72 hours to dry (synthetic casts dry in 20 minutes). The cast and extremity should be elevated to reduce edema if prescribed. A wet cast is handled with the palms of the hand until it is dry, and the extremity is turned (unless contraindicated) so that all sides of the wet cast will dry. A cool setting on the hair dryer can be used to dry a plaster cast (heat cannot be used on a plaster cast because the cast heats up and burns the skin). The cast needs to be kept clean and dry, and the client is instructed not to stick anything under the cast because of the risk of breaking skin integrity. The client is instructed to monitor the extremity for circulatory impairment, such as pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse. The primary health care provider is notified immediately if circulatory impairment occurs

The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply 1.Physical therapy 2.Knee immobilizer 3.Aspiration of joint fluid 4.Ambulation with a walker 5.Anti-inflammatory medications

1.Physical therapy 2.Knee immobilizer 3.Aspiration of joint fluid 5.Anti-inflammatory medications Rationale:The anterior cruciate ligament (ACL) runs diagonally in the middle of the knee. Injury to the ACL can result in a partial tear, a complete tear, and an avulsion. Treatment measures for this injury include physical therapy, use of a knee immobilizer or hinge brace, aspiration of joint fluid if an effusion occurs, ambulation with crutches, anti-inflammatory medications, rest, ice, and possibly reconstructive surgery.

The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the residual (remaining) limb and expects to note which finding? 1.Pink color to the skin flap 2.Hot feeling on palpation of the skin flap 3.Serous fluid leaking from the skin flap incision 4.Absent pulse at the proximal pulse point site closest to the skin flap

1.Pink color to the skin flap Rationale:Following above-the-knee amputation, the nurse's primary focus is to monitor for signs indicating that there is sufficient tissue perfusion and no hemorrhage. The skin flap at the end of the residual (remaining) limb should be pink in a light-skinned person and not discolored (lighter or darker than other skin pigmentation) in a dark-skinned person. The area should be warm but not hot. If the area is hot this could indicate inflammation or infection. The incision should be clean and dry with no serous or other fluid leaking from it. There should be a pulse at the closest proximal pulse point. If no pulse is felt, the nurse would assess for a pulse using a Doppler. If no pulse is detected using the Doppler device, this could indicate lack of perfusion, and the surgeon would need to be notified

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? 1.Temperature of 101.6° F (38.7° C) orally 2.Complaints of discomfort during repositioning 3.Old bloody drainage outlined on the surgical dressing 4.Discomfort during coughing and deep-breathing exercises

1.Temperature of 101.6° F (38.7° C) orally Rationale:The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6° F (38.7° C) should be reported

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? 1.The need for sensory stimulation 2.The amount of home care support available 3The ability to perform activities of daily living 4.The type of transportation available for follow-up care

1.The need for sensory stimulation Rationale:A psychosocial assessment of a client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although home care support, the ability to perform activities of daily living, and transportation are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation. Test-Taking Strategy(ies):Focus on the strategic words, most appropriate, and note the subject, psychosocial adjustment. Option 3 can be eliminated first because it relates to physiological integrity rather than psychosocial integrity. Next, eliminate options 2 and 4 because they are most closely related to physical supports, rather than psychosocial needs of the client

The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented? 1.Use a raised toilet seat. 2.Bend carefully to put on socks and shoes. 3.Sit in chairs without arms for better mobility. 4.Exercise the leg past the point of 90-degree flexion.

1.Use a raised toilet seat. Rationale:The client who has had an insertion of a femoral head prosthesis should use a raised toilet seat. The client should avoid putting on his or her own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion. The client should sit in chairs that have arms to provide assistance in rising from the sitting position. The client also should maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees.

The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk? 1.Yogurt 2.Turkey 3.Shellfish 4.Spaghetti

1.Yogurt Rationale:The major dietary source of calcium is from dairy products including milk, yogurt, and a variety of cheeses. Calcium also can be added to certain products such as orange juice, which are then advertised as being fortified with calcium. Calcium supplements also are available and recommended for persons with typically low calcium intake. Turkey, shellfish, and spaghetti are not high-calcium products.

