Test Four

A patient with a complex pelvic fracture from a motor vehicle crash is on bed rest. Which assessment finding should indicate to the nurse a potential complication of the fracture?

Abdomen is distended and bowel sounds are absent.

What action should the nurse identify as most important before administering botulinum antitoxin to a patient in the emergency department?

Administer an intradermal test dose

After being hospitalized for 3 days with a right femur fracture a patient suddenly develops shortness of breath and tachypnea. The patient tells the nurse, I feel like I am going to die! Which action should the nurse take first?

Administer prescribed PRN O2 at 4 L/min

The day after having a right below the knee amputation, a patient reports pain in the missing right foot. Which action is most important for the nurse to take?

Administer prescribed analgesics.

Before assisting a patient with ambulation 2 days after total hip arthroplasty, which action is most important for the nurse to take?

Administer prescribed pain medication.

A construction worker arrives at an urgent care center with a deep puncture wound from a rusty nail. The patient reports having a tetanus booster 6 years ago. What intervention should the nurse anticipate?

Administration of the tetanus-diphtheria booster.

Which action should the urgent care nurse take for a patient with a possible knee meniscus injury?

Apply an immobilizer to the affected leg.

Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain?

Ask about numbness or tingling of the hands and arms.

What action would help the nurse evaluate outcomes of a glycerol rhizotomy for a patient with trigeminal neuralgia?

Ask the patient about social activities with family and friends.

A 20 year old patient who sustained a t2 spinal cord injury 10 days ago tells the nurse, I want to be transferred to a hospital where the nurses know what they are doing. Which action should the nurse appropriately take?

Ask the patient to provide input for the plan of care.

Which action would the nurse include in the plan of care for a patient who is experiencing pain from trigeminal neuralgia?

Assess fluid and dietary intake

Which action should the nurse take to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fractures of the right femur?

Assess for hip pain.

After a motorcycle accident, a patient arrives in the emergency department with severe swelling of the left lower leg. Which action should the nurse take first?

Assess leg pulses and sensation.

The second day after admission with a fractured pelvis a patient suddenly develops confusion. Which action should the nurse take first?

Assess patient orientation.

A patient with a history of t3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, I have a pounding a headache and I feel sick to my stomach. Which action should the nurse take first?

Assess the blood pressure.

A patient who slipped and fell in the shower at home has a proximal left humerus fracture immobilized with a sling. Which intervention should the nurse include in the plan of care?

Assess the left axilla and change absorbent dressings as needed.

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. What initial action should the nurse take?

Assess the pedal pulses.

A patient undergoes left above the knee amputation with an immediate prosthetic fitting. What should the nurse do when the patient arrives on the orthopedic unit after surgery?

Assess the surgical site for hemorrhage.

What action should the nurse complete before administering alendronate to a patient with osteoporosis?

Assist the patient to sit up at the bedside.

A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action should the nurse include in the plan of care?

Assist the patient with ambulation.

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

Assist to plan a prescribe bowel program.

The nurse should instruct a patient a nondisplaced fractured left radius that the cast will need to remain in place for what amount of time?

At least 6 weeks.

What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures?

Buy shoes that provide good support and are comfortable to wear.

A 54 year old woman who recently reached menopause and has a family history of osteoporosis is diagnosed with osteopenia. Which information should the nurse explain to the patient?

Calcium loss from bones can be slowed by increasing calcium intake and weight bearing exercise.

The nurse identifies a patient with Type 1 diabetes and a history of herpes simplex infections as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

Call the doctor if you experience pain or develop herpes lesions near the ear.

Which information should the nurse include in discharge instructions for a patient with comminuted left forearm fractures and a long arm cast?

Call the health care provider for numbness of the hand.

Which finding in a patient with a Colles' fracture of the left wrist should the nurse identify as most important to communicate immediately to the health care provider?

Capillary refill to the fingers is slow.

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury?

Catheterize patient every 3 to 4 hours.

Based on the information in the accompanying figure obtained for a patient in the emergency room, which action should the nurse take first?

Check the patient's O2 saturation using pulse oximetry.

A patient who has had open reduction and internal fixation of a hip fracture tells the nurse he is ready to get out of bed for the first time. Which action should the nurse take?

Check the patient's prescribed weight bearing status.

Which assessment finding in a patient with a spinal cord tumor requires immediate action by the nurse?

Decreased ability to move the legs.

A 38 year old patient who has had a spinal cord injury returned home following a stay in a rehabilitation facility. The home care nurse notes the spouse is performing many of the activities that the patient had been managing unassisted during rehabilitation. What should the nurse identify as the most appropriate action at this phase of rehabilitation?

Develop a plan to increase the patient's independence in consultation with the patient and the spouse.

The nurse is caring for a patient who is using Buck's traction after a hip fracture. Which action can the nurse delegate to experienced unlicensed assistive personnel?

Ensure the weight for the traction is hanging freely.

