Test 4 - 155
A patient presents with bilateral leg pain, abdominal pain, and difficulty breathing after a motor vehicle accident. The nurse notes obvious deformities to the bilateral lower legs, bruising to the chest, and abrasions on the chest, abdomen, and arms. Which actions should the nurse perform while assessing the severity of the patient's injuries? Select all that apply. Auscultate lung sounds Assess peripheral pulses Assess capillary refill time Start intravenous (IV) infusion with dextrose in 5% water Prepare patient for computed tomography (CT) scan
-Auscultate lung sounds -Assess peripheral pulses -Assess capillary refill time
Which factors could increase the risk for developing compartment syndrome? Edema Active bleeding Application of a half cast Restrictive arm splint Intravenous (IV) infiltration
-Edema -Active bleeding -Restrictive arm splint -Intravenous (IV) infiltration
When caring for a patient with right ankle swelling, the nurse notes edema, bruising, and decreased movement of the foot. Which acute actions should the nurse take? Select all that apply. Elevate the extremity Assess the patient's urine output Perform passive range of motion (ROM) Conduct a baseline neurovascular examination Educate the patient and family about strengthening exercises
-Elevate the extremity -Conduct a baseline neurovascular examination
Place the phases of compartment syndrome in the sequential order in which they would occur.
-Swelling of the arm -Occlusion of the arm arteries and veins -Death of the arm tissue -Muscle and nerve damage -Eruption of fibrotic tissue (-Edema creates pressure that obstructs circulation and causes venous occlusion, which further increases edema. -Blood flow is then compromised, causing ischemia in the extremity. -Muscle and nerve cells are destroyed, leading to myoglobinemia (high serum myoglobin levels from muscle breakdown), which causes obstruction in renal tubules and results in acute tubular necrosis and acute kidney injury (AKI). Dark reddish brown urine is a common sign. -Fibrotic tissue eventually replaces healthy tissue.)
While caring for a patient after a third-degree ankle sprain, the nurse notes the patient can bear weight on the affected foot without discomfort. Which actions would the nurse consider? Select all that apply. Teach strengthening exercises for the ankle Assess neurovascular status of affected extremity Teach patient to continue applying ice packs at home Check X-ray finding with the patient to see if there is no fracture Perform passive range-of-motion (ROM) exercises on the affected foot
-Teach strengthening exercises for the ankle -Assess neurovascular status of affected extremity
What are the normal lab values for AST/ALT?
0-35
A patient arrives in the emergency department after sustaining a fall. The initial assessment reveals that the left leg is shorter than the right and externally rotated. What condition should the nurse suspect? 1 Fractured hip 2 Fractured pelvis 3 Fractured tibia/fibula 4 Nondisplaced fractured femur
1
A patient is hospitalized with severe bleeding in the leg. An x-ray exam of the leg reveals that the periosteum is intact across the fracture and that the bone is still in alignment. What type of fracture does the patient have? 1 Oblique fracture 2 Pathologic fracture 3 Greenstick fracture 4 Comminuted fracture
3
The nurse provides discharge instructions to a patient who has undergone total hip arthroplasty. Which statement by the patient indicates understanding of the instructions? 1 "I'll walk at least two miles a day after I get home." 2 "I may get back to work as soon as I feel that I'm able." 3 "I have to do the physical therapy exercises several times a day." 4 "I should take frequent bike rides to increase my activity and joint flexibility."
3
The nurse reviews the medical record of a patient and notes documentation of class I obesity. The determination was made because the patient has which body mass index (BMI)? 26 32 37 42
32
Which patients will the nurse assess for signs and symptoms of osteomyelitis? (select all that apply) A 60-year-old diabetic who has a blunt injury A 14-year-old boy who sustained an ankle sprain A 50-year-old man who underwent a total hip replacement A 20-year-old women with a closed fracture of the humerus A 30-year-old man with a tibia fracture and a deep wound over it
A 60-year-old diabetic who has a blunt injury A 50-year-old man who underwent a total hip replacement A 30-year-old man with a tibia fracture and a deep wound over it
Place the stages of bone healing in the order they would occur in a patient after a femur fracture.
A hematoma develops over the two ends of the femur. White blood cells rid the area of damaged tissue. The body covers the bone fragments with cartilage, osteoblasts, calcium, and phosphorus. The callus hardens over the site. The bone fragments begin to move closer together. Excess bone tissue is resorbed.
A client comes into the ER with right upper abdomen pain. The nurse notices multiple scratch marks on the arms and torso and the client reports itching; however there is no noticeable rash. Allergic reaction has been ruled out. Which lab studies may be ordered to help diagnose the client? ALT & AST BUN & creatinine Hgb & Hct Amylase & lipase
ALT & AST
The nurse is caring for a patient with an open arm fracture after a horse riding accident. Which actions are important for the nurse to take? Splint the arm An open fracture would not be splinted and manipulated until it is reduced by the health care provider. Administer IV antibiotics Assess capillary refill of fingers Assess airway and cervical spine Administer antitetanus as prescribed Apply heating pads on the affected areas
Administer IV antibiotics The nurse would administer prophylactic antibiotics in patients with open fracture to prevent infection. Correct Assess capillary refill of fingers The nurse should assess the capillary refill of the patient's fingers to determine if distal tissue perfusion is compromised by the fracture. Correct Assess airway and cervical spine Because of the mechanism of injury, the nurse should immediately assess the patient's airway and cervical spine for any compromise. Correct Administer antitetanus as prescribed The nurse should administer an antitetanus injection in patients with open wounds from a fracture to provide protection against tetanus.
A patient undergoing chemotherapy has a low white blood cell (WBC) count. Which intervention would the nurse anticipate? Monitor the respiratory rate Administer WBC growth factors Request that the chemotherapy dose be reduced Allow the patient to visit with family and friends
Administer WBC growth factors
Ms. Fielding reports shortness of breath. The nurse notes shallow, labored breathing. Which intervention is priority for the nurse to take while Ms. Fielding is in the emergency unit? Prepare patient for CT scan Encourage increased oral fluids Administer supplemental oxygen Administer intravenous (IV) morphine
Administer supplemental oxygen
A client who had a permanent sigmoid colostomy is back to learn about irrigation. Which instructions should the nurse teach the client about irrigation? Select all that apply. The client must irrigate a colostomy every day at the same time The client should use 500-1000 ml of warm water to irrigate the colostomy Cold water creates cramping and should be avoided If irrigating the colostomy and cramping occurs, the client should stop the irrigation until cramping subsides The irrigation solution should be raised above the clients shoulder level.
All of the above
Patient comes in with PUD symptoms. What orders does the nurse expect the doctor to order? Select all that apply CBC LFTs CT scan Upper endoscopy with biopsy
All of the above
Which of the following are risk factors for developing a bone fracture? Select all that apply Prolonged bed rest Chronic steroid use Trauma Osteoporosis Child abuse
All of the above
When administering medications to the patient with chronic gout, the nurse recognizes which drug is used as a treatment for this disease? Colchicine Allopurinol Sulfasalazine Cyclosporine
Allopurinol
Which intervention should the nurse perform to relieve stomatitis for a patient experiencing severe side effects of chemotherapy? (select all that apply) Apply topical anesthetics Encourage nutritional supplements Give diuretics and laxatives regularly Encourage oral application of alcohol Discourage the use of irritants like tobacco
Apply topical anesthetics Encourage nutritional supplements Discourage the use of irritants like tobacco
The nurse is caring for a patient with a short leg cast who reports itching and burning inside the cast. Which actions would the nurse perform? Assess capillary refill of the toes Apply ice on the affected leg for 2 days Immobilize joints above and below the cast Report the symptoms to the health care provider Teach the patient to use cool setting of hair dryer for itching
Assess capillary refill of the toes Burning can be a sign of skin irritation or poor neurovascular status. The nurse should assess the capillary refill of the toes to determine the perfusion to the distal extremity. Report the symptoms to the health care provider The nurse should notify the health care provider about the patient's condition because the symptoms may indicate poor neurovascular status. Teach the patient to use cool setting of hair dryer for itching The nurse should teach the patient to use a cool hair dryer setting to treat itching inside the cast
The nurse is caring for a patient who underwent an open hip fracture reduction. The patient reports having pain that radiates down the leg. Which actions should the nurse take? Assess for muscle spasm Administer pain medication Massage the surrounding muscles Assess vital signs and capillary refill Report symptoms immediately to health care provider
Assess for muscle spasm The nurse should assess for muscle spasms in patients who report pain after hip fracture reduction to verify the quality of pain and serve as basis for appropriate intervention. Correct Administer pain medication Pain is a subjective, personal experience. The nurse should treat the patient's pain when reported. Assess vital signs and capillary refill The nurse should assess vital signs and capillary refill when evaluating the pain of a patient after hip fracture reduction to help identify the cause of the pain and determine neurovascular status of the leg.