The community health nurse is providing a teaching session on osteoporosis to women living in the community. The nurse informs these community residents that which is a risk factor for this disorder? 1.A large skeletal frame 2.A diet low in vitamin D 3.Low thyroid hormone levels 4.A high dietary intake of calcium

2.A diet low in vitamin D Rationale:Some of the risk factors related to osteoporosis in females are a small skeletal frame and elevated thyroid hormone. Low dietary intake of calcium and vitamin D also constitutes a risk factor for osteoporosis

A client is admitted to the nursing unit after a left below-the-knee amputation after 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 should the nurse interpret this client statement? 1.A normal response that indicates the presence of phantom limb pain 2.A normal response that indicates the presence of phantom limb sensation 3.An abnormal response that indicates that the client is in denial about the limb loss 4.An abnormal response that indicates that the client needs more psychological support

2.A normal response that indicates the presence of phantom limb sensation Rationale:Phantom limb sensations are felt in the area of the amputated limb. These sensations can include itching, warmth, and cold. The sensations are caused by intact peripheral nerves in the area of the amputation. Whenever possible, the client should be prepared for these sensations. The client also may feel painful sensations in the amputated limb, called phantom limb pain. The origin of the pain is less well understood, but the client should be prepared for this, too, whenever possible.

The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? 1.A trochanter roll to prevent abduction during turning 2.A pillow to keep the right leg abducted during turning 3.A pillow to keep the right leg adducted during turning 4.A trochanter roll to prevent external rotation during turning

2.A pillow to keep the right leg abducted during turning Rationale:After femoral head replacement for a fractured hip with an intracapsular fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the client's legs to keep the affected leg in abduction. The nurse then repositions the client while maintaining proper alignment and abduction. A trochanter roll is useful in preventing external rotation, but it is used after the client has been repositioned. A trochanter roll is not used while the client is being turned

A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? 1.Bed pillow 2.Abductor splint 3.Adductor splint 4.Overhead trapeze

2.Abductor splint Rationale:After surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. A bed pillow and an overhead trapeze also are used, but neither is the priority item to be used in repositioning the client from side to side.

Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the primary health care provider has prescribed which laboratory study? 1.Platelet count 2.Alkaline phosphatase 3.White blood cell count 4.Complete blood cell count

2.Alkaline phosphatase Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Diagnostic laboratory findings for Paget's disease include an elevated serum alkaline phosphatase level and elevated urinary hydroxyproline excretion. The remaining options are unrelated to diagnostic evaluation of this disease.

The nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen. Which instruction should be included in the teaching plan 1.Restrict fluid intake. 2.Avoid the use of alcohol. 3.Stop the medication if diarrhea occurs. 4.Notify the primary health care provider (PHCP) if fatigue occurs

2.Avoid the use of alcohol. Rationale:Baclofen is a skeletal muscle relaxant. The client should be cautioned against the use of alcohol and other central nervous system depressants, because baclofen potentiates the depressant activity of these agents. Constipation, rather than diarrhea, is a side effect. Restriction of fluids is not necessary, but the client should be warned that urinary retention can occur. Fatigue is related to a central nervous system effect that is most intense during the early phase of therapy and diminishes with continued medication use. The client does not need to notify the PHCP about fatigue

A client has several fractures of the lower leg, which has been placed in an external fixation device. The client is upset about the appearance of the leg, which is edematous. The nurse documents which client problem in the plan of care? 1.Feeling isolated 2.Body image alteration 3.Inability to perform activities 4.Inability to engage in physical mobility

2.Body image alteration

A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the primary health care provider will include a new prescription for which vitamin supplement? 1.A 2.D 3.E 4.K

2.D Rationale:Osteomalacia technically refers to bone softening that results from demineralization of bone matrix and failure to calcify. A common cause is vitamin D deficiency in the diet. Other causes are inadequate exposure to sunlight (to synthesize vitamin D) and disorders that interfere with absorption and metabolism of vitamin D. Deficiencies of the vitamins noted in the remaining options are not associated with osteomalacia.

The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? 1.Fever and chills 2.Dyspnea and chest pain 3.External rotation of the right leg 4.Pallor, paresthesia, and pulselessness of the right lower leg

2.Dyspnea and chest pain

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. 1.Ice 2.Heat 3.Analgesics 4.Muscle relaxers 5.Intermittent traction

2.Heat 3.Analgesics 4.Muscle relaxers 5.Intermittent traction Rationale:Heat, analgesics, muscle relaxers, and traction all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the primary health care provider's preference) after an injury. Application of ice to the spine of a client could be uncomfortable and could result in feelings of being chilled

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? 1.Arterial insufficiency 2.Impaired venous return 3.Impaired arterial circulation 4.The presence of an infection

2.Impaired venous return Rationale:Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of "hot spots," which are areas of the cast that feel warmer to the touch than the rest of the cast

A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse should include which interventions to maintain client safety after this procedure? Select all that apply 1.Use the overhead trapeze. 2.Keep the head of the bed flat. 3.Place pillows under the length of the legs. 4.Use a logrolling technique for repositioning. 5.Assist the client with eating meals and drinking fluids.