Which information should the nurse include when teaching a patient with acute low back pain?

Expect symptoms of acute low back pain to improve in a few weeks, avoid activities that require twisting of the back or prolonged sitting, use ibuprofen or acetaminophen to relieve pain.

What should the nurse explain to the patient who has a t2 spinal cord transection injury?

Function of both arms should be maintained.

The nurse is caring for a patient who has a pelvic fracture and an external fixation device. How should the nurse perform assessment of pressure areas and provide skin care to the patient's back and sacrum?

Have the patient lift the back and buttocks using a trapeze.

Which information should the nurse include in discharge teaching for a patient who has had repair of a fractured mandible?

How and when to cut the immobilizing wires.

A patient is being discharged after 1 week of IV antibiotic therapy for acute osteomyelitis in the right leg. Which information should the nurse include in the discharge teaching?

How to monitor and care for a long term IV catheter

The nurse is admitting a patient who has a neck fracture at the c6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock?

Hypotension and warm extremities.

Which statement by a patient with discomfort from a bunion indicates to the nurse that more teaching is needed?

I can only wear sandals no closed toe shoes.

A patient is to be discharged from the hospital 4 days after insertion of a femoral head prosthesis using a posterior approach. Which patient statement to the nurse indicates that additional teaching is needed?

I can sleep in any position that is comfortable for me.

The nurse instructs a patient who has osteosarcoma of the tibia about a scheduled above the knee amputation. Which patient statement indicates to the nurse that additional teaching is needed?

I did not have this bone cancer until my leg broke a week ago.

Which statement by a patient who has had an above the knee amputation indicates the nurse's discharge teaching has been effective?

I should lie flat on my abdomen for 30 minutes 3 or 4 times a day.

A patient is receiving IV antibiotics at home to treat chronic osteomyelitis of the left femur. Which statement by the patient should indicate to the nurse the need for additional teaching related to health maintenance?

I think my left foot is starting to droop down.

Which patient statement indicates understanding of the nurse's teaching about a new short arm synthetic cast?

I will apply an ice pack to the cast over the fracture site off an on for 24 hours.

A high school teacher with ulnar drift caused by rheumatoid arthritis is scheduled for arthroplasty of several joints in the left hand. Which patient statement to the nurse indicates a realistic expectation for the surgery?

I will be able to use my fingers with more flexibility to grasp things.

A patient whose employment requires frequent lifting has a history of chronic back pain. After the nurse has taught the patient about correct body mechanics, which patient statement indicates the teaching has been effective?

I will begin doing exercised to strengthen and support my back.

A patient with acute osteomyelitis of the left femur is hospitalized for regional antibiotic irrigation. Which intervention should the nurse include in the initial plan of care?

Immobilization of the left leg.

A patient hospitalized with a new diagnosis of Guillain-Barre syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate?

Infusion of immunoglobulin

Which patient assessment would help the nurse identify potential complications of trigeminal neuralgia?

Inspect the oral mucosa and teeth.

A patient with paraplegia resulting from a t9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

Instruct the patient how to self-catheterize

What should the nurse include in the teaching plan for a patient who has acute low back pain and muscle spasms?

Keep the head elevated slightly and flex the knees when resting in bed.

A patient is being discharged 4 days after hip arthroplasty using the posterior approach. Which patient action requires intervention by the nurse?

Leaning over to pull on shoes and socks.

Which assessment finding for a 55 year old patient should alert the nurse to the presence of osteoporosis?

Loss of height.

A factory line worker has repetitive strain syndrome in the left elbow. What topic should the nurse plan to include in patient teaching?

Modifying arm movements

Which actions should the nurse include in the plan of care for a patient with metastatic bone cancer of the left femur?

Monitor serum calcium, explain the use of sustained release opioids, support the left leg when repositioning the patient, assist family and patient as they discuss prognosis

A patient who arrives at the emergency department with severe left knee pain is diagnosed with a patellar dislocation. What should be the nurse's initial focus for patient teaching?

Monitored anesthesia care.

A patient with a t4 spinal cord injury asks the nurse if he will be able to be sexually active. Which information should the nurse include in an initial response?

Multiple options are available to maintain sexuality after spinal cord injury.

A patient who had open reduction and internal fixation of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the foot is cool to the touch.

Notify the health care provider.

Which menu choice by a patient with osteoporosis indicates the nurse's teaching about appropriate diet has been effective?

Oatmeal with skim milk and fruit yogurt.

A patient is hospitalized with new onset of Guillain-Barre syndrome. What should the nurse recognize as the most essential assessment to complete?

Observing respiratory rate and effort

What should the occupational health nurse advise a patient whose job involves many hours of typing?

Obtain a keyboard pad to support the wrist.

What should the nurse assess to evaluate the effectiveness of alendronate therapy for a patient with Paget's disease?

Pain intensity.

Which information about a patient with a lumbar vertebral compression fracture should the nurse immediately report to the health care provider?

