Unit 6: Ortho & Oncology Q&As

2. Lung cancers are responsible for almost twice as many deaths among males as any other cancer and more deaths than breast cancer in females.

51. The nurse is discussing cancer statistics with a group from the community. Which information about death rates from lung cancer is accurate? 1. Lung cancer is the number-two cause of cancer deaths in both men and women. 2. Lung cancer is the number-one cause of cancer deaths in both men and women. 3. Lung cancer deaths are not significant in relation to other cancers. 4. Lung cancer deaths have continued to increase in the male population.

3. Initially, most clients with early symptoms of rheumatoid arthritis complain of early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules

1. On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: ■ 1. Limited motion of joints. ■ 2. Deformed joints of the hands. ■ 3. Early morning stiffness. ■ 4. Rheumatoid nodules.

2. Diffi culty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis.

10. A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports diffi culty seeing out of her left eye. Correct interpretation of this assessment fi nding indicates which of the following? ■ 1. Development of a cataract. ■ 2. Possible retinal degeneration. ■ 3. Part of the disease process. ■ 4. A coincidental occurrence.

1. Fat emboli usually result in symptoms of acute respiratory distress syndrome, such as apprehension, chest pain, cyanosis, dyspnea, tachypnea, tachycardia, and decreased partial pressure of arterial oxygen resulting from poor oxygen exchange. Migraine-like headaches are not a symptom of a fat embolism, but mental confusion, memory loss, and a headache from poor oxygen exchange may be seen with central nervous system involvement. Numbness in the right leg is a peripheral neurovascular response that most likely is related to the femoral fracture. Muscle spasms in the right thigh are a symptom of a neuromuscular response affecting the local muscle around the femoral fracture site.

100. Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? ■ 1. Acute respiratory distress syndrome. ■ 2. Migraine-like headaches. ■ 3. Numbness in the right leg. ■ 4. Muscle spasms in the right thigh

1. The client can sit up in bed, remaining in the supine position so that an even, sustained amount of traction is maintained under the bandage used in the Buck's traction. Maintenance of even, sustained traction decreases the chance that the bandage or traction strap might slip and cause compression or stress on the nerves or vascular tracts, resulting in permanent damage. The client does not have to remain fl at but may adjust the head of the bed to varying degrees of elevation while remaining in the supine position. The client should not turn his body to another position because the bandage may slip.

102. The client asks the nurse what his activity limitations are while he is in Buck's traction. The nurse should tell the client: ■ 1. "You can sit up whenever you want." ■ 2. "You must lie fl at on your back most of the time." ■ 3. "You can turn your body." ■ 4. "You must lie on your stomach."

3. The HCP can take biopsies and wash of the lung tissue for pathological diagnosis dur- ing the procedure.

59. The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach? 1. The test will confirm the MRI results. 2. The client can eat and drink immediately after the test. 3. The HCP can do a biopsy of the tumor through the scope. 4. There is no discomfort associated with this procedure.

1. The nurse should assess for signs of skin pressure in the groin area because the Thomas splint, which is a half-ring that slips over the thigh and suspends the lower extremity in direct skeletal traction, may cause discomfort, pressure, or skin irritation in the groin. The nurse always assesses respirations as part of routine vital signs, but assessing for evidence of decreased breath sounds is not a routine assessment related directly to the Thomas splint. The head of the bed can be elevated to facilitate breathing, but not more than 25 degrees, to avoid continually moving the client toward the foot of the bed from the weight of the traction. The nurse always assesses for pressure areas on dependent parts, but assessing for skin breakdown behind the heel is not a routine assessment related directly to the Thomas splint, in which the heel is free of any contact with padding or metal parts of the Pearson attachment for the balanced suspension traction. The client who is in a Thomas splint is able to use a bedpan to urinate, especially the fracture bedpan for a female client and the urinal for a male. Urine retention should not be a special assessment directly related to the Thomas splint, but it may be a clientspecifi c assessment

103. Because a client has a Thomas splint, the nurse should assess the client regularly for which of the following? ■ 1. Signs of skin pressure in the groin area. ■ 2. Evidence of decreased breath sounds. ■ 3. Skin breakdown behind the heel. ■ 4. Urine retention.

1. The client's assisting as much as possible in his care and increasing participation over time indicate that the client has accomplished self-care by gaining a sense of control. If the client lets the nurse complete his care without interfering, his behavior would indicate passivity, possibly from denial or depression. If the client allows his wife to assume total responsibility for his care or to complete his care, he still has a self-care defi cit and a successful outcome has not been reached.

104. The client has a nursing diagnosis of Self-care defi cit related to the confi nement of traction. Which of the following would indicate a successful outcome for this diagnosis? ■ 1. The client assists as much as possible in his care, demonstrating increased participation over time. ■ 2. The client allows the nurse to complete his care in an effi cient manner without interfering. ■ 3. The client allows his wife to assume total responsibility for his care. ■ 4. The client allows his wife to complete his care to promote feelings of usefulness.

2. Fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg are clinical manifestations of osteomyelitis, which is a pyogenic bone infection caused by bacteria (usually staphylococci), a virus, or a fungus. The bone is inaccessible to macrophages and antibodies for protection against infections, so an infection in this site can become serious quickly. The client with a pulmonary or fat embolus would develop symptoms of pulmonary compromise, such as shortness of breath, chest pain, angina, and mental confusion. Signs and symptoms of urinary tract infection would include pain over the suprapubic, groin, or back region with fever and chills, with no restrictive movement of the leg.

105. The client who had an open femoral fracture was discharged to her home where she developed fever, night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the following refl ects the best interpretation of these fi ndings? ■ 1. Pulmonary emboli. ■ 2. Osteomyelitis. ■ 3. Fat emboli. ■ 4. Urinary tract infection

2. The goal of care for this client is healing and tissue growth while the client continues on long-term antibiotic therapy to clear the infection. A diet high in protein and vitamins C and D promotes healing. Herbal supplements may potentiate bleeding (e.g., ginkgo, ginger, tumeric, chamomile, kelp, horse chestnut, garlic, and dong quai) and have not been proven through research to promote healing. Frequent passive motion will increase circulation but may also aggravate localized bone pain. It is not appropriate to advise the client to change antibiotics as treatment may take time.

106. The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following? ■ 1. Use herbal supplements. ■ 2. Eat a diet high in protein and vitamins C and D. ■ 3. Ask the health care provider for a change of antibiotics. ■ 4. Encourage frequent passive range-of-motion to the affected extremity

4. Superfi cial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate.

11. A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is diffi cult." Which of the following responses by the nurse would be most appropriate? ■ 1. "You are probably exercising too much. Decrease your exercise to every other day." ■ 2. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." ■ 3. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." ■ 4. "Take a warm tub bath or shower before exercising. This may help with your discomfort."

3. Respiratory distress is the highest priority. There is a chance to stop the bleeding or treat an infection, but a client who is not breathing dies very quickly.

68. The nurse is writing a care plan for a client newly diagnosed with cancer of the larynx. Which problem would have the highest priority? 1. Wound infection. 2. Hemorrhage. 3. Respiratory distress. 4. Knowledge deficit.

1, 2, 5. An arthrocentesis is performed to aspirate excess synovial fl uid, pus, or blood from a joint cavity to relieve pain or to diagnosis infl ammatory diseases such as rheumatoid arthritis. A local agent may be used to decrease the pain of the needle insertion through the skin and into the joint cavity. Aspiration of the fl uid into the syringe can be very painful because of the size and infl ammation of the joint. Usually a steroid medication is injected locally to alleviate the infl ammation; a compression bandage is applied to help decrease swelling; and the client is asked to rest the joint for up to 24 hours afterwards to help relieve the pain and promote rest to the infl amed joint. The client may experience pain during this time until the infl ammation begins to resolve and swelling decreases.

12. Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply. ■ 1. "A local anesthetic agent may be injected into the joint site for your comfort." ■ 2. "A syringe and needle will be used to withdraw fl uid from your joint." ■ 3. "The procedure, although not painful, will provide immediate relief." ■ 4. "We'll want you to keep your joint active after the procedure to increase blood fl ow." ■ 5. "You will need to wear a compression bandage for several days after the procedure."