2.Keep the head of the bed flat. 3.Place pillows under the length of the legs. 4.Use a logrolling technique for repositioning. 5.Assist the client with eating meals and drinking fluids. Rationale:After a client has spinal fusion, the head of the bed generally is kept flat. Because the client is in the flat position, the nurse should assist the client with eating meals and drinking fluids. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs, in accordance with surgeon preference, to relieve tension on the lower back. The use of an overhead trapeze may decrease control of spinal movement and is contraindicated because its use could promote twisting of the spine after surgery

Colchicine is prescribed for a client with a diagnosis of gout. The nurse reviews the client's record, knowing that this medication would be used with caution in which disorder? 1.Myxedema 2.Kidney disease 3.Hypothyroidism 4.Diabetes mellitus

2.Kidney disease Rationale:Colchicine is used with caution in older clients, debilitated clients, and clients with cardiac, kidney, or gastrointestinal disease. The disorders in options 1, 3, and 4 are not concerns with administration of this medicatio

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? 1.Head elevated lying on the operative side 2.On the nonoperative side with the legs abducted 3.Side-lying with the affected leg internally rotated 4.Side-lying with the affected leg externally rotated

2.On the nonoperative side with the legs abducted Rationale:Positioning after a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the primary health care provider's (PHCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or lying on the operative side (unless specifically prescribed by the PHCP) is avoided to prevent displacement of the prosthesis.

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client? 1.Urinary incontinence 2.Signs of skin breakdown 3.The presence of bowel sounds 4.Signs of infection around the pin sites

2.Signs of skin breakdown Rationale:Skin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.

The nurse is planning to teach the client with below-the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan 1.The residual limb is washed gently and dried every other day. 2.The socket of the prosthesis must be dried carefully before it is used. 3.A residual limb sock must be worn at all times and changed twice a week. 4.The socket of the prosthesis is washed with a harsh bactericidal agent daily.

2.The socket of the prosthesis must be dried carefully before it is used. Rationale:A residual limb sock must be worn at all times to absorb perspiration and is changed daily. The residual limb is washed, dried, and inspected for breakdown twice each day. The socket of the prosthesis is cleansed with a mild detergent and rinsed and dried carefully each day. A harsh bactericidal agent would not be used

A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess? 1.The injection site for itching and edema 2.The white blood cell counts and platelet counts 3.Whether the client is experiencing fatigue and joint pain 4.Whether the client is experiencing a metallic taste in the mouth and a loss of appetite

2.The white blood cell counts and platelet counts Rationale:Infection and pancytopenia are adverse effects of etanercept. Laboratory studies are performed prior to and during medication treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching is a common occurrence following administration. A metallic taste and loss of appetite are not common signs of adverse effects of this medication.

The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? 1.Administer an enema daily. 2.Use a fracture pan for bowel elimination. 3.Use a bedside commode for all elimination needs. 4.Use a regular bedpan to prevent spilling of contents in the bed.

2.Use a fracture pan for bowel elimination. Rationale:A fracture pan is designed to be used for clients with body or leg casts. A client with a spica cast (body cast) involving a lower extremity cannot bend at the hips to sit up; therefore, a regular bedpan and a commode would be inappropriate. Daily enemas are not a part of routine care

The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? 1."A bone fragment has injured the nerve supply in the area." 2."An injured artery caused impaired arterial perfusion through the compartment." 3."Bleeding and swelling caused increased pressure in an area that couldn't expand." 4."The fascia expanded with injury, causing pressure on underlying nerves and muscles.

3."Bleeding and swelling caused increased pressure in an area that couldn't expand Rationale:Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The remaining options are inaccurate descriptions of compartment syndrome

A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the primary health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours? 1."I should place hot packs on my ankle." 2."I should wrap my ankle with blankets." 3."I should elevate my foot above the level of the heart." 4."I should try to ambulate at least 10 minutes out of every hour.

