Test 5 MedSurg
What is the primary purpose of a whirlpool bath given to the patient with a stage III pressure ulcer? a. To prevent infection b. To stimulate granulation tissue growth c. To improve circulation in surrounding skin d. To provide moisture to the ulcer
B.
When caring for a patient who has an abductor wedge in place after a total hip replacement, for which finding should the nurse assess? a. Muscle spasms b. Alteration in peripheral circulation c. Compression fracture d. Appropriateness of the size of the wedge
B.
When the patient returns to the unit from having had an arthrogram, which intervention should the nurse perform first? A. Ambulate the patient in the room. B. Apply ice packs to the knee. C. Perform passive range-of-motion (ROM) exercises. D. Wrap the knee in an elastic bandage.
B.
Which intervention is most important for a person who is in a wheelchair for long periods? a. Reposition self every 2 hours. b. Lift weight on the arms of the chair every 15 minutes. c. Massage bony prominences of the buttocks and hips. d. Use a donut device to keep weight off of the buttocks.
B.
The nurse is instructing a patient with rheumatoid arthritis about a prescribed exercise program. Which information should the nurse include? a. Perform exercises every day, 3 to 10 times for every joint. b. Perform exercises even if inflammation is present. c. Perform exercises past the point of pain. d. Perform twice the number of exercises the next day if one day is missed.
A.
The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change? A. Morphine sulfate B. Sertraline (Zoloft) C. Zolpidem (Ambien) D. Enoxaparin (Lovenox)
A.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A.Return of distal pulses B.Brisk bleeding from the site C.Decreasing edema formation D.Formation of granulation tissue
A.
The nurse is assessing the patient's crutches. Which observation confirms that the crutches are sized correctly? A. the crutches are the same height as the patient's shoulders B. the crutches are approximately 12 inches shorter than the patient's shoulders C. the crutches are approximately 16 inches shorter than the patient's height D. the crutches are tall enough to allow the patient's arms to be fully extended when walking
C.
The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? A. Out-of-bed activities B. Bathroom privileges C. Immobilization of the affected leg D. Placing the affected leg in a dependent position
C.
Which factor(s) could increase the risk for skin tears in a 90-year-old resident? (select all that apply.) a. Incontinence b. Bruised areas c. Obesity d. Prolonged use of corticosteroids e. History of congestive heart disease
B, D, E
A patient with psoriasis is placed on PUVA therapy. What factors compose this therapy? A. Radiation and corticosteroids b. X-rays and methotrexate c. Artificial ultraviolet (UV) rays and a coal tar product d. Laser treatment and antimetabolites
C.
Positioning and range-of-motion (ROM) exercises most help the immobilized patient to prevent which complication? A. increased pain B. Contractures C. pressure ulcers D. compromised circulation
B.
An adult male patient enters the emergency department with full- and partial-thickness burns on the entire right leg, front of the right arm, and one half of the front torso. The nurse, using the "rule of nines," assesses the burn as ____%.
31%
An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?
36%
Using the Parkland formula, the fluid needed for a person weighing 140 pounds with a 25% burn would be _____ mL.
6,360
An 86-year-old resident struck her forearm on a table, causing a category I L-shaped skin tear 6 cm × 2 cm. Which action(s) is/are appropriate for the nurse to take? (select all that apply.) a. Clean the tear with alcohol. b.Approximate the edges of the tear. c. Secure the skin flap with Steri-Strips. d. Cover with a nonadherent dressing. e. Assess closely for 5 days for signs of infection.
B, C, D, E
The nurse is caring for a patient who has experienced a fat embolism. Which intervention has the greatest priority for this patient? a) Place the patient in semi Fowler's position. b) Decrease intravenous fluid infusion rate. c) Encourage coughing and deep-breathing. d) Administer oxygen.
D.
The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (select all that apply) A. Urine output is 80 mL/hour. B. Heart rate is 86 beats/minute. C. Urine specific gravity is 1.025. D. Mean arterial pressure is 54 mm Hg. E. Systolic blood pressure is 88 mm Hg.
A, B, C
Which age-related change(s) occur(s) in the integumentary system? (select all that apply.) a. Elastic fibers and adipose tissue diminish. b. Skin thins and becomes transparent. c. Hair thickens as follicles decrease. d. Skin becomes dry. e. Thinned skin leads to cold intolerance.
A, B, D, E
The patient is returning to the unit with a wet long leg cast. To prevent damage to the wet cast, what action(s) should the nurse take? (select all that apply.) A. Determine the cast material. B. Prop the casted limb on a footboard and elevate it until the cast is dry. C. Support the cast with the palms of the hands rather than holding it with the fingers. D. Assess heat generated from the drying cast. E. Explain that the cast has dried when it acquires a grayish color.