1, 4, 5. To prepare a client for an arthrocentesis, the nurse should tell the client that a local anesthetic administered by the physician will decrease discomfort. There may be bleeding after the procedure, so the nurse should check the dressing. The client may experience pain. The nurse should offer pain medication and evaluate outcomes for pain relief. Because a local anesthetic is used, the client will not require preoperative medication. The client will rest the knee for 24 hours and then should begin range-of-motion and muscle strengthening exercises.

13. A client with osteoarthritis will undergo an arthrocentesis on his painful edematous knee. What should be included in the nursing plan of care? Select all that apply. ■ 1. Explain the procedure. ■ 2. Administer preoperative medication 1 hour before surgery. ■ 3. Instruct the client to immobilize the knee for 2 days after the surgery. ■ 4. Assess the site for bleeding. ■ 5. Offer pain medication.

1. Metal will interfere with the test. Metallic objects within the examination fi eld, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not infl uence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis

14. A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client? ■ 1. Request that the client remove all metal objects on the day of the scan. ■ 2. Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test. ■ 3. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. ■ 4. Tell the client that she should report any signifi cant pain to her physician at least 2 days before the test.

1. Shorter sessions will allow the client to rest between the sessions. Changing the physician's order to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-infl ammatory agent. Thus, it would not help this client avoid the adverse effects of a lengthy X-ray examination. Although the X-ray table is hard, there are other options for making the client comfortable, rather than canceling the examination

15. A physician orders a lengthy X-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy? ■ 1. Contact the X-ray department and ask the technician if the lengthy session can be divided into shorter sessions. ■ 2. Contact the physician to determine if an alternative examination could be scheduled. ■ 3. Provide a dose of acetaminophen (Tylenol). ■ 4. Cancel the examination because of the hard X-ray table.

4. Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain, unlike rheumatoid arthritis, which has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight

16. Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? ■ 1. Anemia. ■ 2. Osteoporosis. ■ 3. Weight loss. ■ 4. Local joint pain

1, 2, 3. A diet with adequate amounts of vitamin D aids in the regulation, absorption, and subsequent utilization of calcium and phosphorus, which are necessary for the normal calcifi cation of bone. Figs, broccoli, and almonds are very good sources of calcium. Moderate intake of alcohol has no known negative effects on bone density but excessive alcohol intake does reduce bone density. Swimming, biking, and other non-weight-bearing exercises do not maintain bone mass. Walking and running, which are weight-bearing exercises, do maintain bone mass. The client should eat a balanced diet but does not need to avoid the use of high-fat foods.

17. A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply. ■ 1. Maintain a diet with adequate amounts of vitamin D, as found in fortifi ed milk and cereals. ■ 2. Choose good calcium sources, such as fi gs, broccoli, and almonds. ■ 3. Use alcohol in moderation because a moderate intake has no known negative effects. ■ 4. Try swimming as a good exercise to maintain bone mass. ■ 5. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods.

1. Capsaicin cream, which produces analgesia by preventing the reaccumulation of substance P in the peripheral sensory neurons, is made from the active ingredients of hot peppers. Therefore, clients should wash their hands immediately after applying capsaicin cream if they do not wear gloves, to avoid possible contact between the cream and mucous membranes. Clients are instructed to avoid wearing tight bandages over areas where capsaicin cream has been applied because swelling may occur from infl ammation of the arthritis in the joint and lead to constriction on the peripheral neurovascular system. Capsaicin cream should be stored in areas between 59° F and 86° F (15° C and 30° C). The cabinet over the stove in the kitchen would be too warm. Capsaicin cream should not come in contact with irritated and broken skin, mucous membranes, or eyes. Therefore it should not be used on cuts or burns.

18. Which of the following statements indicates that the client with osteoarthritis understands the effects of capsaicin (Zostrix) cream? ■ 1. "I always wash my hands right after I apply the cream." ■ 2. "After I apply the cream, I wrap my knee with an elastic bandage." ■ 3. "I keep the cream in the cabinet above the stove in the kitchen." ■ 4. "I also use the same cream when I get a cut or a burn."

3. Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should use warmth and stretching until he gets food in his stomach

19. At which of the following times should the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? ■ 1. At bedtime. ■ 2. On arising. ■ 3. Immediately after a meal. ■ 4. On an empty stomach.

1. Based on the client's complaints, the most appropriate nursing diagnosis would be Activity intolerance related to fatigue and pain. Nursing interventions would focus on helping the client conserve energy and decrease episodes of fatigue. Although the client may develop a self-care defi - cit related to the activity intolerance and increasing joint pain, the client is voicing concerns about household chores and diffi culty around the house and yard, not self-care issues. Over time, the client may develop ineffective coping or body image disturbance as the disorder becomes chronic with increasing pain and fatigue.

2. A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which nursing diagnosis would be most appropriate? ■ 1. Activity intolerance related to fatigue and pain. ■ 2. Self-care defi cit related to increasing joint pain. ■ 3. Ineffective coping related to chronic pain. ■ 4. Disturbed body image related to fatigue and joint pain

1. Corticosteroids are used for clients with osteoarthritis to obtain a local effect. Therefore, they are given only via intra-articular injection. Oral corticosteroids are avoided because they can cause an acceleration of osteoarthritis. Rheumatoid arthritis and osteoarthritis are two different diseases.

20. The client diagnosed with osteoarthritis states, "My friend takes steroid pills for her rheumatoid arthritis. Why don't I take steroids for my osteoarthritis?" Which of the following is the best explanation? ■ 1. Intra-articular corticosteroid injections are used to treat osteoarthritis. ■ 2. Oral corticosteroids can be used in osteoarthritis. ■ 3. A systemic effect is needed in osteoarthritis. ■ 4. Rheumatoid arthritis and osteoarthritis are two similar diseases.

2. Weight-bearing exercise plays a very important role in stimulating regeneration of cartilage, which lacks blood vessels, by driving synovial fl uid through the joint cartilage. Joint mobility is increased by weight-bearing exercises, not rangeof-motion exercises, because surrounding muscles, ligaments, and tendons are strengthened. Pain is an early sign of degenerative joint bone problems. Swelling may not occur for some time after pain, if at all. Osteoarthritic pain is worsened in cold, damp weather; therefore, exercising outdoors is not recommended year round in all settings.

21. After teaching a group of clients with osteoarthritis about using regular exercise, which of the following client statements indicates effective teaching? ■ 1. "Performing range-of-motion exercises will increase my joint mobility." ■ 2. "Exercise helps to drive synovial fl uid through the cartilage." ■ 3. "Joint swelling should determine when to stop exercising." ■ 4. "Exercising in the outdoors year-round promotes joint relaxation."

4. The hip spica cast is used for treatment of femoral fractures; it immobilizes the affected extremity and the trunk securely. It extends from above the nipple line to the base of the foot of both extremities in a double hip spica. Constipation, possible due to lack of mobility, can cause abdominal distention or bloating. When the spica cast becomes too tight due to distention, the cast will compress the superior mesenteric artery against the duodenum. The compression produces abdominal pain, abdominal pressure, nausea, and vomiting. The nurse should assess the abdomen for decreased bowel sounds, not the superior mesenteric artery. The surgeon cannot manipulate a fracture through a small window in a double hip spica cast. The nurse cannot use the window to aid in repositioning because the window opening can break and cause cast disruption.

22. A client in a double hip spica cast is constipated. The surgeon cuts a window into the cast. Which of the following outcomes should the nurse anticipate? ■ 1. The window will allow the nurse to palpate the superior mesenteric artery. ■ 2. The window will allow the surgeon to manipulate the fracture site. ■ 3. The window will allow the nurses to reposition the client. ■ 4. The window will provide some relief from pressure due to abdominal distention as a result of constipation.

3. With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle spasms and external rotation. The client also experiences severe pain in the region of the fracture.

23. A client has an intracapsular hip fracture. The nurse should conduct a focused assessment to detect: ■ 1. Internal rotation. ■ 2. Muscle fl accidity. ■ 3. Shortening of the affected leg. ■ 4. Absence of pain in the fracture area

4. Multiple sclerosis would be the least likely chronic health problem for an older client with a hip fracture. Typically, multiple sclerosis is considered a severe crippling disorder of young clients. Hypertension is a common chronic health problem in older clients. Cardiac decompensation is common in older clients; it arises from cardiac musculature changes and age-related changes in the heart. This comorbid condition can complicate the treatment and care when the older client experiences a hip fracture. Pulmonary disease commonly arises from age-related changes in the respiratory system. These comorbid conditions can complicate the treatment and care when the older client experiences a hip fracture

24. The nurse is developing the plan of care for an older adult client with a hip fracture. Which of the following chronic health problems would the nurse be least likely to assess in the client? ■ 1. Hypertension. ■ 2. Cardiac decompensation. ■ 3. Pulmonary disease. ■ 4. Multiple sclerosis.