3."I should elevate my foot above the level of the heart." Rationale:Soft tissue injuries such as sprains are treated with RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on health care provider prescription. Ice is applied intermittently for 20 to 30 minutes at a time. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. The client should rest and not walk around, and the foot should be elevated and not placed in a dependent position.

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? 1.Bed rest 2.Ibuprofen 3.Bending or lifting 4.Application of heat

3.Bending or lifting Rationale:Low back pain that radiates down 1 leg (sciatica) is consistent with herniated lumbar disk. The nurse assesses the client to see whether the pain is aggravated by events that increase intraspinal pressure, such as bending, lifting, sneezing, and coughing, or by lifting the leg straight up while supine (straight leg-raising test). Bed rest, heat (or sometimes ice), and nonsteroidal antiinflammatory drugs (NSAIDs) usually relieve back pain.

The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? 1.Tinnitus 2.Fatigue 3.Bone pain 4.Difficulty with ambulating

3.Bone pain Rationale:Paget's disease is a chronic metabolic disorder in which bone is excessively broken down and reformed. The result is bone that is structurally disorganized, causing bone to be weak with increased risk for bowing of long bones and fractures. Bone pain is the most common symptom of Paget's disease and may manifest in areas close to a joint. The pain is related to progressive enlargement and deformity of the bone. Hearing loss, numbness of the face, or (more rarely) blindness can occur when the thickened bone of Paget's disease compresses vital nerves in the skull. Fatigue or difficulty with ambulation may occur but would not be the most common symptom.

The nurse is administering an intravenous dose of methocarbamol to a client with a muscle skeletal injury. For which adverse effect should the nurse monitor? 1.Tachycardia 2.Rapid pulse 3.Bradycardia 4.Hypertension

3.Bradycardia Rationale:Intravenous administration of methocarbamol can cause hypotension and bradycardia. The nurse needs to monitor for these adverse effects. Options 1, 2, and 4 are not effects with administration of this medication

The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? 1.Provide pin care. 2.Medicate the client. 3.Call the primary health care provider. 4.Remove 2 lb (0.9 kg) of weight from the traction system.

3.Call the primary health care provider. Rationale:Severe pain in a client in skeletal traction may indicate a need for realignment, or the traction weights applied to the limb may be too heavy. The nurse realigns the client. If this measure is ineffective, the nurse then calls the primary health care provider. Severe leg pain once traction has been established indicates a problem. Providing pin care is unrelated to the problem as described. Medicating the client should be done after trying to determine and treat the cause. The nurse should never remove the weights from the traction system without a specific prescription to do so

The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings should the nurse identify as early signs of possible fat embolism? 1.Decreased heart rate and increased restlessness 2.Decreased heart rate and decreased respiratory rate 3.Increased heart rate and adventitious breath sounds 4.Increased heart rate and increased oxygen saturation

3.Increased heart rate and adventitious breath sounds Rationale:Fat embolism commonly causes signs and symptoms related to respiratory or neurological impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However, adventitious breath sounds and an increased heart rate may be easily and quickly observed, even before the client demonstrates labored breathing. The remaining options are incorrect

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1.Apply restraints to the client. 2.Ask the family to stay with the client. 3.Place a clock and calendar in the client's room. 4.Ask the laboratory to perform electrolyte studies.

3.Place a clock and calendar in the client's room. Rationale:An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed; agency policies and procedures should be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1.Apply ice to the site. 2.Call the primary health care provider (PHCP). 3.Rewrap the residual limb with an elastic compression bandage. 4.Apply a dry, sterile dressing and elevate the residual limb on 1 pillow.

3.Rewrap the residual limb with an elastic compression bandage. Rationale:If the client with an amputation has a cast or elastic compression bandage that slips off, the nurse must wrap the residual limb immediately with another elastic compression bandage. Otherwise, excessive edema will form rapidly, which could cause a significant delay in rehabilitation. If the client had a cast that slipped off, the nurse would have to call the PHCP so that a new one could be applied. Elevation on 1 pillow is not going to impede the development of edema greatly once compression is released. Ice would be of limited value in controlling edema from this cause. If the PHCP were called, the prescription likely would be to reapply the compression dressing anyway

A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? 1.Strain 2.Sprain 3.Fracture 4.Contusion