A, C, D
A patient presents to the emergency department immediately after an injury. An x-ray has been ordered for a suspected dislocation. Before confirmation by x-ray, which finding(s) support the potential diagnosis? (select all that apply.) A. History of forceful injury B. Purple-black hematoma over joint C. Severe pain, aggravated by motion D. Muscle spasm E. Abnormal appearance of joint
A, C, D, E
The nurse is educating patients about dietary selections that will promote wound healing. Which menu options should the nurse include? (select all that apply.) a. Tofu b. White bread c. Lean beef d. Citrus fruits e. Leafy green vegetables
A, C, D, E
A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. A. Restrict fluids. B. Assess for airway patency. C. Administer oxygen as prescribed. D. Place a cooling blanket on the client. E. Elevate extremities if no fractures are present. F. Prepare to give oral pain medication as prescribed.
B, C E
Soft-tissue injuries require the nurse to assist with or instruct about the importance of which components of care? (select all that apply.) a. Bed rest b. Pain control c. Immobilization d. Activity restrictions e. Prevention of recurrence
B, C, D, E
Which age-related change(s) occur(s) in the musculoskeletal system? (select all that apply.) a. Increased bone density b. Increased brittleness and fragility of bones c. Decreased healing times d. Decreased muscle mass e. Tendon sclerosis
B, C, D, E
The nurse is performing morning care for a patient who sustained a fractured pelvis and bilateral femur fractures yesterday in a motorcycle collision. The patient complains of shortness of breath. Assessment reveals audible wheezes and oxygen saturation of 76%. What action should the nurse take first? a. Establish a peripheral intravenous (IV) line. b. Inform the charge nurse. c. Explain the patient's change in status to his family. d. Raise patient to high Fowler position.
D.
The home health nurse is educating the family of a child with head lice. Which instructions are most important for the nurse to include? a.Lice cannot be transmitted to pets. b.Insects must be moving across the scalp to confirm diagnosis of head lice. c.Wash and dry all linens on the hottest setting. d.Apply a dime-sized amount of alcohol-based lotion to hair.
C.
The nurse is caring for a patient who just returned from surgical decompression of the carpal tunnel. Which finding requires the nurse's immediate action? a. The patient's fingers swollen and warm. b. The patient complains of generalized pain 5/10. c. The capillary refill time is 8 seconds. d. The patient's fingers are pink and cool bilaterally.
C.
Which component(s) is/are functions of the musculoskeletal system? (select all that apply.) a. Motion b. Fighting of infections c. Support d. Protection of organs e. Body shape
A, C, D, E
The nurse is advising an older adult regarding age-appropriate bathing practices. Which instruction(s) is/are most important for the nurse to include? (select all that apply.) a. Using lotion-based soaps. b. Using hot water to stimulate skin. c. Towel skin dry with quick, brisk motions. d. Apply lotion twice a day. e. Apply talcum powder after bathing.
A, D
A patient at risk for the development of osteoporosis has reported plans to increase calcium intake. Which meal choice is most appropriate for this patient? A. Grilled salmon, green beans, and milk B. Hamburger patty on a wheat bun, baked chips, and milk C. Grilled chicken breast, tossed salad, and fruit punch D. Bacon, lettuce, and tomato sandwich on whole-grain bread, orange slices, and milk
A.
A patient is learning to use crutches on the stairs. Which action indicates that the patient needs further instruction? A. The patient places the good leg on the step to be climbed first. B. The patient places the affected leg on the step to be climbed first. C. The patient places the crutches on the floor and uses a swing-through method to get to the next step. D. The patient places the crutch on the affected side on the next step first.
A.
An older adult has fallen and sprained his ankle in a local park. Which action should the responder perform first? A. elevate the foot B. apply ice C. administer aspirin D. assist the patient with ambulation
A.
The nurse is assessing the patient's cane for appropriate length. Which observation affirms that an appropriate cane has been selected? a. The handgrip is at hip level. b. The elbow flexes at 45 degrees when weight is placed on the cane. c. The cane tip is placed touching outside the good foot. d. The rubber tip has been removed when measuring cane length.
A.
The nurse is caring for a burn patient. Which action best prevents contractures? a. Assist the patient with ambulation as soon as fluid shifts stabilize. b. Medicate the patient approximately 30 minutes prior to dressing changes. c. Ensure adequate hydration. d. Ensure adequate nutritional intake.
A.
The nurse is caring for a patient diagnosed with shingles who complains of constant pain along the sciatic nerve. What intervention best helps to provide pain relief? a. Distract the patient with conversation. b. Massage the area of pain. c. Move the affected leg through range-of-motion (ROM). d. Change the patient's position frequently.