4. Insertion of a pin for the internal fi xation of an extracapsular fractured hip provides good fi xation of the fracture. The fracture site is stabilized and fractured bone ends are well approximated. As a result, the client is able to be mobilized sooner, thus reducing the risks of complications related to immobility. Internal fi xation with a pin insertion does not prevent hemorrhage or decrease the risk of neurovascular impairment, potential complications associated with any joint or bone surgery. It does not lessen the client's risk of infection at the site.

25. When teaching a client with an extracapsular hip fracture scheduled for surgical internal fi xation with the insertion of a pin, the nurse bases the teaching on the understanding that this surgical repair is the treatment of choice. Which of the following explains the reason? ■ 1. Hemorrhage at the fracture site is prevented. ■ 2. Neurovascular impairment risk is decreased. ■ 3. The risk of infection at the site is lessened. ■ 4. The client is able to be mobilized sooner.

3. The primary purpose of the drainage tube is to prevent fl uid accumulation in the wound. Fluid, when it accumulates, creates dead space. Elimination of the dead space by keeping the wound free of fl uid greatly enhances wound healing and helps prevent abscess formation. Although the characteristics of the drainage from the tube, such as a change in color or appearance, may suggest a possible infection, this is not the tube's primary purpose. The drainage tube does not eliminate the need for wound irrigation or provide a way to instill antibiotics into the wound.

26. A client with an extracapsular hip fracture returns to the nursing unit after internal fi xation and pin insertion with a drainage tube at the incision site. Her husband asks, "Why does she have this tube inserted in her hip?" Which of the following responses would be best? ■ 1. "The tube helps us to detect a wound infection early on." ■ 2. "This way we won't have to irrigate the wound." ■ 3. "Fluid won't be allowed to accumulate at the site." ■ 4. "We have a way to administer antibiotics into the wound."

2, 3, 4, 5. A client who has had a posterolateral total hip replacement should not adduct the hip joint, which would lead to dislocation of the ball out of the socket; therefore, the client should be encouraged to keep the toes pointed slightly outward when using a walker. An abduction pillow should be kept between the legs to keep the hip joint in an abducted position. The client should rotate between lying supine and lateral on the unoperated side, but not on the operated side. Ice is used to reduce swelling on the operative side. The client should not fl ex the operated hip beyond a 90-degree angle, such as when bending down to tie or slip on shoes. Doing so could lead to joint dislocation.

27. A client had a posterolateral total hip replacement 2 days ago. What should the nurse include in the client's plan of care? Select all that apply. ■ 1. When using a walker, encourage the client to point the toes inward. ■ 2. Position a pillow between the legs to maintain abduction. ■ 3. Allow the client to be in the supine position or in the lateral position on the unoperated side. ■ 4. Do not allow the client to bend down to tie or slip on shoes. ■ 5. Place ice on the incision after physical therapy.

1, 3, 4. A client who has had a total hip replacement via an anterolateral approach has almost the opposite precautions as those for a client who has had a total hip replacement through the posterolateral approach. The hip joint should not be actively abducted. The client should avoid turning the toes or knee outward. The client should keep the legs side by side without a pillow or wedge. The client should use an elevated toilet seat and shower chair and should not extend the operative leg backwards. The client should perform range-of-motion exercises as directed by the physical therapist.

28. Which information should the nurse include when performing discharge teaching with a client who had an anterolateral approach for a total hip replacement? Select all that apply. ■ 1. Avoid turning the toes or knee outward. ■ 2. Use an abduction pillow between the legs when in bed. ■ 3. Use an elevated toilet seat and shower chair. ■ 4. Do not extend the operative leg backwards. ■ 5. Restrict motion for 2 weeks after surgery.

2. Being unable to move the affected leg suggests neurologic impairment. A decrease in the distal pulse, diminished capillary refi ll, and coolness to touch of the affected extremity suggest vascular compromise

29. The nurse is assessing a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity? ■ 1. Decreased distal pulse. ■ 2. Inability to move. ■ 3. Diminished capillary refi ll. ■ 4. Coolness to the touch.

2. Placing a towel over the mirror indicates the client is having difficulty looking at his reflection, a body-image problem.

69. The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image? 1. The client requests a consultation by the speech therapist. 2. The client has a towel placed over the mirror. 3. The client is attempting to shave himself. 4. The client practices neck and shoulder exercises.

1, 2, 4. Rheumatoid arthritis (RA) affects women three times more often than men, between the ages of 20 and 55 years. Research has determined that RA occurs in clients who have had infectious disease, such as the Epstein-Barr virus. The genetic link, specifi cally HLA-DR4, has been found in 65% of clients with RA. People with osteoarthritis are not necessarily at risk for developing rheumatoid arthritis

3. Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply. ■ 1. Adults between the ages of 20 and 50 years. ■ 2. Adults who have had an infectious disease with the Epstein-Barr virus. ■ 3. Adults that are of the male gender. ■ 4. Adults who possess the genetic link, specifi - cally HLA-DR4. ■ 5. Adults who also have osteoarthritis.

1. Any activity or position that causes fl exion, adduction, or internal rotation of greater than 90 degrees should be avoided until the soft tissue surrounding the prosthesis has stabilized, at approximately 6 weeks. Crossing the legs while sitting down can lead to dislocation of the femoral head from the hip socket. Sitting on a raised commode seat prevents hip fl exion and adduction. Using an abductor splint while side-lying keeps the hip joint in abduction, thus preventing adduction and possible dislocation. Rising straight from a chair to a standing position is acceptable for this client because this action avoids hip fl exion, adduction, and internal rotation of greater than 90 degrees. CN

30. A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which of the following activities should the nurse instruct the client to avoid? ■ 1. Crossing the legs while sitting down. ■ 2. Sitting on a raised commode seat. ■ 3. Using an abductor splint while lying on the side. ■ 4. Rising straight from a chair to a standing position

3. A high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly fl exed femoral head to dislocate. CN: R

31. The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the fi rst 6 to 8 weeks after surgery. Which would be the correct type to recommend? ■ 1. A desk-type swivel chair. ■ 2. A padded upholstered chair. ■ 3. A high-backed chair with armrests. ■ 4. A recliner with an attached footrest

2. Although pets and furniture, such as snack tables and rocking chairs, may pose a problem, scatter rugs are the single greatest hazard in the home, especially for elderly people who are unsure and unsteady with walking. Falls have been found to account for almost half the accidental deaths that occur in the home. The risk of falls is further compounded by the client's need for crutches.

32. The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which of the following would pose the greatest hazard to the client as a risk for falling at home? ■ 1. A 4-year-old cocker spaniel. ■ 2. Scatter rugs. ■ 3. Snack tables. ■ 4. Rocking chairs

33. 3. When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.

33. In preparation for total knee surgery, a 200-lb client with osteoarthritis must lose weight. Which of the following exercises should the nurse recommend as best if the client has no contraindications? ■ 1. Weight lifting. ■ 2. Walking. ■ 3. Aquatic exercise. ■ 4. Tai chi exercise.

4. Before implementing a teaching plan, the nurse should determine the client's fears about the procedure. Only then can the client begin to hear what the nurse has to share about the individualized teaching plan designed to meet the client's needs. In the preoperative period, the client needs to learn how to correctly prevent hip fl exion and to demonstrate coughing and deep breathing. However, this teaching can be effective only after the client's fears have been assessed and addressed. Although the client may appreciate seeing what a hip prosthesis looks like, so as to understand the new body part, this is not a necessity.

34. Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time? ■ 1. Teaching how to prevent hip fl exion. ■ 2. Demonstrating coughing and deep-breathing techniques. ■ 3. Showing the client what an actual hip prosthesis looks like. ■ 4. Assessing the client's fears about the procedure.

1. The nurse should suspect nerve damage if numbness is present. However, whether the damage is short-term and related to edema or long-term and related to permanent nerve damage would not be clear at this point. The nurse needs to continue to assess the client's neurovascular status, including pain, pallor, pulselessness, paresthesia, and paralysis (the fi ve P's). Bleeding would suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would suggest adequate circulation to the area. Numbness would suggest neurologic damage.