Patient has been incontinent of urine and stool.

A nurse who works on the orthopedic unit has just received change of shift report. Which patient should the nurse assess first?

Patient who has not voided 8 hours after a laminectomy.

After change of shift report on the neurology unit, which patient should the nurse assess first?

Patient with botulism who is drooling and experiencing difficulty swallowing.

After change of shift report, which patient should the nurse assess first?

Patient with repaired right femoral shaft fracture who reports tightness in the calf.

Which nursing action for a patient with Guillain-Barre syndrome should the nurse identify as appropriate to delegate to experienced unlicensed assistive personnel?

Performing passive range of motion to extremities.

Which action should the nurse take when repositioning the patient who has just had a laminectomy and discectomy?

Place a pillow between the patient's legs and turn the entire body as a unit.

A patient has an incomplete left spinal cord lesion at the level of t7 resulting in Brown-Sequard Syndrome. Which action should the nurse include in the plan of care?

Positioning the patient's left leg when turning the patient.

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30 year old patient with a c6 spinal cord injury?

Propel a manual wheelchair on a flat surface

Which action should the nurse take when caring for a patient who develops tetanus from injectable substance use?

Provide a quiet environment.

A patient who had a c7 spinal cord injury 1 week ago has a weak cough effort and crackles. What initial intervention should the nurse perform?

Push upward on the epigastric area as the patient coughs.

For a patient who has had right hip arthroplasty which nursing action can the nurse delegate to experienced unlicensed assistive personnel?

Reposition the patient every 1 to 2 hours.

A patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. What is the nurse's best response?

Respect the patient's feelings and arrange for privacy at mealtimes

Which action should the nurse take before administering gentamicin to a patient with acute osteomyelitis?

Review the patient's serum creatinine results.

After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. What action should the nurse take?

Review the preoperative assessment data in the health record.

A 60 year old patient had open reduction and internal fixation for an open displaced tibial fracture. What should the nurse identify as the priority patient problem?

Risk for infection

A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider?

Slow capillary refill of the left foot.

Which action should the nurse include in the plan of care for a patient who had a cemented right total knee arthroplasty?

Start progressive knee exercises to obtain 90 degree flexion.

Which action should the nurse take when caring for a patient osteomalacia?

Teach about the use of vitamin D supplements

After the health care provider recommends amputation for a patient who has nonhealing ischemic foot ulcers, the patient tells the nurse that he would rather die than have an amputation. Which response by the nurse is best?

Tell me what you know about your options for treatment.

A patient has had surgical reduction of an open fracture of the right radius. Which assessment findings should the nurse report immediately to the health care provider?

Temperature 101.4

A patient who is to have no weight bearing on the left leg is learning to use crutches. Which observation by the nurse indicates the patient can safely ambulate independently?

The patient advances the left leg and both crutches together and then advances the right leg.

A patient is being evaluated for a possible spinal cord tumor. Which finding should the nurse recognize as requiring the most immediate action?

The patient has new-onset weakness of both legs.

Which assessment data for a patient who has Guillain-Barre syndrome will require the nurse's most immediate action?

The patient is continuously drooling saliva.

A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding should the nurse identify as most important to communicate to the health care provider?

The right arm appears shorter than the left.

A patient with possible right carpal tunnel syndrome. What symptom should the nurse expect with a positive Tinel's sign?

Tingling in the right thumb and index finger.

What information would the nurse seek from a patient with newly diagnosed trigeminal neuralgia?

Triggers leading to facial discomfort

Which collaborative and nursing action should the nurse include in the plan of care for a patient who experienced a t2 spinal cord transection 24 hours ago?

Urinary catheter care, continuous cardiac monitoring, administration of h2 receptor blockers, maintenance of a warm room temperature.

When a patient arrives in the emergency department with a facial fracture, which action should the nurse take first?

Use a cervical collar to stabilize the spine.

Which discharge instruction should the emergency department nurse include for a patient with a sprained ankle?

Use pillows to elevate the ankle above the heart

A young adult arrives in the emergency department with ankle swelling and severe pain after twisting an ankle playing basketball. Which prescribed action will the nurse implement first?

Wrap the ankle and apply an ice pack.

A tennis player has an arthroscopic repair of a rotator cuff injury performed in same day surgery. Which information will the nurse include in postoperative teaching?

You will begin work with a physical therapist tomorrow.

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

assessment of respiratory rate and effort

A patient with a right lower leg fracture will be discharged home with an external fixation device in place. Which statement should the nurse include in discharge teaching?

check and clean the pin insertion sites daily.

A patient is admitted with possible botulism poisoning after eating home canned green beans. Which intervention ordered by the health care provider should the nurse question?

encourage fluids to 3 L/ day.

Which action included in the care of a patient after laminectomy can the nurse delegate to experienced unlicensed assistive personnel?

log roll the patient from side to side every 2 hours.