3.fracture Rationale:Typical signs and symptoms of fracture include pain, loss of function in the area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. Not all fractures lead to the development of every sign or symptom. A strain results from a pulling force on the muscle, resulting in soreness and pain with muscle use. A sprain is an injury to a ligament caused by a wrenching or twisting motion and is manifested by pain, swelling, and inability to use the joint or bear weight normally. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this problem? A 25-year-old woman who runs 2.A 36-year-old man who has asthma 3.A 70-year-old man who consumes excess alcohol 4.A sedentary 65-year-old woman who smokes cigarettes

4.A sedentary 65-year-old woman who smokes cigarettes Rationale:Risk factors for osteoporosis include female gender, being postmenopausal, advanced age, a low-calcium diet, excessive alcohol intake, being sedentary, and smoking cigarettes. Long-term use of corticosteroids, anticonvulsants, and/or furosemide also increases the risk.

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? 1.Elevate the casted leg. 2.Contact the primary health care provider. 3.Administer another dose of pain medication. 4.Check the neurovascular status of the toes on the casted leg.

4.Check the neurovascular status of the toes on the casted leg. Test-Taking Strategy(ies):Use the steps of the nursing process as a guide to answer this question, and note the strategic word, initial. Remember that assessment is the first step of the nursing process. This will direct you to the correct option Rationale:An increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) often is the first sign of increasing pressure within a tissue compartment. The nurse needs to obtain additional assessment data to determine if the primary health care provider needs to be notified immediately or whether other interventions are appropriate. Options 1, 2, and 3 are inappropriate and would delay necessary treatment

The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? 1.Simple fracture 2.Greenstick fracture 3.Compound fracture 4.Comminuted fracture

4.Comminuted fracture Rationale:A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone: one side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone Test-Taking Strategy(ies):Focus on the subject, a fracture with splintering of the bone into fragments. Recalling that a comminuted fracture describes a fracture in which the bone is broken into minute (small) pieces will direct you to the correct option.

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg 1.Elevated for 3 hours, then flat for 1 hour 2.Flat for 3 hours, then elevated for 1 hour 3.Flat for 12 hours, then elevated for 12 hours 4.Elevated on pillows continuously for 24 to 48 hour

4.Elevated on pillows continuously for 24 to 48 hour Rationale:A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. Options 1, 2, and 3 are incorrect.

A client with a hip fracture asks the nurse about Buck's (extension) traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? 1.Allows bony healing to begin before surgery and involves pins and screws 2.Provides rigid immobilization of the fracture site and involves pulleys and wheels 3.Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws 4.Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

4.Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels Rationale:Buck's (extension) traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not allow for bony healing to begin or provide rigid immobilization. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. This type of traction involves pulleys and wheels, not pins and screws.

A client is having a plaster cast placed on the lower extremity that will extend from mid-thigh to the center of the foot. Which instruction should be given to the client before hospital discharge? 1.How to petal the edges of the cast to prevent crumbling of these edges 2.The need to notify the nurse if the plaster cast becomes warm during the first 24 hours 3.The correct method of using a thin object when the client needs to scratch the area beneath the cast 4.The need to notify the primary health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale

4.The need to notify the primary health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale Rationale:Numbness, swelling, and cool, pale skin are findings that indicate a state of neurovascular compromise. This can lead to significant problems and potential loss of the limb. Although teaching the client how to petal the edge of a cast is commonly done to keep the edges from crumbling, this is not the priority at this time. Chemical reaction occurs while a plaster cast dries, causing the cast to be warm. This effect can last from 24 to 48 hours, depending on how long it takes for the cast to dry. It is inappropriate to place any objects under the edge of the cast because such maneuvers can result in tissue injury and consequent infection.

The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? 1.The client's mobility status 2.The renal and endocrine systems 3.The cardiovascular and renal systems 4.The neurological and respiratory systems

4.The neurological and respiratory systems Rationale:The early signs of the complication of fat embolism include changes in the client's mental status and signs of impaired respiratory function as a result of impaired perfusion distal to the site of the embolus. Cardiovascular and renal impairments are likely to be secondary to impaired respiratory function. Effects on the endocrine system usually are not seen. The client's mobility status is unrelated to the signs of fat embolism

The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? 1.In 48 hours 2.In 24 hours 3.In approximately 8 hours 4.Within 20 to 30 minutes of application

4.Within 20 to 30 minutes of application Rationale:A fiberglass cast is made of water-activated polyurethane material that is dry to the touch within minutes and reaches full rigid strength in about 20 minutes. Accordingly, the client can bear weight on the cast within 20 to 30 minutes. The remaining options are incorrect.