35. The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment fi ndings should lead the nurse to suspect possible nerve damage? ■ 1. Numbness. ■ 2. Bleeding. ■ 3. Dislocation. ■ 4. Pinkness.

3. The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include infl ammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fi xed form before the wound is closed.

36. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these fi ndings as indicating which of the following? ■ 1. A developing infection. ■ 2. Bleeding in the operative site. ■ 3. Joint dislocation. ■ 4. Glue seepage into soft tissue.

1. An average adult requires approximately 1,100-1,400 mL of fl uids per day. In some instances, such as when a person has an increase in body temperature or has increased perspiration, additional water may be necessary. With an increase in body temperature, there is also an increase in insensible fl uid loss. The increased loss of fl uid causes an increased need for fl uid replacement. If the loss is signifi cant and/or goes untreated, an individual's intake will not be balanced with output. Managing the incision, changing the bed linens, or keeping the client's skin cool are not outcomes indicative of resolution of a fl uid volume defi cit.

37. A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fl uid volume defi cit related to diaphoresis is made. Which of the following is the most appropriate outcome? ■ 1. The client drinks 2,000 mL of fl uid per day. ■ 2. The client understands how to manage the incision. ■ 3. The client's bed linens are changed as needed. ■ 4. The client's skin remains cool throughout hospitalization.

4. After knee arthroplasty, the knee will be extended and immobilized with a fi rm compression dressing and an adjustable soft extension splint in place. A sequential compression device (SCD) will be applied. The SCD can be discontinued when the client is ambulatory, but while the client is in bed the SCD needs to be maintained to prevent thromboembolism. The SCD should be positioned on the bed, but not on two pillows. Settings for the SCD are ordered by the orthopedic surgeon. Initial dressing changes are completed by the orthopedic surgeon and changed as needed per physician order.

38. After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following? ■ 1. Elevate the sequential compression device (SCD) on two pillows. ■ 2. Change the settings on the SCD to make the client more comfortable. ■ 3. Stop the SCD to remove dressings and bathe the leg. ■ 4. Discontinue the SCD when the client is ambulatory.

1, 2, 3. The nurse should instruct the client to notify the dentist and other health care providers of the need to take prophylactic antibiotics if undergoing any procedure (e.g., tooth extraction) due to the potential of bacteremia. The nurse should also advise the client that the metal components of the joint may set off the metal-detector alarms in airports. The client should also avoid MRI studies because the implanted metal components will be pulled toward the large magnet core of the MRI. Any weight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to 5 lb. Post surgery, the client can resume a normal diet with regular fl uid intake.

39. The nurse is preparing the discharge of a client who has had a knee replacement with a metal joint. The nurse should instruct the client about which of the following? Select all that apply. ■ 1. Notify health care providers about the joint prior to invasive procedures. ■ 2. Avoid use of Magnetic Resonance Imaging (MRI) scans. ■ 3. Notify airport security that the joint may set off alarms on metal detectors. ■ 4. Refrain from carrying items weighing more than 5 lb. ■ 5. Limit fl uid intake to 1,000 mL/day.

3. Maintaining usual ways of accomplishing tasks would be the lowest priority during the acute phase. Rather, the focus is on developing less stressful ways of accomplishing routine tasks. Pain relief is a high priority during the acute phase because pain is typically severe and interferes with the client's ability to function. Preserving joint function and preventing joint deformity are high priorities during the acute phase to promote an optimal level of functioning and reduce the risk of contractures.

4. A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care? ■ 1. Relieving pain. ■ 2. Preserving joint function. ■ 3. Maintaining usual ways of accomplishing tasks. ■ 4. Preventing joint deformity.

4. After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction. The client must not abduct or fl ex the operated hip because this may produce dislocation

40. Following a total hip replacement, the nurse should position the client in which of the following ways? ■ 1. Place weights alongside of the affected extremity to keep the extremity from rotating. ■ 2. Elevate both feet on two pillows. ■ 3. Keep the lower extremities adducted by use of an immobilization binder around both legs. ■ 4. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs

2, 4, 5. Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to fl ex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.

41. Following a total hip replacement, the nurse should do which of the following? Select all that apply. ■ 1. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours. ■ 2. Encourage the client to use the overhead trapeze to assist with position changes. ■ 3. For meals, elevate the head of the bed to 90 degrees. ■ 4. Use a fracture bedpan when needed by the client. ■ 5. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises.

1, 3, 4. Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck's traction. The client will require anti-embolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per physician order.

42. A client is to have a total hip replacement. The preoperative plan should include which of the following? Select all that apply. ■ 1. Administer antibiotics as prescribed to ensure therapeutic blood levels. ■ 2. Apply leg compression device. ■ 3. Request a trapeze be added to the bed. ■ 4. Teach isometric exercises of quadriceps and gluteal muscles. ■ 5. Demonstrate crutch walking with a 3-point gait. ■ 6. Place Buck's traction on the bed.

1, 2, 3, 4. Client/family teaching should include advising the client to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or diffi culty breathing to healthcare provider immediately. Instruct the client not to take aspirin or nonsteroidal anti-infl ammatory drugs without consulting health care provider while on therapy. A low-molecular weight heparin is considered to be a high-risk medication and the client should wear or carry medical identifi cation. The air bubble should not be expelled from the syringe because the bubble insures the client receives the full dose of the medication. The client should allow 5 seconds to pass before withdrawing the needle to prevent seepage of the medication out of the site.

43. The nurse is teaching the client to administer enoxaparin (Lovenox) following a total hip arthroplasty? The nurse should instruct the client about which of the following? Select all that apply. ■ 1. Report promptly any diffi culty breathing, rash, or itching. ■ 2. Notify the health care provider of unusual bruising. ■ 3. Avoid all aspirin-containing medications. ■ 4. Wear or carry medical identifi cation. ■ 5. Expel the air bubble from the syringe before the injection. ■ 6. Remove needle immediately after medication is injected.

3. Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90- degree fl exion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.

44. A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying which of the following? ■ 1. "Don't worry. Your new hip is very strong." ■ 2. "Use of a cushioned toilet seat helps to prevent dislocation." ■ 3. "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." ■ 4. "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation."

1, 2, 3. Dislocation of a hip prosthesis may occur with positioning that exceeds the limits of the prosthesis. The nurse must recognize dislocation of the prosthesis. Signs of prosthesis dislocation include: acute groin pain in the affected hip, shortening of the affected leg, restricted ability or inability to move the affected leg, and reported "popping" sensation in the hip. Toe wiggling is not a test for potential hip dislocation.

45. The nurse is assessing a client who had a left hip replacement 36 hours ago. Which of the following indicates the prosthesis is dislocated? Select all that apply. ■ 1. The client reported a "popping" sensation in the hip. ■ 2. The left leg is shorter than the right leg. ■ 3. The client has sharp pain in the groin. ■ 4. The client cannot move his right leg. ■ 5. The client cannot wiggle the toes on the left leg.

4. If a prosthesis becomes dislocated, the nurse should immediately notify the surgeon. This is done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintain circulation. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. If ordered by the surgeon, an ice pack may be applied post reduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may order the client be turned toward the side of the reduced hip but that is not the nurse's fi rst response.

46. A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should fi rst? ■ 1. Stabilize the leg with Buck's traction. ■ 2. Apply an ice pack to the affected hip. ■ 3. Position the client toward the opposite side of the hip. ■ 4. Notify the orthopedic surgeon

3. Infection is a serious complication of total hip replacement and may necessitate removal of the implant. Clients who are obese, poorly nourished, elderly, have poorly controlled diabetes, rheumatoid arthritis, or concurrent infections (e.g., dental, urinary tract) are at high risk for infection. Clients who are of normal weight and have well-controlled chronic diseases are not at risk for infection. Living alone is not a risk factor for infection.

47. The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed fi rst? ■ 1. A 55-year-old client who is 6 feet tall and weighs 180 lb. ■ 2. A 90-year-old who lives alone. ■ 3. A 74-year-old who has periodontal disease with periodontitis. ■ 4. A 75-year-old who has asthma and uses an inhaler.