Which of the following potential complications of pancreatitis should the nurse monitor for? Select all that apply. Hypercalcemia Atelectasis Hypertension Pseudocyst Peritonitis
Atelectasis Pseudocyst Peritonitis
The nurse is caring for a client post bowel diversion surgery with a colostomy. In the first 24 hours, which assessment finding should the nurse report immediately? Abdominal distention Incorrectly fitted faceplate Blue appearance to stoma Mucus oozing from the stoma
Blue appearance to stome
Which conditions can increase the risk for fractures? Select all that apply. Diabetes Bone cyst Hypertension Osteoporosis Metastatic cancer
Bone cyst Osteoporosis Metastatic cancer
A nurse discusses chemotherapy treatment with a patient who has colon cancer. Which body system will the nurse tell the patient is most susceptible to the side effects of the antineoplastic drugs? Lymphatic Respiratory Bone marrow Cardiovascular
Bone marrow
A 42 year old is interested in making dietary changes to reduce the risk of colon cancer. What dietary selection should the nurse suggest? Croissant, granola, peanut butter squares, and whole milk Bran muffin, skim milk, stir-fried broccoli Granola, bagel with cream cheese, cauliflower salad Oatmeal raisin cookies, baked potato with sour cream, turkey sandwich
Bran muffin, skim milk, stir-fried broccoli
A nurse is reviewing the medical history of a patient with a pathologic fracture of the hip. Which condition may be a cause for the fracture of this patient? Breast cancer Lactose intolerance Rheumatoid arthritis Systemic lupus erythematosus (SLE)
Breast cancer Cancer can cause a decrease in bone density and increase the risk for pathologic fractures.
Which precautions would the nurse follow while caring for a patient with both hepatitis A and hepatitis B infections? (select all that apply) Keep the patient in a private room, and close the door Carefully dispose of the needles and syringes used for the patient Wear gloves while handling articles contaminated by urine & feces Always wear a mask, gown, and gloves when entering patient's room Follow procedures while injecting the patient and avoid getting stuck by the used needle
Carefully dispose of the needles and syringes used for the patient Wear gloves while handling articles contaminated by urine & feces Follow procedures while injecting the patient and avoid getting stuck by the used needle
Which of the following increases an individual's risk for developing osteoporosis? Select all that apply. Caucasian or Asian ethnicity Long-term use of corticosteroids Increased estrogen levels Male gender Celiac disease
Caucasian or Asian Ethnicity Long-term use of corticosteroids Celiac disease
The nurse is caring for a patient who is scheduled for a liver biopsy. Which interventions are appropriate to be included in the patient's plan of care? (select all that apply) -Check the bleeding time -Check the prothrombin time -Instruct the patient to avoid red meat for the 48 hours before the test -Maintain NPO status for 8 hours before the test -Instruct the patient to expire fully and not breathe when the needle is inserted
Check the bleeding time Check the prothrombin time Maintain NPO status for 8 hours before the test Instruct the patient to expire fully and not breathe when the needle is inserted
Which pain or discomfort is most associated with gastroesophgeal reflux disease (GERD)? Select all that apply. Chest Scapula Lower Jaw Substernal Epigastric
Chest Epigastric
A 42-year-old female client arrives in the emergency department exhibiting RUQ pain radiating to the right shoulder, chills, tachycardia, and vomiting. The nurse suspects the client will be diagnosed with which condition? Cholecystitis Pancreatitis Ulcerative colitis Crohn's disease
Cholecystitis
The nurse is performing discharge teaching to a client who was diagnosed with acute pancreatitis. Which symptom of pancreatitis should the client report to the health care provider (HCP)? Abdominal tenderness Weight gain Foamy urine Clay-colored stools
Clay-colored stools
Which symptom would cause the nurse to suspect a fat embolism in the client with a fractured left femur? Client reports leg pain as 9/10 Pedal edema +2 in left leg Client restless and trying to get out of bed Swelling and bruising noted on left thigh
Client restless and trying to get out of bed
The nurse understands a bowel prep is required for the following procedures. Select all that apply Colonoscopy EGD sigmoidoscopy GI series
Colonoscopy Sigmoidoscopy GI series
A patient with a leg fracture is scheduled for a fasciotomy. Which complication is identified as having caused the need for this type of surgery? Infection Fat embolism syndrome Compartment syndrome Venous thromboembolism
Compartment syndrome
A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing which complication? Osteomyelitis A fat embolism A pressure ulcer Compartment syndrome
Compartment syndrome
The nurse provides discharge instructions for a patient who has undergone total hip arthroplasty. Which statement by the patient indicates understanding of the instructions? "I'll walk at least two miles a day after I get home" "I may go back to work as soon as I feel that I'm able" "I have to do the physical therapy exercises several times a day" "I should take frequent bike rides to increase my activity and joint flexibility"
"I have to do the physical therapy exercises several times a day"
The nurse is caring for a patient with a suspected arm fracture. The nurse notes an increased risk for fracture based on which patient statement? "I am a strict vegetarian." "I have two pet dogs at home." "I use daily inhaled steroids for asthma." "I worked out 3 or 4 times a week before the injury."
"I use daily inhaled steroids for asthma."
Which statement made by the patient indicates the need for further teaching about laparoscopic cholecystectomy? "Small punctures will be made in my abdomen" "I may be discharged the same day as the surgery" "I will have work restrictions for six weeks after surgery" "An instrument with a camera will be inside my abdomen"
"I will have work restrictions for six weeks after surgery"
Which statement by the student nurse indicates understanding of treatment for acute osteomyelitis? "Oral antibiotics often are required for several months" "IV antibiotics are usually required for several weeks" "Surgery is almost always necessary to remove the dead tissue that is likely to be present" "Drainage of the foot and instillation of antibiotics into the affected area is the usual therapy"
"IV antibiotics are usually required for several weeks"
Which statement made by the patient on chemotherapy with a low platelet count requires further nursing education? "Playing football with my kids makes me feel normal" "I will use a soft toothbrush to brush with" "I am taking a stool softener everyday" "I have stopped taking a daily baby aspirin"
"Playing football with my kids makes me feel normal" (physical activity is good BUT any sports that cause contact needs to be avoided; the pt with low platelets are at risk for bleeding)
A patient with osteomyelitis undergoes surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers (select all that apply) -"Oral or IV antibiotics are not effective in most cases of bone infection." -"The beads are an adjunct to debridement and antibiotics for deep infections." -"The beads are used to deliver antibiotics directly to the site of the infection." -"This is the safest method to deliver long-term antibiotic therapy for bone infection." -"Ischemia and bone death related to osteomyelitis are impenetrable to IV antibiotics."
"The beads are an adjunct to debridement and antibiotics for deep infections." "The beads are used to deliver antibiotics directly to the site of the infection."
Which instructions would the nurse include in a teaching plan for a patient with mild gastroesophageal reflux disease (GERD)? a. "The best time to take an as-needed antacid is 1 to 3 hours after meals." b. "A glass of warm milk at bedtime will decrease your discomfort at night." c. "Do not chew gum; the excess saliva will cause you to secrete more acid." d. "Limit your intake of foods high in protein because they take longer to digest."
"The best time to take an as-needed antacid is 1 to 3 hours after meals."