A.
The nurse is caring for a patient who has had an arthrocentesis. The nurse has completed discharge instructions. Which statement indicates the patient needs further instruction? a. "I should avoid moving my knee for at least 2 weeks." b. "The steroids prescribed by my physician will reduce the inflammation in my knee." c. "Some pain is anticipated." d. "My elastic bandage will be worn for 2 to 3 days."
A.
The nurse is caring for a patient with a stage III pressure ulcer. Which assessment findings are consistent with this stage of ulcer? a. A crater-like lesion b. Skin that does not blanch with fingertip pressure c. Presence of mottled skin d. Excoriation around the lesion
A.
The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? A. Administer 100% humidified oxygen. B. Teach the patient deep breathing exercises. C. Encourage the patient to express his feelings. D. Assist the patient to a high Fowler's position.
A.
While bathing a patient, the nurse assesses a red, non blanchable area on the coccyx. Which type of dressing should the nurse apply? a. Transparent film b. Hydrocolloid c. Fluffy absorbent d. Wet-to-dry
A.
A newly admitted 86-year-old patient has scratch marks in the groin and axilla and on her limbs. There are small, punctate red lesions that the patient says itch "like crazy." Which nursing action is most appropriate? a. Employ skin tear precautions b. Employ Standard Precautions c. Employ use of emollient d. Employs focused assessment for cause
B.
For which patient would the nurse question an order for isotretinoin (Accutane)? a. A 20-year-old epileptic man with nodular acne and epilepsy b. A 22-year-old pregnant woman with severe acne c. A 46-year-old woman on oral contraceptive pills with cystic acne d. A 50-year-old hypertensive man with cystic acne
B.
The industrial nurse examines an employee who complains of right shoulder pain on abduction. He points with one finger to the exact location of the pain and mentions that he won a racquetball tournament yesterday. The nurse suspects the employee is suffering from which problem? a. Rotator cuff tear b. Bursitis c. Dislocation d. Subluxation
B.
The nurse encourages the patient to use the four-point crutch gait technique. Which statement indicates that the patient accurately understands the nurse's teaching? A. "This way of walking takes weight off of one leg." B. "This way of walking is the most stable gait." C. "This way of walking mimics normal walking pattern." D. "This way of walking allows the most rapid pace."
B.
The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? A. Vital signs B. Urine output C. Mental status D. Peripheral pulse
B.
The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? A. Skin is hard with a dry, waxy white appearance. B. Skin is shiny and red with clear, fluid-filled blisters. C. Skin is red and blanches when slight pressure is applied. D. Skin is leathery with visible muscles, tendons, and bones.
B.
The nurse is caring for a patient with a stage III pressure ulcer that is not healing. Which statement accurately describes the goal of electrical stimulation of the pressure ulcer? a. To sterilize the wound b. To increase blood vessel growth c. To cause the ulcer to close by scabbing d. To coagulate the drainage
B.
The nurse is caring for a patient with an order for an "open dressing." Which action indicates that the nurse accurately understands the order? a. The nurse leaves the entire lesion open to air. b. The nurse changes wet compresses frequently enough to keep them wet. c. The nurse applies medicated ointment directly in the open wound. d. The nurse applies dressings to the perimeter of the wound while leaving the center of the wound open to air.
B.
The nurse is educating a patient with psoriasis. Which information is most important for the nurse to include in the teaching plan? a. Liberally apply a lubricating cream three times daily. b. Use a humidifier at night. c. Use an alcohol-based cleanser in the morning. d. Take hot baths to reduce skin discomfort.
B.
The nurse observes the CNA who is changing a patient's bed. Which action demonstrates that the CNA requires additional teaching? a. Lifting the patient on the draw sheet to the stretcher. b. Pulling the draw sheet out from under the patient. c. Rolling the patient to the side to change the draw sheet. d. Using the gait belt to lift the patient from the bed to a wheelchair.
B.
The school nurse is advising a group of high school girls about ways to avoid permanent skin damage from sun exposure. Which information is most important to include in the teaching plan? a. Avoid using cosmetics that have sunscreen added. b. Consider a spray tan in the summer. c. Limit sunbathing times on a cloudy day. d. Wear light, loose clothing while in the sun.
B.
A 75-year-old patient questions the nurse about vaccination to prevent shingles. Which response is most appropriate? a. "The incidence of shingles in people your age is not overly common, so vaccination is unnecessary." b. "The vaccination has not yet been approved for use in the older adults." c. "Because of the incidence of shingles in your age group, you should consider taking the vaccination." d. "The vaccination is expensive but will provide lifelong immunity."