3. Expected outcomes at the time of discharge from the surgical unit after a hip replacement include the following: increased independence in transfers, participates in progressive ambulation without pain or assistance, and raises the affected leg without assistance. The client will not be able to walk throughout the hospital, walk for a distance without some postoperative pain, or raise the affected leg more than several inches. The client may be referred to a rehabilitation unit in order to achieve the additional independence, strength, and pain relief.

48. The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit? ■ 1. The client can walk throughout the entire hospital with a walker. ■ 2. The client can walk the length of a hospital hallway with minimal pain. ■ 3. The client has increased independence in transfers from bed to chair. ■ 4. The client can raise the affected leg 6 inches with assistance

1, 2, 3, 4. Postoperatively, the knee in a total knee replacement is dressed with a compression bandage and ice may be applied to control edema and bleeding. Recurrent assessment by the nurse for neurovascular changes can prevent loss of limb. Normal neurovascular fi ndings include: color normal, extremity warm, capillary refi ll less than 3 seconds, moderate edema, tissue not palpably tense, pain controllable, normal sensations, no paresthesia, normal motor abilities, no paresis or paralysis, and pulses strong and equal.

49. The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal fi ndings? Select all that apply. ■ 1. Reduced edema of the left knee. ■ 2. Skin warm to touch. ■ 3. Capillary refi ll response. ■ 4. Moves toes. ■ 5. Pain absent. ■ 6. Pulse on left leg weaker than right leg

4. Smoking is the number-one risk factor for developing cancer of the lung. More than 85% of lung cancers are attributable to inhalation of chemicals. There are more than 400 chemicals in each puff of cigarette smoke, 17 of which are known to cause cancer.

49. The nurse is taking the social history from a client diagnosed with small cell carcinoma of the lung. Which information is significant for this disease? 1. The client worked with asbestos for a short time many years ago. 2. The client has no family history for this type of lung cancer. 3. The client has numerous tattoos covering both upper and lower arms. 4. The client has smoked two (2) packs of cigarettes a day for 20 years.

3. Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold

5. The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge defi cit? ■ 1. "I can use heat and cold as often as I want." ■ 2. "With heat, I should apply it for no longer than 20 minutes at a time." ■ 3. "Heat-producing liniments can be used with other heat devices." ■ 4. "Ten to 15 minutes per application is the maximum time for cold applications."

50. 4. The knee is usually protected with a knee immobilizer (splint, cast, or brace) and is elevated when the client sits in a chair. Pre- and post-surgery, the physician prescribes weight-bearing limits and use of assistive devices for progressive ambulation. Positioning a straight-backed chair at the foot of the bed is not an action conducive for getting the client out of bed on the evening of surgery for a total knee replacement.

50. On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following? ■ 1. Encourage the client to apply full weightbearing. ■ 2. Order a walker for the client. ■ 3. Place a straight-backed chair at the foot of the bed. ■ 4. Apply a knee immobilizer.

1. Respiratory distress is a common finding in clients diagnosed with lung cancer. As the tumor grows and takes up more space or blocks air movement, the client may need to be taught positioning for lung expan- sion. The administration of oxygen will help the client to use the lung capacity that is available to get oxygen to the tissues. 2. Clients with lung cancer frequently become fatigued trying to eat. Providing six (6) small meals spaces the amount of food the client eats throughout the day. 4. Clients with cancer of the lung are at risk for developing an infection from lowered resistance as a result of treatments or from the tumor blocking secretions in the lung. Therefore, monitoring for the presence of fever, a possible indication of infection, is important. 5. Assessment of the lungs should be com- pleted on a routine and PRN basis.

50. The nurse writes a problem of "impaired gas exchange" for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply. 1. Apply O2 via nasal cannula. 2. Have the dietitian plan for six (6) small meals per day. 3. Place the client in respiratory isolation. 4. Assess vital signs for fever. 5. Listen to lung sounds every shift.

1, 4. After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. After discharge, the client may undergo physical therapy on an outpatient basis per physician order. The client should leave the dressing in place until the follow-up visit with the surgeon.

51. When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information in the discharge plan? Select all that apply. ■ 1. Report signs of infection to health care provider. ■ 2. Keep the affected leg and foot on the fl oor when sitting in a chair. ■ 3. Remove anti-embolism stockings when sleeping. ■ 4. The physical therapist will encourage progressive ambulation with use of assistive devices. ■ 5. Change the dressing daily

1. Deep vein thrombosis is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a DVT or PE are at high risk. Immobility produces venous stasis, increasing the client's chance to develop a venous thromboembolism. Signs of a DVT include: unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the physician for defi nitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Intussusception of the bowel and wound evisceration tend to occur after abdominal surgeries. CN: Reduction of

52. Following a total joint replacement, which of the following complications has the greatest likelihood of occurring? ■ 1. Deep vein thrombosis (DVT). ■ 2. Polyuria. ■ 3. Intussception of the bowel. ■ 4. Wound evisceration.

3. Biologic response modifiers that stimulate the bone marrow can increase the client's blood pressure to dangerous levels. This BP is very high and warrants immediate attention.

52. The nurse and an unlicensed nursing assistant are caring for a group of clients on a medical unit. Which information provided by the assistant warrants immediate inter- vention by the nurse? 1. The client diagnosed with cancer of the lung has a small amount of blood in the sputum collection cup. 2. The client diagnosed with chronic emphysema is sitting on the side of the bed and leaning over the bedside table. 3. The client receiving Procrit, a biologic response modifier, has a T 99.2°, P 68, R 24, and BP of 198/102. 4. The client receiving prednisone, a steroid, is complaining of an upset stomach after eating breakfast.

53. 1. This situation indicates a terminal process, and the client should make decisions for the end of life.

53. The client diagnosed with lung cancer has been told that the cancer has metastasized to the brain. Which intervention should the nurse implement? 1. Discuss implementing an advance directive. 2. Explain the use of chemotherapy for brain involvement. 3. Teach the client to discontinue driving. 4. Have the significant other make decisions for the client.

2. Investigational treatments are just that— treatments being investigated to see if they are effective in the care of clients diagnosed with cancer. There is no guarantee the treatments will help the client.

54. The client diagnosed with lung cancer is in an investigational program and receiving a vaccine to treat the cancer. Which information regarding investigational regimens should the nurse teach? 1. Investigational regimens provide a better chance of survival for the client. 2. Investigational treatments have not been proved helpful to clients. 3. Clients will be paid to participate in an investigational program. 4. Only clients that are dying qualify for investigational treatments.

3. Shared governance is a system where the staff is empowered to make decisions such as scheduling and hiring of certain staff. Staff members are encouraged to partici- pate in developing policies and procedures to reach set goals.

55. The staff on an oncology unit is interviewing applicants for a position as the unit manager. Which type of organizational structure does this represent? 1. Centralized decision-making. 2. Decentralized decision-making. 3. Shared governance. 4. Pyramid with filtered-down decisions.

56. 1. Research indicates that smoking will still interfere with the client's response to treat- ment.

56. The client diagnosed with lung cancer is being discharged. Which statement made by the client indicates that more teaching is needed? 1. "It doesn't matter if I smoke now. I already have cancer." 2. "I should see the oncologist at my scheduled appointment." 3. "If I begin to run a fever I should notify the HCP." 4. "I should plan for periods of rest throughout the day."

4. Coughing up blood could indicate a lung cancer and should be investigated.

57. The nurse working in an outpatient clinic is interviewing clients. Which information provided by the client warrants further investigation? 1. The client uses Vicks VapoRub every night before bed. 2. The client has had an appendectomy. 3. The client takes a multiple vitamin pill every day. 4. The client has been coughing up blood in the mornings.

2. This is about a pint of blood loss and could indicate the client is hemorrhaging.

58. The client is four (4) hours post-lobectomy for cancer of the lung. Which assessment data warrant immediate intervention by the nurse? 1. The client has an intake of 1500 mL IV and an output of 1000 mL. 2. The client has 450 mL of bright-red drainage in the chest tube. 3. The client is complaining of pain at a "10" on a 1-10 scale. 4. The client has absent lung sound on the side of the surgery.

. 4. The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the physician's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions from the client about the physician. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for cases that are worse than the client's demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client not to worry ignores the underlying emotions associated with the question, totally discounting the client's feelings.

6. The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate? ■ 1. "It's the physician's prerogative to decide how to treat you. The physician has chosen what is best for your situation." ■ 2. "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." ■ 3. "That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about it." ■ 4. "Every person is different. What works for one client may not always be effective for another."