A client recently diagnosed with hepatitis C states: "now that you know what is wrong with me, you can just get me those new drugs to take care of it right?" The nurse should tell the client: -"The treatment is complex. There are new antiviral drugs available that may make treatment more effective and can help you tolerate it better" -"There are drugs to help with the symptoms, but once you have hepatitis C you will never be cured" -"The medicine currently used to treat hepatitis C is very expensive, and your insurance probably will not pay for it" -"If you continue to make the same lifestyle choices the medicine will not make any difference"
"The treatment is complex. There are new antiviral drugs available that may make treatment more effective and can help you tolerate it better"
The nurse provides care one day after a patient underwent an amputation just below the level of the elbow. The patient reports a sensation of pain in the missing portion. How does the nurse respond? "You are having illusions" "This is fairly common" "You are having hallucinations" "You are experiencing delusions"
"This is fairly common"
Which teaching will the nurse include regarding skincare following radiation therapy? (select all that apply) "You may wash off the markings used to guide the radiation" "Use a gentle soap to wash the irradiated area" "Use a washcloth, not your hand, to wash the area" "Do not expose the area to sunlight" "Soft clothing is suggested" "Do not apply heating pads to the area"
"Use a gentle soap to wash the irradiated area" "Do not expose the area to sunlight" "Soft clothing is suggested" "Do not apply heating pads to the area" **use hand to wash the area NOT washcloth**
Which dietary advice will the nurse give a patient after a cholecystectomy? (select all that apply) Eat a high-fiber diet Limit intake of water Use the same diet as before Have small but frequent meals Avoid or keep fats to a minimum
eat a high-fiber diet have small but frequent meals avoid or keep fats to a minimum
A patient with a humeral fracture is returning for a 4-week checkup. The nurse explains that initial evidence of healing on x-ray is indicated by formation of callus complete bony union hematoma at the fracture site presence of granulation tissue
formation of callus
The nurse assists the patient who has undergone bariatric surgery in making dietary selections. Which types of food items are recommended? High protein High carbohydrate High fat High roughage
high protein
The nurse teaches the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes hip flexion contracture clot formation at the incision. skin irritation and breakdown. increased risk for wound dehiscence.
hip flexion contracture
Which criteria must be met for a diagnosis of metabolic syndrome? (select all that apply) a. Hypertension b. High triglycerides c. Elevated plasma glucose d. Increased waist circumference e. Decreased low-density lipoproteins
hypertension high triglycerides elevated plasma glucose increase waist circumference
What suggestion may the nurse make for a client with a left arm cast to keep the left shoulder from becoming stiff and frozen? A. Lift the left arm up over the head B. Lift the right arm up over the head C. Make a fist with the left hand D. Use a sling on the left arm
lift the left arm over the head
The best nutritional therapy plan for a person who is obese a. is high in animal protein. b. is fat-free and low in carbohydrates. c. restricts intake to under 800 calories per day. d. lowers calories with foods from all the basic groups.
lowers calories with foods from all the basic groups
A patient with extreme obesity has undergone Roux-en-Y gastric bypass surgery. In planning postoperative care, the nurse anticipates that the patient a. may have severe diarrhea early in the postoperative period. b. will not be allowed to ambulate for 1 to 2 days postoperatively. c. will require nasogastric suction until the drainage is pale yellow. d. may have limited amounts of oral liquids during the early postoperative period.
may have limited amounts of oral liquids during the early postoperative period
The nurse assesses an elderly patient who reports abdominal pain. Which assessment finding may indicate a serious gastrointestinal (GI) disorder? Loss of appetite A slow metabolic rate Diminished sense of smell Melena
melena
A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when -the patient is unable to tolerate prolonged immobilization -the patient cannot tolerate the surgery for a closed reduction -other nonsurgical methods cannot achieve adequate alignment -a temporary cast would be too unstable to provide normal mobility
other nonsurgical methods cannot achieve adequate alignment
A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the provider of possible early compartment syndrome when the patient has increased edema of the limb muscle spasms of the lower arm bounding pulse at the fracture site pain when passively extending the fingers
pain when passively extending the fingers
A complication of a small bowel obstruction is due to pressure build-up behind the small intestine. The perforation of the bowel is called: peritonitis embolism atelectasis edema
peritonitis
The nurse is teaching the patient and family that peptic ulcers are a. caused by a stressful lifestyle and other acid-producing factors, such as H. pylori. b. inherited within families and reinforced by bacterial spread of Staphylococcus aureus in childhood. c. promoted by factors that cause over secretion of acid, such as excess dietary fats, smoking, and alcohol use. d. promoted by a combination of factors that cause erosion of the gastric mucosa, including certain drugs and H. pylori.
promoted by a combination of factors that cause erosion of the gastric mucosa, including certain drugs and H. pylori
Following an endoscopy, the client is told they have Barrett's esophagus without dysplasia due to uncontrolled gastroesophageal reflux disease. Which is the priority for this client? Endoscopic resection Immediate cryotherapy procedure One month endoscopic followup Proton pump inhibitors treatment
proton pump inhibitors treatment
A patient with osteoarthritis is scheduled for total hip arthroplasty. The nurse explains the purpose of this procedure is to (select all that apply) fuse the joint. replace the joint. prevent further damage. improve or maintain ROM. decrease the amount of destruction in the joint.
replace the joint improve or maintain ROM
Teaching in relation to home management after a laparoscopic cholecystectomy should include a. keeping the bandages on the puncture sites for 48 hours. b. reporting any bile-colored drainage or pus from any incision. c. using over-the-counter antiemetics if nausea and vomiting occur. d. emptying and measuring the contents of the bile bag from the T tube every day.
reporting any bile-colored drainage or pus from any incision
Which subjective description of pain would the nurse expect from a patient who has cholecystitis? Left-flank pain with intermittent exacerbations Right lower-quadrant pain with rebound tenderness Right upper-quadrant pain radiating to the should and scapula Epigastric-area pain that intensifies when patient is lying down
right upper-quadrant pain radiating to the shoulder and scapula
Which diagnostic test is utilized to diagnose cholecystitis? x-ray of abdomen ultrasound of abdomen MRI of abdomen colonoscopy
ultrasound of abdomen
A patient reports hematemesis and burning pain in the stomach. The nurse suspects peptic ulcer disease and anticipates that which diagnostic test will be prescribed? Colonoscopy Upper gastrointestinal (GI) study Abdominal ultrasound MRI
upper gastrointestinal (GI) study
A patient who is scheduled for gastric bypass surgery asks for information about dumping syndrome. How does the nurse explain dumping syndrome? The inability to digest high-fat foods When the passage of food into the small intestine occurs too rapidly A decrease in the secretion of insulin caused by carbohydrates An increase in secretion of both bile and pancreatic enzymes
when the passage of food into the small intestine occurs too rapidly
A patient is hospitalized with a cast on the right leg that is maintained in external traction. While assessing the patient, the nurse finds that the patient has compartment syndrome. The nurse identifies that which interventions are effecting in treating the syndrome? (select all that apply) Cutting the cast in half Reducing external traction weight Removing or loosening any bandage Applying cold compresses to the leg Elevating the affected limb above heart level
Cutting the cast in half Reducing external traction weight Removing or loosening any bandage
What is the pathophysiology of primary gout? An underlying bone marrow disorder Cancer clients receiving chemotherapy Decreased renal excretion of uric acid An open wound usually found on the great toe.
Decreased renal excretion of uric acid
Which nursing intervention will the nurse select for a patient with cancer and dysgeusia? Encourage frequent oral care Discuss alternative seasonings for food Apply lotion to the skin Test the stool for occult blood
Discuss alternative seasonings for food
The client has just been prepared for a bone scan. What education should the nurse provide? A. Report any feelings of nausea or flushing B. Ambulate at least 3 times before the end of the day C. Eat only small meals for the rest of the day D. Drink plenty of water for the next couple of days following the procedure
Drink plenty of water for the next couple of days following the procedure
Which side effect of radiation therapy will the nurse anticipate for a patient who has laryngeal cancer? Nausea Diarrhea Dry mouth Blistering gums
Dry mouth
Which of the following are risk factors for cholelithiasis? Select all that apply. Eating a high-fat diet Obesity with BMI >30 Age over 40 years old Female clients Male clients
Eating a high-fat diet Obesity with BMI >30 Age over 40 years old Female clients
The nurse is receiving a client who will be having chemotherapy and radiation for his tumor. Which of these will the nurse need to implement for this client? Ensure client gets a private room and private bathroom. Make sure the client and staff understand there should be no visitors. Limit time with client by clustering care 30-minutes per shift Educate nursing aides that the client is not to receive any skin irritating products.