C.
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mmHg, a pulse rate of 110 beats/minute, and a urine output of 20mL over the past hour. The nurse reports the findings to the healthcare provider (HCP) and anticipates which prescription? A. Transfusing 1 unit of packed red blood cells B. Administering a diuretic to increase urine output C. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour D. Changing the IV lactated Ringer's solution to one that contains dextrose in water
C.
A skin biopsy has been scheduled on a patient to rule out the presence of a malignancy. Which instruction is most important for the nurse to include in patient teaching? a. General anesthesia will be used during the procedure. b. Change the bandage the day after the procedure and then weekly for 2 weeks. c. Sutures placed at the site of the biopsy will be removed in approximately 10 days. d. Do not eat or drink anything after midnight the night before the procedure.
C.
An 80-year-old man falls and suffers a compound fracture of the femur. Which immediate action is most appropriate? a. Position him flat on his back. b. Apply a tourniquet on the leg. c. Carefully splint the leg as it is. d. Carefully straighten the leg.
C.
The nurse is caring for a patient who works as a legal secretary. The patient asks the nurse about ways to avoid developing carpal tunnel syndrome (CTS). Which action should the nurse suggest? a. "Exercise your wrists with repetitive flexion movements nightly." b. "Wrap your wrists with elastic bandages." c. "Acquire a pad to support your wrists while typing." d. "Apply warm compresses to wrists every evening."
C.
The nurse is educating a patient with acne rosacea that has facial erythema and telangiectasis. Which information should the nurse include in the teaching plan? a. Drink 4 ounces of wine daily to promote vasodilation. b. Wash your face at least three times daily. c. Avoid direct sunlight. d. Apply tea bags to the affected areas.
C.
The nurse is performing an assessment on the patient who is in bilateral Buck traction. Which finding indicates the need to reposition the patient? A. The patient's heels are not touching the surface of the mattress. B. The elastic bandages need to be rewrapped. C. The patient's feet are against the footboard. D. The weights are hanging free.
C.
The nurse is providing fluid resuscitation for a burn victim according to the Parkland formula. The nurse determines that the patient requires 8000 mL in a 24-hour time period. The burn occurred at noon, and the present time is 1400. How many milliliters of fluid should infuse by 2000? a. 2000 mL b. 3000 mL c. 4000 mL d. 7000 mL
C.
The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? A. Using sterile sheets and linens B. Performing strict hand washing technique C. Wearing gloves and a gown only when giving direct care to the client D. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron
C.
The patient with osteoporosis calls the nurse in the doctor's office to report that she should have taken but has forgotten to take her weekly bisphosphonate (alendronate [Fosamax]) that was due 2 days ago. How should the nurse advise the patient? a. "Take the dose now with 8 ounces of water." b. "Take two doses 3 days apart." c. "Skip this week and pick up the schedule next week." d. "Take two tablets now with a snack."
C.
When instructing a patient with arthritis on the application of heat for pain and stiffness, the nurse will inform the patient that a) dry heat devices will penetrate the tissue better than moist heat. b) heat is recommended for the acute phase inflammation or acute pain. c) heat should be used for 20 to 30 minutes every 1 to 2 hours, as needed, while the patient is awake. d) hot water bottles directly against the skin provide the best penetration of heat.
C.
When the clinic nurse starts to take the "air cast" off the grade 2 sprain, the patient asks why it is being removed since he still has pain. Which explanation is best? a. "Long-term immobilization can interfere with adequate circulation." b. "Long-term immobilization may increase long-term edema." c. "Long-term immobilization can cause permanent disability." d. "This cast will be replaced with a heavier cast."
C.
Which patient should the nurse prepare to transfer to a regional burn center? A. A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% B. A 39-year-old patient with a partial-thickness burn to the right upper arm C. A 53-year-old patient with a chemical burn to the anterior chest and neck D. A 42-year-old patient who is scheduled for skin grafting of a burn wound
C.
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? A. 100% oxygen via an aerosol mask B. Oxygen via nasal cannula at 6L/minute C. Oxygen via nasal cannula at 15L/minute D. 100% oxygen via a tight-fitting, non rebreather face mask
D.
A patient has come to the ambulatory care clinic with a sprain. The nurse correctly differentiates a grade 2 sprain from a grade 3 sprain with the assessment of which finding? a. Pain b. Swelling c. Bleeding into the joint d. Minor loss of function
D.
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Decreased heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels
D.
The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? A. Pallor of all extremities B. Pulse oximetry reading of 93% C. Peripheral pulses are diminished D. High pressure alarm keeps sounding on the ventilator
D.