4. The priority action any time a client makes a statement regarding taking his or her own life is to determine if the client has thought it through enough to have a plan. A plan indicates an emergency situation.

60. The client diagnosed with oat cell carcinoma of the lung tells the nurse, "I am so tired of all this. I might as well just end it all." Which should be the nurse's first response? 1. Respond by saying, "This must be hard for you. Would you like to talk?" 2. Tell the HCP of the client's statement. 3. Refer the client to a social worker or spiritual advisor. 4. Find out if the client has a plan to carry out suicide.

3. A laryngoscopy will be done to allow for visualization of the vocal cords and to obtain a biopsy for pathological diagnosis.

61. The nurse is admitting a client with a diagnosis of rule out cancer of the larynx. Which information should the nurse teach? 1. Demonstrate the proper method of gargling with normal saline. 2. Perform voice exercises for 30 minutes three (3) times a day. 3. Explain that a lighted instrument will be placed in the throat to biopsy the area. 4. Teach the client to self-examine the larynx monthly.

1. The teeth will be in the area of radiation and the roots of teeth are highly sensitive to radiation, which results in root abscesses. The teeth are removed and the client is fitted for dentures prior to radiation.

62. The client is diagnosed with cancer of the larynx and is to have radiation therapy to the area. For which prophylactic procedure will the nurse prepare the client? 1. Removal of the teeth. 2. Taking anti-emetic medications every four (4) hours. 3. Wearing sunscreen on the area at all times. 4. Placement of a PEG tube.

2. The client should be eating normal foods by this time. The consistency should be soft to allow for less chewing of the food and easier swallowing because a portion of the throat musculature has been removed. The client should be taught to turn the head toward the affected side when swal- lowing to help prevent aspiration.

63. The client is three (3) days post-partial laryngectomy. Which type of nutrition should the nurse offer the client? 1. Total parenteral nutrition. 2. Soft, regular diet. 3. Partial parenteral nutrition. 4. Clear liquid diet.

4. The client is having the vocal cords removed and will be unable to speak. Communication is a high priority for this client. If the client is able to read and write, a Magic Slate or pad of paper should be provided. If the client is illiterate, the nurse and the client should develop a method of communication using pictures.

64. The nurse is preparing the client diagnosed with laryngeal cancer for a laryngectomy in the morning. Which intervention would have priority? 1. Take the client to the intensive care unit for a visit. 2. Explain that the client will need to ask for pain medication. 3. Demonstrate the use of an anti-embolism hose. 4. Find out if the client can read and write.

3. The Lost Chord Club is an American Cancer Society-sponsored group of survi- vors of larynx cancer. These clients are able to discuss the feelings and needs of clients that have had laryngectomies because they have all had this particular surgery.

65. The client has had a total laryngectomy. Which referral is specific for this surgery? 1. CanSurmount. 2. Dialogue. 3. Lost Chord Club. 4. SmokEnders.

1. The most serious complication resulting from a radical neck dissection is rupture of the carotid artery. A continuous bright-red drainage indicates bleeding, and this client should be assessed immediately.

66. The nurse and unlicensed nursing assistant are caring for a group of clients on a surgi- cal floor. Which information provided by the nursing assistant requires immediate intervention by the nurse? 1. There is a small, continuous amount of bright-red drainage coming out from under the dressing of the client who had a radical neck dissection. 2. The client who has had a right upper lobectomy is complaining that the patient controlled analgesia (PCA) pump is not giving any relief. 3. The client diagnosed with cancer of the lung is complaining of being tired and short of breath. 4. The client admitted with chronic

1. Chest tubes are part of the nursing education curriculum. The new graduate should be capable of caring for this client or at least knowing when to get assistance.

67. The charge nurse is assigning clients for the shift. Which client should be assigned to the new graduate nurse? 1. The client diagnosed with cancer of the lung who has chest tubes. 2. The client diagnosed with laryngeal spasms who has stridor. 3. The client diagnosed with laryngeal cancer who has multiple fistulas. 4. The client who is two (2) hours post-partial laryngectomy.

4. Positions of fl exion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders

7. The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods? ■ 1. Proper body alignment. ■ 2. Elevating the part. ■ 3. Prone lying positions. ■ 4. Positions of fl exion.

70. 1. This is an example of nonmalfeasance where the nurse "does no harm." In attempting to discuss the client's refusal, the nurse is not trying to influence the client; the nurse is merely attempting to listen therapeutically.

70. The HCP has recommended a total laryngectomy for a male client diagnosed with cancer of the larynx but the client refuses. Which intervention by the nurse illustrates the ethical principle of nonmalfeasance? 1. The nurse listens to the client explain why he is refusing surgery. 2. The nurse and significant other insist that the client have the surgery. 3. The nurse refers the client to a counselor for help with the decision. 4. The nurse asks a cancer survivor to come and discuss the surgery with the client.

4. The esophagus is extremely radiosensitive, and esophageal ulcerations are common. The pain can become so severe that the client cannot swallow saliva. This is a situation in which the client will be admit- ted to the hospital for IV narcotic pain medication and possibly total parenteral nutrition.

71. The client diagnosed with cancer of the larynx has had four (4) weeks of radiation ther- apy to the neck. The client is complaining of severe pain when swallowing. Which scientific rationale explains the pain? 1. The cancer has grown to obstruct the esophagus. 2. The treatments are working on the cancer and the throat is edematous. 3. Cancers are painful and this is expected. 4. The treatments are also affecting the esophagus, causing ulcerations.

3. Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease. Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because of the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/dL are considered a risk factor for peripheral vascular disease.

71. Which of the following should the nurse identify as the least likely factor contributing to a client's peripheral vascular disease? ■ 1. Uncontrolled diabetes mellitus for 15 years. ■ 2. A 20-pack-year history of cigarette smoking. ■ 3. Current age of 39 years. ■ 4. A serum cholesterol concentration of 275 mg/dL

. 2. The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insuffi ciency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal fi nding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.

72. A client has severe arterial occlusive disease and gangrene of the left great toe. Which of the following fi ndings is expected? ■ 1. Edema around the ankle. ■ 2. Loss of hair on the lower leg. ■ 3. Thin, soft toenails. ■ 4. Warmth in the foot

2. The client breathes through a stoma in the neck. Care should be taken not to allow water to enter the stoma. 4. The client has lost the use of the nasal passages to humidify the inhaled air, and artificial humidification is useful until the client's body adapts to the change. 5. There is special equipment available for clients who cannot hear or speak.

72. The client who has undergone a radical neck dissection and tracheostomy for cancer of the larynx is being discharged. Which discharge instructions should the nurse teach? Select all that apply. 1. The client will be able to speak again after the surgery area has healed. 2. The client should wear a protective covering over the stoma when showering. 3. The client should clean the stoma and then apply a petroleum-based ointment. 4. The client should use a humidifier in the room. 5. The client can get a special telephone for communication.

3. The client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arteries. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive an opioid analgesic, not a sedative, to control the pain as the blood pressure cuffs are infl ated during the Doppler studies to determine the ankle-to-brachial pressure index. The client's ankle should not be covered with a blanket because the weight of the blanket on the ischemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet off the affected foot.

73. A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should: ■ 1. Have the client sign a consent form for the procedure. ■ 2. Administer a pretest sedative as appropriate. ■ 3. Keep the client tobacco-free for 30 minutes before the test. ■ 4. Wrap the client's affected foot with a blanket

2. Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insuffi ciency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.

74. The client with peripheral arterial disease says, "I've really tried to manage my condition well." Which of the following should the nurse determine as appropriate for this client? ■ 1. Resting with the legs elevated above the level of the heart. ■ 2. Walking slowly but steadily for 30 minutes twice a day. ■ 3. Minimizing activity as much and as often as possible. ■ 4. Wearing antiembolism stockings at all times when out of bed.

1. Daily lubrication, inspection, cleaning, and patting dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the feet in warm water should be avoided because soaking can lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insuffi ciency typically experiences sensory changes, so the client may be unable to detect water that is too warm, thus placing the client at risk for burns. Antiembolism stockings, appropriate for clients with venous insuffi ciency, are inappropriate for clients with arterial insuffi ciency and could leadto a worsening of the condition. Footwear should be roomy, soft, and protective and allow air to circulate. Therefore, fi rm, supportive leather shoes would be inappropriate.