Educate nursing aides that the client is not to receive any skin irritating products.
A client is admitted with a possible diagnosis of pancreatitis. Which of the following is a strong indicator for this diagnosis? Pain in the right upper quadrant of the abdomen Elevated lipase and amylase levels Hyperactive bowel sounds Oxygen saturation level of 95%
Elevated lipase and amylase levels
A patient is undergoing a noninvasive electrical bone growth stimulation on a nonunion fracture of the spine after a spinal fusion surgery that was performed 6 months ago. Which action should the nurse take? Check if the electrode is implanted in the bone fragment. Ensure that treatment is administered while patient is sleeping. Assist patient in walking while in treatment for at least three times for 15 minutes. Check if the external power supply is inserted properly through the skin and bone.
Ensure that treatment is administered while patient is sleeping. Electrical bone growth stimulation is typically performed while the patient is sleeping because it takes 10 to 12 hours to complete the procedure.
Which instructions does the nurse give to a patient with a long leg cast to prevent edema and skin breakdown? (select all that apply) Exercise joints above and below the cast Cover the cast with plastic for prolonged periods Remove the padding of the cast after going home Apply ice on the fracture site during the first 24 hours Elevate the leg above the heart on pillow for the first 24 hours
Exercise joints above and below the cast Apply ice on the fracture site during the first 24 hours Elevate the leg above the heart on pillow for the first 24 hours
A patient tells the nurse, "gallstones were removed by passing shock waves into my gallbladder". Which procedure is the patient referring to? Cholecystojejunostomy Pancreaticoduodenectomy Balloon spinchteroplasty Extracorporeal shock-wave lithotripsy (ESWL)
Extracorporeal shock-wave lithotripsy (ESWL)
A client comes to the clinic for an annual exam and asks the nurse what are his risk factors of acquiring gout. The client stated his father has gout and he does not want it. What is the nurse's best response? Select all that apply. Family history of gout Eating a high purine diet Obesity Diabetes A uric acid level below 6 mg/dL
Family history of gout Eating a high purine diet Obesity Diabetes
Which dietary substance would the nurse recommend limiting for a patient with acute cholecystitis? Fat Protein Calcium Carbohydrates
Fat
The nurse is providing discharge education for a patient with a fiberglass cast and includes which information? It must not get wet Remove padding if it is bulky under the cast It will need to be replaced every one to two weeks For itching, direct a hair dryer on a cool setting under the cast
For itching, direct a hair dryer on a cool setting under the cast (fiberglass cast is relatively waterproof; does not require replacement; padding should never be removed)
A patient who fractured the humerus 5 weeks prior presents for a follow-up X-ray. Which result should the nurse expect to find on the X-ray? Soft tissue damage Fracture still evident Joint union complete Distance between bone fragments decreasing
Fracture still evident The patient is expected to be in the ossification stage of healing five weeks after the injury. During this stage, the fracture is still evident on the X-ray.
Serum analysis of uric acid levels is used in the diagnosis of which condition? Gout Scleroderma Osteoarthritis Rheumatoid arthritis
Gout
When preparing a patient for external pelvic radiation treatment, the nurse recognizes that it is essential to take which action? Assessing for enteritis Having the patient empty the bladder Avoiding activities that increase pelvic congestion Applying an abdominal binder to prevent distention
Having the patient empty the bladder
The nurse is triaging a 55-year-old African-American male client with a past history of colon polyps who complains of recent unexplained weight loss, abdominal pain, and change in bowel habits. Which lab study will the nurse want to review based on these symptoms? Urinalysis BUN Hemoglobin Bilirubin
Hemoglobin
After identifying Ms. Fielding's rib fractures, which potential signs and symptoms should the nurse monitor to detect related injuries? Hemoptysis High blood pressure Low oxygen saturation Right lower quadrant pain Random blood sugar of 120
Hemoptysis Low oxygen saturation
The nurse is evaluating lab studies on her newly admitted client. Labs reveal albumin 3.0, calcium 8.1 mg/dL, bilirubin 1.7 mg/dL. She also notes bruising on the client's arms. Based on the findings, which will the nurse suspect? Pancreatic injury Hepatic failure Gallbladder disease Splenic trauma
Hepatic failure
Which type of hepatitis may be diagnosed with an immunoglobin M (IgM) antibody test? Hepatitis A Hepatitis B Hepatitis C Hepatitis D
Hepatitis A
Which clinical manifestations are seen with chronic hepatitis? (select all that apply) Hepatomegaly Low-grade fever Nausea and vomiting Elevated liver enzymes Decreased sense of taste
Hepatomegaly Elevated liver enzymes
A patient with pustules and redness only on the left side of the face may be diagnosed with which skin condition? Furuncle Candidiasis Verruca vulgaris Herpes zoster (shingles)
Herpes zoster (shingles)
The nurse provides care for a patient who is hospitalized with an abdominal mass. Colorectal cancer is suspected. Which factor in the patient's history increases the patient's risk for colorectal cancer? Osteoarthritis History of adenomatous polyps History of lactose intolerance Use of herbs as dietary supplements
History of adenomatous polyps
A patient with a pelvic fracture is non-weight bearing and is unable to ambulate. Which dietary modifications should the nurse anticipate for this patient? Increase dietary fiber Limit oral fluid intake Increase iron-rich foods Increase calcium-rich foods Decrease protein-rich foods
Increase calcium-rich foods The nurse would recommend calcium-rich foods, such as green leafy vegetables, salmon, and sardines with bones, because these foods are necessary for bone growth and healing. Increase dietary fiber The nurse would encourage the patient to eat more fruits and vegetables, which are fiber-rich foods, to help prevent constipation while being immobile.
Which of the following describes the pathophysiology of peptic ulcer disease (PUD)? Increased amount of stomach acid that burns the esophagus, leading to pain and inflammation Increased amount of stomach acid that burns the lining of the stomach, leading to pain and inflammation Increased amount of stomach acid that erodes the gastric lining, creating sores in the esophagus, stomach, and duodenum Increased amount of stomach acid that erodes the lining of the mouth.
Increased amount of stomach acid that erodes the gastric lining, creating sores in the esophagus, stomach, and duodenum
The nurse provides postoperative care for a patient following an external fixation of the tibia. The nurse identifies that it is critical to include which patient assessments? (select all that apply) Indications of infection Manifestations of cast syndrome Pin loosening A Lachman's test Indications of remodeling
Indications of infection Pin loosening
A patient with joint deterioration from osteoarthritis is recommended for a total hip arthroplasty (THA). The patient asks the nurse how this will relieve the discomfort. Which explanation does the nurse give? -It will remove degenerative debris from the joint, allowing for increased mobility and decreased pain -It removes a wedge of bone to restore alignment to the joint, alleviating pain and promoting mobility -It will provide increased mobility for patients with arthritis by reshaping the ball of the femur rather than replacing it -It can provide significant pain relief for patients with joint deterioration from arthritis by replacing the ball-and-socket joint as well as the upper shaft of the femur
It can provide significant pain relief for patients with joint deterioration from arthritis by replacing the ball-and-socket joint as well as the upper shaft of the femur
Which statements by the nurse best explain the advantages of radiation therapy to a patient with breast cancer who is hesitant to undergo radiation? (select all that apply) It helps to prevent the development of lymphedema It helps to relieve pain caused by local or distant recurrence It helps to prevent local and nodal recurrences after mastectomy It helps to prevent local breast cancer recurrences after a breast-conserving surgery It ensures that there are no rashes or other skin changes associated with this surgery
It helps to relieve pain caused by local or distant recurrence It helps to prevent local and nodal recurrences after mastectomy It helps to prevent local breast cancer recurrences after a breast-conserving surgery
A patient with a fracture of the femur is being treated with Buck's traction. How does the nurse explain the functions of Buck's traction to the patient? (select all that apply) It immobilizes the fracture It reduces muscle spasms It reduces injury-related edema It prevents or reduces pain It helps in the union of the fractured bone
It immobilizes the fracture It reduces muscle spasms It prevents or reduces pain
The postprocedure plan of care for a patient who underwent a liver biopsy includes which nursing intervention? Keep an abdominal binder in place over the needle insertion Encourage cough and deep breathing exercises Maintain bed rest for 24 hours Keep the patient side-lying on the right side
Keep the patient side-lying on the right side
The nurse is caring for a patient with skeletal traction for an extremity fracture and takes which actions to maintain the traction? (select all that apply) Keep the weights off the floor Elevate the end of the bed as needed Ensure the weights are secured to the pulleys Confirm that the forces are pulling in the same direction Make sure that the traction ranges from 5-45 lbs Apply the traction intermittently
Keep the weights off the floor Elevate the end of the bed as needed Make sure the traction ranges from 5-45 lbs
A nurse is teaching a client with hepatitis B about home care. Which of the following instructions should be included with the teaching?(select all that apply) Limit physical activity Avoid alcohol Take acetaminophen for comfort Wear a mask when in public spaces Eat small frequent meals
Limit physical activity Avoid alcohol Eat small frequent meals
The nurse is caring for a patient with a right humeral fracture after a skating accident. Which type of splint would the nurse use for this patient? Cylinder Sugar tong Long arm splint Short arm splint
Long arm splint
The nurse is educating a client with acute hepatitis about the proper dietary plan to ensure nutrition. Which of the following diets should the nurse instruct the client to follow? Select all that apply. High protein diet Low protein diet Low fat foods High fat foods Avoid alcohol
Low protein diet Low fat diet Avoid alcohol
Interprofessional care for the management of osteoarthritis (OA) may be utilized for which treatment goals? (select all that apply) Managing pain Curing osteoarthritis Prevention of disability Managing inflammation Improving joint function Reviewing diagnostic labs
Managing pain Prevention of disability Managing inflammation Improving joint function
A patient reports moderate pain and spasm after a left arm injury with suspected fracture due to a fall. Which medication would the nurse anticipate the health care provider to prescribe? Meperidine Nalbuphine Methocarbamol Mefenamic acid
Methocarbamol
The nurse is caring for a patient who reports having severe pain and decreased movement after an ankle dislocation. After verifying the prescription and patient allergies, which medication would the nurse safely administer to this patient? Morphine Cyclobenzaprine Acetaminophen/codeine Oxycodone/acetaminophen
Morphine Morphine, an opioid analgesic, would be administered intravenously to treat the patient's severe pain.
A 65-year-old client is admitted with a small bowel obstruction. Which of the following actions should be implemented after receiving orders from the healthcare provider for treatment? Select all that apply. NPO with insertion of a NG tube Start IV fluids for the client Control pain with nonopioid pain medication Position the client in semi-fowlers Insert a catheter
NPO with insertion of a NG tube Start IV fluids for the client Control pain with nonopioid pain medication Position the client in semi-fowlers
A patient with lung cancer is scheduled for radiation therapy. The nurse educates the patient about which complication associated with this type of cancer treatment? (select all that apply) Fatigue Nausea Anorexia Vomiting Weight loss
Nausea Anorexia Vomiting
When preparing an osteoporosis client's home to help prevent falls, which instructions should the nurse include? Select all that apply. No throw rugs Keep hallways well lit Rubber mat in the shower use furniture to keep balance when ambulating Ambulate frequently with assistive devices
No throw rugs Keep hallways well lit Rubber mat in the shower Ambulate frequently with assistive devices
Which type of medication increases a patient's risk for upper gastrointestinal bleeding? Antacids Anticholinergics Tricyclic antidepressants Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (NSAIDs)
A client had placement of a cast to the right lower extremity 10 minutes ago and is complaining of severe pain and the inability to feel or move the right toes. What should the nurse do immediately? Notify the health care provider Apply a cold compress to the clients toes Administer pain medication Administer oxygen
Notify the health care provider, this could be a sign of compartment syndrome
Which statement best describes the etiology of obesity? a. Obesity primarily results from a genetic predisposition. b. Psychosocial factors can override the effects of genetics in causing obesity. c. Obesity is the result of complex interactions between genetic and environmental factors. d. Genetic factors are more important than environmental factors in the etiology of obesity.
Obesity is the result of complex interactions between genetic and environmental factors
The nurse is caring for a patient with swelling, discoloration, and obvious deformity to the right forearm after a fall. Which order should the nurse anticipate from the health care provider? Administer cephalosporin Prepare for STAT closed reduction Obtain an X-ray of the right arm Obtain a computed tomography (CT) scan of the right arm
Obtain an X-ray of the right arm
After a motor vehicle accident, a patient presents with a deformity to the leg with decreased pedal pulses. The fibula protrudes from the lateral aspect of the leg. How should the nurse classify the fracture? Open Spiral Closed Displaced Incomplete
Open The patient has an open fracture because the fibula protrudes through the skin Displaced The patient has a displaced fracture because one portion of the fibula protrudes through the skin and the ends of the bone are separated and out of their normal position.
Which food suggestion should the nursing preceptor intervene and correct if a novice nurse is teaching a client just diagnosed with gouty arthritis? 2 mugs of regular coffee 2 cups of broccoli florets order of chicken livers couple handfuls of nuts
Order of chicken livers
A nurse is caring for a client newly diagnosed with osteoporosis. Which statements should be included with teaching? Select all that apply. A. Osteoporosis is common in females after menopause. B. Osteoporosis is a degenerative disease characterized by a decrease in bone density. C. The disease is inherited, caused by an inability to tolerate milk products. D. Osteoporosis can cause pain and injury. E. Passive ROM exercises can promote bone growth. F. Weight-bearing exercise would be avoided.
Osteoporosis is common in females after menopause. Osteoporosis is a degenerative disease characterized by a decrease in bone density. Osteoporosis can cause pain and injury.
Patient comes in with a gastric ulcer. The nurse suspects they will have these symptoms. Select all that apply. Pain occurring immediately or 30 to 60 mins after eating Awake with pain at night Weight loss Dull, gnawing pain or burning sensation in the back or epigastric area Pain occurs 2-3 hours after meal Food temporarily relieves pain Pain is worse during day
Pain occurs immediately or 30-60 mins after eating Weight loss Dull, gnawing pain or burning sensation in the back or mid epigastric area Pain is worse during day
The nurse will suggest which action for a patient with osteoarthritis? Limit physical activity in the morning Participate in physical activities Eliminate the use of narcotic analgesics if diarrhea develops Limit pain medications to nonnarcotic drugs to prevent addiction
Participate in physical activities
A patient with a cast for a fractured radius reports, "My fingers feel numb." Which is a priority nursing action? Elevating the arm on two pillows Notifying the health care provider Performing a neurovascular assessment Encouraging the patient to exercise the fingers
Performing a neurovascular assessment (after the assessment - elevate the arm on two pillows)
The nurse prepares discharge education for a patient with a hip fracture who has been treated by insertion of a prosthesis using a posterior approach. Which information does the nurse include in the instructions? (select all that apply) Use low toilet seats and chairs without arms An adaptive device is not necessary for putting on shoes Place a chair inside the tub and remain seated while washing Inform the dentist about the prosthesis before any dental work Keep the hip in neutral, straight position when sitting or lying
Place a chair inside the tub and remain seated while washing Inform the dentist about the prosthesis before any dental work Keep the hip in neutral, straight position when sitting or lying
A client is receiving monthly doses of chemotherapy for treatment of stage III colon cancer. Which results should the nurse report to the oncologist before the next dose of chemotherapy is administered? (select all that apply) Hemoglobin 14.5 Platelet count 40,000 Blood urea nitrogen 12 WBC 2.3 x 10 Temperature 101.2 F Urine specific gravity 1.020
Platelet count 40,000 WBC 2.3 x 10 Temperature 101.2 F
The nurse is caring for a patient with a right leg deformity who reports numbness of the toes and plantar aspect of the foot. On further assessment, the nurse notes no pedal pulse and cool skin. Which action should the nurse take next after notifying the provider? Prepare for reduction and splint Start IV infusion with normal saline Prepare the patient for a STAT X-ray Elevate the right leg and apply ice pack
Prepare for reduction and splint The patient has no pedal pulse and cool skin. Thus, the nurse should anticipate a reduction and splinting procedure to restore perfusion and prevent tissue death of the deformed extremity.