75. Which of the following should the nurse include in the teaching plan for a client with arterial insuffi ciency to the feet that is being managed conservatively? ■ 1. Daily lubrication of the feet. ■ 2. Soaking the feet in warm water. ■ 3. Applying antiembolism stockings. ■ 4. Wearing fi rm, supportive leather shoes.

2. Encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, "At least you will still have one good leg to use," that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term "invalid." The nurse needs to focus on this concern and not try to complete the teaching fi rst before discussing what is on the client's mind. The client's needs, not the nurse's needs, must be met fi rst. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the client's wife caring for him may reinforce the client's feelings of helplessness as an invalid.

76. A client says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be the nurse's most therapeutic response? ■ 1. "At least you will still have one good leg to use." ■ 2. "Tell me more about how you're feeling." ■ 3. "Let's fi nish the preoperative teaching." ■ 4. "You're lucky to have a wife to care for you."

2. The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fi tting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the client's ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant.

77. The client asks the nurse, "Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?" On which of the following should the nurse base the response? ■ 1. The need to remove as much of the leg as possible. ■ 2. The adequacy of the blood supply to the tissues. ■ 3. The ease with which a prosthesis can be fi tted. ■ 4. The client's ability to walk with a prosthesis

4. The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identifi ed, the surgeon should be notifi ed. The stump is not elevated because adhesions may occur, interfering with the ability to fi t a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing.

78. A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should: ■ 1. Elevate the stump. ■ 2. Reinforce the dressing. ■ 3. Call the surgeon. ■ 4. Draw a mark around the site.

4. The nurse's fi rst action should be to administer the prescribed opioid analgesic to the client, because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.

79. A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do fi rst? ■ 1. Tell the client it is impossible to feel the pain. ■ 2. Show the client that the toes are not there. ■ 3. Explain to the client that her pain is real. ■ 4. Give the client the prescribed opioid analgesic.

4. Carrying a laundry basket with clinched fingers and fists is not an example of conserving energy of small joints. The laundry basket should be held with both hands opened as wide as possible and with outstretched arms so that pressure is not placed on the small joints of the fingers. When rising from a chair, the palms should be used instead of the fingers so as to distribute weight over the larger area of the palms. Holding packages close to the body provides greater support to the shoulder, elbow, and wrist joints because muscles of the arms and hands are used to stabilize the weight against the body. This decreases the stress and weight or pull on small joints such as the fingers. Objects can be slid with the palm of the hand, which distributes weight over the larger area of the palms instead of stressing the small joints of the fingers to pick up the weight of the object to move it to another place.

8. After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching? ■ 1. Pushing with palms when rising from a chair. ■ 2. Holding packages close to the body. ■ 3. Sliding objects. ■ 4. Carrying a laundry basket with clinched fi ngers and fi sts.

4. Use of crutches requires signifi cant strength from the triceps muscles. Therefore, efforts are focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-ups are excellent exercises targeted at the triceps muscles. Abdominal exercises, range-of-motion and isometric exercises of the shoulders, and quadriceps and gluteal setting exercises are not helpful in preparing for crutch walking.

80. The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches? ■ 1. Abdominal exercises. ■ 2. Isometric shoulder exercises. ■ 3. Quadriceps setting exercises. ■ 4. Triceps stretching exercises.

4. When using crutches, the client is taught to support her weight primarily on the hands. Supporting body weight on the axillae, elbows, or upper arms must be avoided to prevent nerve damage from excessive pressure.

81. The nurse teaches a client about using the crutches, instructing the client to support her weight primarily on which of the following body areas? ■ 1. Axillae. ■ 2. Elbows. ■ 3. Upper arms. ■ 4. Hands

4. Before beginning dietary instructions and interventions, the nurse must fi rst assess the client's and family's food preferences, such as pattern of food intake, life style, food preferences, and ethnic, cultural, and fi nancial infl uences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base.

82. The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's fi rst step in planning the dietary instructions? ■ 1. Determining the client's knowledge level about cholesterol. ■ 2. Asking the client to name foods that are high in fat, cholesterol, and salt. ■ 3. Explaining the importance of complying with the diet. ■ 4. Assessing the client's and family's typical food preferences.

3. Isometric contractions increase the tension within a muscle but do not produce movement. Repeated isometric contractions make muscles grow larger and stronger. Adduction of the leg puts work onto the hip joint as well as altering the pull of traction. Rolling the leg, or external rotation, alters the pull of traction. Additional weight should not be added to traction unless ordered by the physician; it will not prevent muscle atrophy

83. A client has a leg immobilized in traction. Which of the following activities demonstrated by the client indicate that the client understands actions to take to prevent muscle atrophy? ■ 1. The client adducts the affected leg every 2 hours. ■ 2. The client rolls the affected leg away from the body's midline twice per day. ■ 3. The client performs isometric exercises to the affected extremity three times per day. ■ 4. The client asks the nurse to add a 5-lb weight to the traction for 30 minutes/day.

3. Methocarbamol is a muscle relaxant and acts primarily to relieve muscle spasms. It has no effect on microorganisms, does not reduce itching, and has no effect on nervousness.

84. The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect? ■ 1. Lack of infection. ■ 2. Reduction in itching. ■ 3. Relief of muscle spasms. ■ 4. Decrease in nervousness

1, 2, 3. Acetaminophen is an alternative for a client who is allergic to aspirin. It does not affect platelet aggregation and the client does not need to have coagulation studies (such as INR). Acetaminophen causes little or no gastric distress. Acetaminophen exerts no anti-infl ammatory effects.

85. When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply. ■ 1. The drug can be used if the person is allergic to aspirin. ■ 2. Acetaminophen does not affect platelet aggregation. ■ 3. This drug causes little or no gastric distress. ■ 4. Acetaminophen exerts a strong antiinfl ammatory effect. ■ 5. The client should have the International Normalized Ratio (INR) checked regularly.

3. Hypotension, tachycardia, and depressed respirations are signs of high levels of ingestion of muscle relaxants, and the client may be developing a habit of taking this drug for a prolonged period. The potential for abuse should be considered when large doses of a muscle relaxant such as carisoprodol are taken for prolonged periods. Expected common adverse effects would include drowsiness, fatigue, lassitude, blurred vision, headache, ataxia, weakness, and gastrointestinal upset. Hemorrhage from gastrointestinal irritation is not associated with this drug. Hypersensitivity reactions would be manifested by pruritus and rashes.

86. A client who has been taking carisoprodol (Soma) at home for a fractured arm is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115 bpm, and respirations of 8 breaths/minute and shallow. The nurse interprets these fi ndings as indicating which of the following? ■ 1. Expected common adverse effects. ■ 2. Hypersensitivity reaction. ■ 3. Possible habituating effect. ■ 4. Hemorrhage from gastrointestinal irritation

3. The nursing assessment is fi rst focused on the region distal to the fracture for neurovascular injury or compromise. When a nerve or blood vessel is severed or obstructed at the actual fracture site, innervation to the nerve or blood fl ow to the vessel is disrupted below the site; therefore, the area distal to the fracture site is the area of compromised neurologic input or vascular fl ow and return, not the area above the fracture site or the fracture site itself. The nurse may assess the opposite extremity at the area proximal to the fracture site for a baseline comparison of pulse quality, color, temperature, size, and so on, but the comparison would be made after the initial neurovascular assessment.

87. When admitting a client with a fractured extremity, the nurse should fi rst focus the assessment on which of the following? ■ 1. The area proximal to the fracture. ■ 2. The actual fracture site. ■ 3. The area distal to the fracture. ■ 4. The opposite extremity for baseline comparison

3. Clients should not pull out cast padding to scratch inside the cast because of the hazard of skin breakdown and subsequent potential for infection. Clients are encouraged to elevate the casted extremity above the level of the heart to reduce edema and to exercise or move the joints above and below the cast to promote and maintain fl exibility and muscle strength. Applying ice for 10 minutes during the fi rst 24 hours helps to reduce edema.

88. Which of the following client statements identifi es a knowledge defi cit about cast care? ■ 1. "I'll elevate the cast above my heart initially." ■ 2. "I'll exercise my joints above and below the cast." ■ 3. "I can pull out cast padding to scratch inside the cast." ■ 4. "I'll apply ice for 10 minutes to control edema for the fi rst 24 hours."