Doxorubicin is prescribed for a female client with breast cancer. The client is distressed about hair loss. What should the nurse do? Have the client wash and massage the scalp daily to stimulate hair growth Explain the hair loss is temporary and will quickly grow back to its original appearance Provide resources for a wig selection before hair loss begins Recommend that the client limit social contacts until hair regrows
Provide resources for a wig selection before hair loss begins
You are caring for a client undergoing chemotherapy treatment for lung cancer. Based on the following lab results, what would the priority nursing diagnosis be? WBC: 9,500; HGB: 14.5; HCT: 42.2%; PLT: 30,000 Risk for infection Risk for bleeding Imbalanced nutrition: Less than body requirements Disturbed body image
Risk for bleeding
Which factors place a patient at higher risk for developing osteoporosis? (select all that apply) Obesity Smoking Asian descent Hyperlipidemia Sedentary lifestyle
Smoking Asian descent Sedentary lifestyle
Which client is at highest risk for colorectal cancer? The client who smokes The client who eats a vegetarian diet The client who has been treated for Crohn's disease for 20 years The client who has a family history of lung cancer
The client who has been treated for Crohn's disease for 20 years
A patient presents at the emergency department and is found to have a closed fracture of the humerus. Which description is consistent with this type of fracture? The skin remains intact. The skin is broken while the bone is exposed. The line of the fracture extends across the bone shaft. The line of the fracture extends in a twisting direction.
The skin remains intact.
While caring for a client receiving brachytherapy for endometrial cancer, the student nurse understands that there are three important factors to consider. Select all that apply. Time spent with the client Recording the amount of exposure Shielding against radiation Distance to the client Providing education to the client
Time spent with the client Shielding against radiation Distance to the client
Which is the only definitive means of diagnosing cancer? Tissue biopsy Mammography Liver function studies CT scan
Tissue biopsy
A patient with a fracture of the femur has the extremitiy in skeletal traction and is encourage to use an overhead trapeze apparatus. Which is the primary purpose of the overhead trapeze? To assist with leg exercises To enhance breathing and lung expansion To promote circulation throughout the body To facilitate independent movement while the patient is in bed
To facilitate independent movement while the patient is in bed
The nurse provides care for a patient with lung cancer who is scheduled to receive radiation therapy before a surgical resection. Which is the rationale for the preoperative treatment? To reduce the tumor mass To relieve dyspnea and hemoptysis To remove lesions obstructing the airway To delay extension of the tumor into the airway lumen
To reduce the tumor mass
Which priority action should the nurse implement when caring for a client with bleeding esophageal varices? Administer morphine Assess for jaundice and amount of ascites Turn the client to a side-lying position Obtain stat liver function test and CBC
Turn the client to a side-lying position
A client who is receiving chemotherapy develops stomatitis. What should the nurse instruct the client to do? Rinse the mouth with full-strength hydrogen peroxide every 4 hours Use a soft-bristled toothbrush after every meal Drink hot tea with honey to soothe the painful oral mucosa Increase flossing until the stomatitis is resolved
Use a soft-bristled toothbrush every meal
Which nursing action is appropriate to improve nutrition for a patient with cancer? Provide large meals so the patient can eat more Avoid the use of high protein shakes Use alternative seasonings for food Encourage NPO until chemotherapy is complete
Use alternative seasonings for food
A nurse is caring for a patient undergoing brachytherapy for prostate cancer. Which actions would the nurse take for protection from radiation hazards? (select all that apply) Use shielding when providing care to the patient Share the film badge with a colleague who doesn't have one Wear the film badge when off duty to indicate your nature of work Organize care to limit the time spent in direct contact with patient Limit close proximity to the patient to only those care tasks that must be performed up closed
Use shielding when providing care to the patient Organize care to limit the time spent in direct contact with patient Limit close proximity to the patient to only those care tasks that must be performed up closed
Following an amputation of the left lower extremity, a patient reports shooting pain and heaviness in the area of the missing leg. The nurse identifies that which intervention may improve the patient's symptoms? Using mirror therapy Administering an opioid analgesic Reapplying the surgical bandage Reminding the patient that the left leg is no longer present
Using mirror therapy
The nurse caring for a patient with suspected acute cholecystitis would anticipate (select all that apply) a. ordering a low-sodium diet. b. administration of IV fluids. c. monitoring of liver function tests. d. administration of antiemetics for patients with nausea. e. insertion of an indwelling catheter to monitor urinary output.
administration of IV fluids monitoring of liver function tests administration of antiemetics for patients with nausea
The obesity classification that is most often associated with cardiovascular health problems is a. primary obesity. b. secondary obesity. c. gynoid fat distribution. d. android fat distribution.
android fat distribution
The teaching plan for the patient being discharged after an acute episode of upper GI bleeding includes information about the importance of (select all that apply) a. limiting alcohol intake to 1 serving per day. b. only taking aspirin with milk or bread products. c. avoid taking aspirin and drugs containing aspirin. d. only taking drugs prescribed by the health care provider. e. taking all drugs 1 hour before mealtime to prevent further bleeding.
avoid taking aspirin and drugs containing aspirin only taking drugs prescribed by the health care provider
The nurse is providing postprocedural care to a patient following a colonoscopy. The nurse reports which assessment finding to the health care provider immediately? Vomiting Blood in the feces Abdominal cramps An urge to defecate
blood in the feces
A patient with a pelvic fracture should be monitored for changes in urine output petechiae on the abdomen a palpable lump in the buttock sudden increase in blood pressure
changes in urine output
The nurse notes that a patient is scheduled for gallbladder removal. Which name for the procedure will be on the consent form? Splenectomy Cholecystectomy Cholecystojejunostomy Pancreaticoduodenectomy
cholecystectomy
Health risks associated with obesity include (select all that apply) a. colorectal cancer. b. rheumatoid arthritis. c. polycystic ovary syndrome. d. nonalcoholic steatohepatitis. e. systemic lupus erythematosus.
colorectal cancer polycystic ovary syndrome nonalcoholic steatohepatitis
Which injuries are susceptible to compartment syndrome? Select all that apply. Fractured rib Orbital fracture Upper arm fracture Basilar skull fracture Third-degree ankle strain
-Upper arm fracture -Third-degree ankle strain
A newborn baby has sustained an uncomplicated midshaft fracture of the femur. In how many weeks will the fracture heal? Record your answer as a whole number. 1 3 weeks 2 7 weeks 3 10 weeks 4 20 weeks
1
The nurse is caring for a patient with a fracture who has a Buck's traction boot in place. Which complication is prevented by the use of the boot? 1 Muscle spasms 2 Posttraumatic arthritis 3 Intraarticular adhesions 4 Extraarticular adhesions
1
A patient with a peptic ulcer beings vomiting. Which type of vomitus is associated with bleeding in the stomach? Fecal Bilious "Coffee ground" Undigested food
"Coffee ground"
Which statement shows the client understands discharge instructions after arthroscopy of the left knee? A. "I can bear weight on my left leg as tolerated" B. "I can resume my regular exercise tomorrow" C. "I should refrain from eating yogurt this evening" D. "I should report only fever with inflammation to my physician"
"I can bear weight on my left leg as tolerated"
Which statement made by a patient who underwent a bariatric surgery indicates the need for further teaching about steps to maintain proper weight? "I should reduce carbohydrates in my diet" "I should limit cheese and butter in my diet" "I should drink plenty of fluids with my meals" "I should increase the protein content in my diet"
"I should drink plenty of fluids with my meals"
The nurse is caring for a patient with adenocarcinoma. Which statement made by the patient demonstrates an understanding of the condition? "It is the most common cancer in nonsmokers" "It is the most malignant form of lung cancer" "It is associated with endocrine disturbances" "It does not have a strong tendency to metastasize"
"It is the most common cancer in nonsmokers"
Which signs and symptoms would the nurse find in a patient with compartment syndrome? Select all that apply. Erythema 1+ pulses Warmth at the affected site Pain not relieved by morphine Tingling sensation of the fingers
-1+ pulses -Pain not relieved by morphine -Tingling sensation of the fingers
A patient with an upper arm fracture is diagnosed with compartment syndrome. After the health care provider cuts the cast, the nurse notes continued swelling, absent radial pulse, pallor, and cool skin. Which initial action should the nurse take? Begin preoperative checklist Raise the fractured arm above the head Obtain samples for urinalysis and serum creatinine Continue doing the neurovascular examination until patient is stable
-Begin preoperative checklist
The registered nurse teaches a student nurse about care of a patient with a fracture of the humerus, compartment syndrome, and a plaster cast in place. The student nurse provides discharge education to the patient. Which statement made by the student nurse needs correction? 1 "Elevate the extremity above the heart level." 2 "Use a hair dryer on a low setting to dry the cast thoroughly." 3 "Avoid covering the cast with plastic for extended periods of time." 4 "Control the itching sensation by using a hair dryer on a cool setting at the site of itching."
1
The nurse is caring for the patient with skeletal traction for an extremity fracture. What action(s) by the nurse are most appropriate? Select all that apply. 1 Keep the weights off of the floor. 2 Elevate the end of the bed as needed. 3 Ensure that the weights are secured to the pulleys. 4 Confirm that the forces are pulling in the same direction. 5 Make sure that the traction ranges from 5 to 45 pounds (2.3 to 20.4 kg). 6 Apply the traction intermittently as prescribed by the health care provider (HCP).
1, 2, 5
What instructions should be given to a patient with a cast to prevent edema and skin breakdown? Select all that apply. 1 Exercise joints above and below the cast. 2 Cover the cast with plastic for prolonged periods. 3 Remove the padding of the cast after going home. 4 Apply ice on the fracture site during the first 24 hours. 5 Elevate the affected limb above heart level during the first 48 hours.
1, 4, 5
A nurse is attending a patient who has sustained a fracture of the femur. What interventions should the nurse perform to ensure a healthy diet for optimal healing of the injured tissues? Select all that apply. 1 Include 1g/kg of protein daily. 2 Include foods rich in vitamins C and D. 3 Increase calcium-rich foods in the diet. 4 Decrease the intake of foods rich in B vitamins. 5 Decrease magnesium- and phosphorus-rich foods.
1,2,3
Which factor makes women more prone to osteoporosis than men? Greater bone mass Earlier bone resorption High-impact aerobic Bisphosphonates intake
Earlier bone resorption
A 43-year-old female client underwent a laparoscopic cholecystectomy 8 hours ago. Which of the following actions should be implemented postoperatively? Select all that apply. Early ambulation Turn, cough, and deep breathing exercises Assess the incision sites for redness and swelling Assist the client to take bath in the unit tub Consult OT to assist with ADLs
Early ambulation Turn, cough, and deep breathing exercises Assess the incision sites for redness and swelling
What is the patient teaching for PUD?
Eat 3 regular meals a day, limit coffee caffeine and alcohol, avoid extremely hot or cold foods, keep food diaries, avoid NSAIDs, take antacids 1-3 hours after meals, report and bleeding or tarry stools, quit smoking
What is the normal lab value for ammonia?
10-80
The nurse teaches a student nurse about traction. Which statement made by the student nurse reflects effective learning? 1 "Traction prevents active and passive exercise." 2 "Traction provides immobilization to the joint or body part." 3 "Traction decreases the joint space before a major joint reconstruction." 4 "A Buck's traction boot is a type of skeletal traction."
2
What action should a nurse implement to prevent foot drop in a patient who has a full-leg cast? 1 Encourage bed rest 2 Support the foot with 90 degrees of flexion 3 Maintain the foot in a boot with 45 degrees of flexion 4 Place an antiembolic garment on the affected leg and foot.
2
Which condition may require a patient's scheduled percutaneous liver biopsy to be rescheduled? (select all that apply) Chronic hepatitis Hepatic cirrhosis Bleeding disorder Autoimmune hepatitis Low hemoglobin level
Bleeding disorder Low hemoglobin level
Which is the priority laboratory result to report to the health care provider for a patient with possible osteomyelitis? Rheumatoid factor: negative Blood culture: positive for S. aureus Alkaline phosphatase: 60 IU/L ESR: 10 mm/hour
Blood culture: positive for S. aureus
A patient sustains a femoral shaft fracture. The nurse identifies that the patient is at risk for which complications? (select all that apply) Rhabdomyolysis Fat embolism syndrome (FES) Nerve and vascular damage Problems associated with bone fusion Soft tissue damage Open fracture
Fat embolism syndrome (FES) Nerve and vascular damage Problems associated with bone fusion Soft tissue damage Open fracture
Which of the following are risk factors of gastroesophageal reflux disease (GERD)? A BMI greater than 30 Sitting up after meals Elevating the head of the bed at night Eating a meal 3 hrs before bed
A BMI greater than 30
A patient with a leg fracture is scheduled for a fasciotomy. What complication is identified to have caused the need for this type of surgery? 1 Infection 2 Fat embolism syndrome 3 Compartment syndrome 4 Venous thromboembolism
3
The nurse is caring for a patient who has hepatitis C. Which nutritional interventions would the nurse plan? (select all that apply) Avoid serving very hot or very cold foods Provide the patient with liquid foods, such as soups Provide the patient with only raw foods, such as fruits & salads Ensure that the patient drinks at least 2500-3000 mL of water daily Ensure that the patient has a good breakfast & small frequent meals
Avoid serving very hot or very cold foods Ensure that the patient drinks at least 2500-3000 mL of water daily Ensure that the patient has a good breakfast & small frequent meals
Which suggestions would the nurse include when teaching a patient about the prevention of breast cancer? (select all that apply) Avoid smoking Avoid exposure to harmful radiation Increase the use of oral contraceptives Avoid gaining excess weight during adulthood Use combined hormone therapy after menopause
Avoid smoking Avoid exposure to harmful radiation Avoid gaining excess weight during adulthood
A patient diagnosed with compartment syndrome begins to complain of left flank pain. The nurse notes dark red urine. Which action would the nurse take to manage this patient's symptoms? Increase fluid intake Provide a cold compress Elevate the affected limb above the head Increase traction weight on the affected limb
Increase fluid intake
The nurse is providing discharge education to a patient with a fiberglass cast. What should the nurse be sure to include with the education? 1 It must not get wet. 2 The fiberglass is heavier than a plaster cast. 3 It has to be replaced every one to two weeks. 4 Skin irritation is more common than with a plaster cast.
4
The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient? 1 Administer enoxaparin 2 Provide range of motion exercises 3 Apply sequential compression boots 4 Immobilize the fracture preoperatively
4
What is the normal lab values for albumin?
3.5-5 g/dL
Which instructions would the nurse give when teaching a patient about prevention of peptic ulcers? (select all that apply) -Avoid smoking -Consume raw, uncooked food -Use nonsteroidal anti-inflammatory drugs (NSAIDs) for treatment of pain -Wash hands thoroughly with soap after using the restroom and before eating -Report symptoms of gastric irritation, such as nausea and epigastric pain, to the health care provider
Avoid smoking Wash hands thoroughly with soap after using the restroom and before eating Report symptoms of gastric irritation, such as nausea and epigastric pain, to the health care provider
A client is brought by ambulance to the emergency department with continuous nausea, vomiting, abdominal distention, and colicky intermittent abdominal pain. The nurse suspects the client has which of the following? A small bowel obstruction A large bowel obstruction Gallstones Stomach virus
A small bowel obstruction
What is the normal lab value for bilirubin?