2. The client in a double hip spica cast should avoid eating foods that can be constipating, such as cheese. Rather, fresh fruits and vegetables should be encouraged and the client should be encouraged to drink at least 2,500 mL/day. Drinking cranberry juice, which helps keep urine acidic, thereby avoiding the development of renal calculi, is encouraged. The client should be encouraged to establish regular times for elimination to promote regularity in bowel and bladder habits. The client will develop orthostatic hypotension unless the circulatory system is reconditioned slowly through dangling and standing exercises

89. Which of the following interventions would be least appropriate for a client who is in a double hip spica cast? ■ 1. Encouraging the intake of cranberry juice. ■ 2. Advising the client to eat large amounts of cheese. ■ 3. Establishing regular times for elimination. ■ 4. Having the client dangle at the bedside.

1. Because some over-the-counter vitamin supplements contain folic acid, the client should avoid self-medication with vitamins while taking methotrexate, a folic acid antagonist. Because methotrexate is hepatotoxic, the client should avoid the intake of alcohol, which could increase the risk for hepatotoxicity. Methotrexate can cause bone marrow depression, placing the client at risk for infection. Therefore, meticulous mouth care is essential to minimize the risk of infection. Contraception should be used during methotrexate therapy and for 8 weeks after the therapy has been discontinued because of its effect on mitosis. Methotrexate is considered teratogenic.

9. After teaching the client with severe rheumatoid arthritis about prescribed methotrexate (Rheumatrex), which of the following statements indicates the need for further teaching? ■ 1. "I will take my vitamins while I'm on this drug." ■ 2. "I must not drink any alcohol while I'm taking this drug." ■ 3. "I should brush my teeth after every meal." ■ 4. "I will continue taking my birth control pills."

2. A two-point gait involves partial weight bearing on each foot, with each crutch advancing simultaneously with the opposing leg. Advancing a crutch on one side and then advancing the opposite foot, and repeating on the opposite side, illustrates the four-point gait. When the client advances both crutches together and follows by lifting both lower extremities to the same level as the crutches, the gait is called a "swing to" gait. When the client advances both crutches together and follows by lifting both lower extremities past the level of the crutches, the gait is called a "swing through" gait. The "swing through" gait is often used by paraplegic clients because it allows them to place weight on their legs while the crutches are moved one stride ahead

90. The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include? ■ 1. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side. ■ 2. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. ■ 3. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches. ■ 4. Advance both crutches together and then follow by lifting both lower extremities past the level of the crutches

1. The wound was left open with a three-way drainage system in place to irrigate the debrided wound with normal saline or an antibiotic. Before the debridement, a sample of the wound would be taken for culture and sensitivity testing so that an organism-specifi c antibiotic could be administered to prevent possible serious sequelae of osteomyelitis. Therefore, the nurse should review the results of the culture and sensitivity report. A pressure dressing would not be applied to an open wound. Rather, a wet-to-dry dressing most likely would be used. There should not be increased pain related to the exposure of nerve endings in the subcutaneous tissue of the wound that was left open to the environment. The bleeding of vessels should be controlled as it would have been if the wound had been closed. Therefore, additional vessel bleeding should not be a problem.

91. A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should fi rst: ■ 1. Review the results of culture and sensitivity testing of the wound. ■ 2. Look for the presence of a pressure dressing over the wound. ■ 3. Determine if the client has increased pain from exposed nerve endings. ■ 4. Check the client's blood pressure for hypotension resulting from additional vessel bleeding

1. The nurse should assess the client's ability to move her toes and for the presence of distal pulses, including a neurovascular assessment of the area below the cast. Increasing pain unrelieved by usual analgesics and occurring 4 to 12 hours after the onset of casting or trauma may be the fi rst sign of compartment syndrome, which can lead to permanent damage to nerves and muscles. Although the nurse can use a pain rating scale or assess for changes in vital signs to objectively assess the client's pain, the client's complaints suggest early and important signs of compartment syndrome requiring immediate intervention. The nurse should not confuse these signs with the potential for drug tolerance. This assessment might be appropriate once the suspicion of compartment syndrome has been ruled out

92. A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment? ■ 1. Presence of a distal pulse. ■ 2. Pain with a pain rating scale. ■ 3. Vital sign changes. ■ 4. Potential for drug tolerance.

4. The client with compartment syndrome may release myoglobin from damaged muscle cells into the circulation. This becomes trapped in the renal tubules, resulting in dark, scanty urine, possibly leading to acute renal failure. Crackles may suggest respiratory complications; jaundice suggests liver failure; and generalized edema may suggest heart failure. However, these are not associated with compartment syndrome.

93. A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? ■ 1. Crackles. ■ 2. Jaundice. ■ 3. Generalized edema. ■ 4. Dark, scanty urine.

4. Skeletal traction is not used to pull weight with a boot. Skeletal traction involves the insertion of a wire or a pin into the bone to maintain a pull of 5 to 45 lb on the area, promoting proper alignment of the fractured bones over a long term

95. After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching? ■ 1. To align injured bones. ■ 2. To provide long-term pull. ■ 3. To apply 25 lb of traction. ■ 4. To pull weight with a boot

4. The client with a femoral fracture in balanced suspension traction should not be given a complete bed bath. Rather, the client is encouraged to participate in self-care and movement in bed, such as with a trapeze triangle. Use of a fracture bedpan is appropriate. A fracture bedpan is lower, and it is easier for the client to move on and off the bedpan without altering the line of traction. Checking for areas of redness or pressure over all areas in contact with the traction or bed, including the ischial tuberosity, is important to prevent possible skin breakdown. The client should be positioned so that the feet do not press against the footboard. Therefore, elevating the head of the bed no more than 25 degrees is recommended to keep the client from moving down in the bed.

96. The nurse is planning care for the client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care? ■ 1. Use of a fracture bedpan. ■ 2. Checks for redness over the ischial tuberosity. ■ 3. Elevation of the head of bed no more than 25 degrees. ■ 4. Personal hygiene with a complete bed bath

. 3. Neurovascular checks should be performed distal or past the site of the splint, not proximal or above the site of the splint, at least every 4 hours. An injury or compromise to the peripheral nervous innervation or blood fl ow will refl ect a change on the site of the splint after the pathway from the heart and brain. Checking the skin over the greater trochanter is appropriate because the half-ring of the Thomas splint can slide around the greater trochanter area where the traction is applied; it should be checked routinely along with other areas at high risk for pressure necrosis, such as the fi bular head, ischial tuberosity, malleoli, and hamstring tendons. Inspecting the pin site is appropriate because any drainage or redness might indicate an infection in the bone in which the pin is inserted. Immediate treatment is imperative to avoid osteomyelitis and possible loss of the limb. Evaluation of the foot for movement is important to obtain neuromuscularvascular data for assessment in comparison with the baseline data of the affected extremity and with the opposite extremity to detect any compromise of the client's condition.

97. A client is in balanced suspension traction using a half-ring Thomas splint with a Pearson attachment that suspends the lower extremity and applies direct skeletal traction for a hip fracture. Which of the following nursing assessments would not be appropriate? ■ 1. Greater trochanter skin checks. ■ 2. Pin site inspection. ■ 3. Neurovascular checks proximal to the splint. ■ 4. Foot movement evaluation

3. The nurse should send the client to the operating room on his bed with extra help to keep the traction from moving to maintain the femur in the proper alignment before surgery. Transferring the client to a cart with manually suspended traction is inappropriate because doing so places the client at risk for additional trauma to the surrounding neurovascular and soft tissues, as would removing the traction. The surgeon need not be called because the decision about transferring the client is an independent nursing action.

98. The client in balanced suspension traction is transported to surgery for closed reduction and internal fi xation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room? ■ 1. Transfer the client to a cart with manually suspended traction. ■ 2. Call the surgeon to request an order to temporarily remove the traction. ■ 3. Send the client on his bed with extra help to stabilize the traction. ■ 4. Remove the traction and send the client on a cart.

1. The Pearson attachment supports the lower leg and provides increased stability in the overall traction setup. It also makes it easier to maintain correct alignment. It does not support the thigh and upper leg or prevent fl exion deformities in the ankle and foot. It is not attached to the skeletal pin.

99. A client has a Pearson attachment on the traction setup. Which of the following is the purpose of this attachment? ■ 1. To support the lower portion of the leg. ■ 2. To support the thigh and upper leg. ■ 3. To allow attachment of the skeletal pin. ■ 4. To prevent fl exion deformities in the ankle and foot