<1
When caring for a patient with a right leg fracture, the patient reports pain not relieved by analgesic and tingling of the toes. The nurse also notes diminished pedal pulses and swelling above the dressing. Which action should the nurse take? Loosen the dressing Maintain the traction weight Prepare for emergency decompression Immediately inform the health care provider
Loosen the dressing
Which interventions will the nurse include in the plan of care for a patient with gout? (select all that apply) Encourage weight gain Provide warm compresses Decrease joint mobilization Encourage increased oral water intake Encourage intake of spinach, mushroom, and cauliflower
Provide warm compresses Decrease joint mobilization Encourage increased oral water intake
Which instructions should be given to the client with a leg cast? Select all that apply A. Avoid walking on wet, slippery floors B. You may wipe dirt off the cast with a damp cloth C. Do not scratch the skin underneath the cast D. If the cast gets wet, dry it with a hair dryer on the warm setting E. I should report severe pain that is unrelieved by pain medications to my physician ASAP
Avoid walking on wet, slippery floors You may wipe dirt off the cast with a damp cloth Do not scratch the skin underneath the cast I should report severe pain that is unrelieved by pain medications to my physician ASAP
Which lifestyle changes may help to prevent osteoarthritis? (select all that apply) Avoiding alcohol Avoiding smoking Avoiding heavy lifting Maintaining a healthy weight Promptly treating any joint injury Sliding objects rather than lifting them
Avoiding smoking Maintaining a healthy weight Promptly treating any joint injury
Which action does the nurse take to prevent footdrop in a patient who has a long leg cast? Encourage bed rest Apply a splint to keep the foot in a neutral position Maintain the foot in a boot with 45 degrees of flexion Place an antiembolic garment on the affected leg and foot
Apply a splint to keep the foot in a neutral position
A client is admitted for acute pancreatitis. Which symptoms will the nurse expect the client to demonstrate? Flu-like symptoms of malaise and fatigue Indigestion, belching, and flatulence Intense abdominal pain at McBurney's point Abdominal pain with radiation to the back
Abdominal pain with radiation to the back
This bariatric surgical procedure involves creating a gastric pouch that is reversible, and no malabsorption occurs. Which surgical procedure is this? a. Vertical gastric banding b. Biliopancreatic diversion c. Roux-en-Y gastric bypass d. Adjustable gastric banding
Adjustable gastric banding
What are normal lab values for amylase/lipase?
Amylase <120 Lipase <160
Which dietary selection is most appropriate for the patient with cancer? An omelet with bacon, ham, and spinach Chips and salsa with avocado Spaghetti with marinara sauce Grilled cheese with French fries
An omelet with bacon, ham, and spinach (most protein & caloric density)
Which information will the nurse include in discharge teaching for a patient with cancer? (select all that apply) Avoid large crowds Take aspirin to prevent blood clots You may continue to play soccer Protein shakes can be used to increase protein intake Inspect your mouth daily Do not reuse cups or dishes without washing them
Avoid large crowds Protein shakes can be used to increase protein intake Inspect your mouth daily Do not reuse cups or dishes without washing them
A client is being discharged to a rehab facility following a hip replacement because of degenerative arthritis. When reporting to the LPN, which nursing actions would the nurse stress as essential. Select all that apply. A.Place the client in high Fowler's position. B.Avoid any hip flexion exercises. C.Place two pillows between the client's knees. D.Place a raised toilet seat in the bathroom. E.Keep the client's feet elevated. F.Maintain the client on bed rest until the incision heals.
Avoid any hip flexion exercises Place two pillow between the client's knees Place a raised toilet seat in the bathroom
A nurse is preparing discharge instructions for an AKA client. Which instructions would be a priority for home care? Select all that apply. A. Massage the residual limb in a motion away from the suture line. B. Avoid using heat application to ease pain. C. Immediately report twitching, spasms, or phantom limb pain. D. Avoid exposing the skin around the residual limb to excessive perspiration. E. Be sure to perform the prescribed exercises. F. Rub the residual limb with a dry washcloth for 4 minutes three times daily if the limb is sensitive to the touch.
Avoid exposing the skin around the residual limb to excessive perspiration Be sure to perform the prescribed exercises Rub the residual limb with a dry washcloth for 4 minutes three times daily if the limb is sensitive to the touch
Which finding is normal for a client during the icteric phase of hepatis A? Tarry stools Yellowed sclerae Shortness of breath Light, frothy urine
Yellowed sclerae
Malaise and weakness in a patient receiving multidrug chemotherapy 10 days ago can be assessed with which laboratory test? Urinalysis Liver function tests Basic metabolic panel Complete blood count
Complete blood count
Which manifestation can be seen in a patient with a third-degree back strain? Mild edema Pain and pallor Active bleeding Complete loss of function
Complete loss of function
Which nursing intervention would improve the comfort of a patient with herpes zoster? Direct sunlight Dry heating pad Cool, wet dressing Petroleum jelly to lesions
Cool, wet dressing
The nurse is caring for a patient who has swelling on the right forearm after a fall. Which order by the health care provider should the nurse anticipate next? Obtain STAT X-ray Administer intravenous morphine Apply warm compress on the right forearm Start intravenous (IV) infusion with normal saline
Obtain STAT X-ray
Which intervention will the nurse select to prevent mucositis? Administering antiemetics Oral cryotherapy Limiting visitors Avoiding sunlight
Oral cryotherapy
The nurse is caring for a patient after an open reduction of a hip fracture that requires immobilization. Which form of immobilization would the nurse anticipate? Skin traction Skeletal traction Internal fixation External fixation
Skeletal traction Skeletal traction involves the insertion of pins or screws into the bone, and is frequently used in hip and femur fractures.
The nurse is providing postoperative care two days after a patient underwent surgical repair of a fractured hip. Which assessment finding indicates the need for immediate nursing action? Pain at the surgical site Sudden shortness of breath Serosanguineous wound drainage Limited range of motion of the affected leg
Sudden shortness of breath
Which signs and symptoms would be expected in a patient who has a first-degree ankle sprain? Tenderness Severe pain Loss of function Minimal swelling Diminished pulses
Tenderness Minimal swelling
Which assessment would the nurse obtain prior to administering a second round of chemotherapy for a patient with breast cancer? Memory Vitamin B level Skin for breakdown White blood cell count
White blood cell count
The nurse witnesses a client who fell and sustained a compound fracture to the left arm. Which nursing intervention is the priority to take with this type of fracture? Wrap the fractured arm with a compression bandage Attempt to manually reduce the fracture Keep the fractured arm below the heart Wrap the fracture with a sterile gauze and kerlix
Wrap the fracture with a sterile gauze and kerlix
A severely obese patient has undergone Roux-en-Y gastric bypass (RYGB) surgery. The nurse monitors for dumping syndrome, which is characterized by which symptoms? (select all that apply) Diarrhea Sweating Faintness Constipation Nausea and vomiting
diarrhea sweating faintness nausea and vomiting
The nurse suspects a neurovascular problem based on assessment of exaggeration strength with movement increased redness and heat below the injury decreased sensation distal to the fracture site purulent drainage at the site of an open fracture
decreased sensation distal to the fracture site
In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes are often red, swollen, and tender indicate osteophyte formation at the PIP joints. are the result of pannus formation at the DIP joints. occur from deterioration of cartilage by proteolytic enzymes
indicate osteophyte formation at the PIP joints
Which information would the nurse include when teaching a student nurse about an open cholecystectomy? Insertion of a T-tube following surgery Insertion of a needle into the core of the tumor Resection of the proximal pancreas and duodenum Administration of an embolic agent through a catheter
insertion of a T-tube following surgery
Which condition is the most common cause for hematemesis? Thalassemia Sickle cell disease Pernicious anemia Peptic ulcer disease
peptic ulcer disease
Which of the following is used in the process of diagnosing gout? Serum glucose x-rays Urinalysis Serum uric acid
serum uric acid