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A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first?
A. Remind the client to push the button for the PCA device
B. Discuss activities the client can use to distract from the pain
C. Ask the client to describe the characteristics of the pain
D. Pause the CPM machine briefly to apply a cold pack to the client’s knee
This situation requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to acquire further data by asking the client to describe the characteristics of the pain.
A nurse in an ambulatory clinic is caring for a client who sustained facial trauma to the nose. Which of the following actions should the nurse take first?
A. Determine the client’s ability to take deep breaths
B. Place a cold compress on the nasal area
C. Palpate the nasal area for crepitation
D. Offer the client an analgesic medication
The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse’s priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the first action the nurse should take is to acquire further data by determining the client's ability to take deep breaths
A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery?
A. Balanced skeletal traction
B. Pelvic belt
C. Pelvic sling
D. Buck's traction
Buck's traction is used prior to hip arthroplasty to maintain alignment and prevent muscle spasms prior to surgery.
A nurse is collecting data from a client who has rheumatoid arthritis. The client's medical record indicates the presence of Heberden's nodes. Which of the following findings should the nurse expect?
A. Inflamed, fluid-filled sacs over the joints
B. Clubbing of the fingernails
C. Flexion contracture of the fingers
D. Hard lumps over the joints of the fingers
Heberden's nodes are hard, bony lumps or nodules in the joints of the fingers.
A nurse is assisting with preparing a client who is postoperative following a conventional lumbar disk excision for discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
A. "I should have no problem climbing stairs when I get home."
B. "I'll wait about 3 weeks before I return to my usual activities."
C. "I'll use my heating pad if I feel any muscle spasms in my back."
D. "I can start driving again in about 2 weeks or so."
Weight-bearing exercises help maintain bone mass and prevent osteoporosis. Walking is generally a safe activity for older clients.
A nurse is reinforcing post-procedural teaching with a client who had a diagnostic knee arthroscopy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
A. "I'll take aspirin to relieve my pain."
B. "I'll keep my leg elevated for the first day."
C. "I'll put a heating pad on my knee for the first day."
D. "I'll resume my usual activities as soon as I leave."
Following a diagnostic arthroscopy, the client should keep the leg elevated for 12 to 24 hours to help reduce pain and swelling.
A nurse is performing medication reconciliation for a newly admitted client who has rheumatoid arthritis (RA). Which of the following medications should the nurse identify as a treatment for this condition?
A. Misoprostol
B. Dantrolene
C. Celecoxib
D. Colchicine
Celecoxib is a type of NSAID, also called cyclooxygenase-2 (COX-2) inhibitors, that is used to relieve some of the manifestations caused by RA in adults. This medication is also prescribed for osteoarthritis, spondylitis, and painful menstruation.
A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following prescriptions should the nurse verify with the provider?
A. Meperidine
B. Amitriptyline
C. Gabapentin
D. Propranolol
Opioids are more effective for residual limb pain rather than phantom limb pain; additionally, meperidine is not recommended for chronic pain because long-term use can lead to the accumulation of a toxic metabolite.
A nurse is caring for a client following a hip arthroplasty. The nurse should place an abduction pillow on the client for which of the following purposes?
A. Raising the bed linens off the client's feet to prevent plantar flexion
B. Keeping the client’s heels off the bed to prevent pressure ulcers
C. Positioning the client off the operative site while in bed
D. Preventing dislocation of the hip during position changes or movement
Following surgery, the nurse should use an abduction pillow to prevent dislocation of the new hip joint. The nurse should place the wedge-shaped pillow between the client’s legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body during position changes or client movement, which can lead to subluxation or total dislocation of the hip joint.
A nurse is reinforcing discharge teaching with a client who had a left total hip arthroplasty. Which of the following client statements indicates the teaching was effective?
A. "I should expect swelling of the affected leg for several weeks."
B. "I should not cross my legs at the ankles or knees."
C. "I will inspect my hip incision every other day for redness."
D. "I can bend over at the hip to pick up objects."
The nurse should instruct the client to avoid crossing the legs at the knees or ankles because it can result in the dislocation of the femoral head.
Adduction of a limb means to position it toward the midline of the body. Therefore, the nurse should provide these instructions to explain the provider’s prescription
A nurse is talking with a group of clients at a senior center about risk factors for osteoporosis. Which of the following statements should the nurse include?
A. "Extended periods of immobility increase your risk of osteoporosis."
B. "Prolonged periods of sun exposure increase your risk of osteoporosis."
C. "Eating a diet high in protein can reduce your risk of osteoporosis."
D. "Corticosteroid therapy will reduce your risk of osteoporosis."
Osteoporosis is a disorder of weakened bones due to a loss of bone mass and a change in bone structure. Immobility can result in osteoporosis; therefore, weight-bearing exercise such as walking can help prevent osteoporosis.
A nurse is collecting data from a client who has several risk factors for osteoporosis. Which of the following findings should the nurse identify as an indication that the client requires further evaluation for this disorder?
A. Leg cramps with exercise
B. Stress incontinence
C. Abdominal distention
D. Lower back pain
Lower back pain is common among clients who have osteoporosis, especially when they lift, stoop, or bend. Back pain and tenderness that cause movement restriction might indicate vertebral compression fractures, which are the most common type of fracture resulting from osteoporosis.
A nurse is assisting with preparing a client for a bone scan. Which of the following statements indicates that the client understands the pre-procedure instructions? (Select all that apply.)
A. "I will have to drink a radioactive solution before the test begins."
B. "A special camera will scan the bones in my entire body."
C. "There will be better absorption of the radiation in healthy bone."
D. "I'll have to drink a lot of water to help get the radiation out of my body."
E. "I understand the radiation is harmless, and I don't have to worry about it."
A nurse is assisting with discharge preparations for a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
A. "I'll use alcohol pads to clean my incision each day."
B. "When I'm doing my exercises, I'll include bent-leg raises."
C. "I'll use a reacher to help me pick up anything I drop on the floor."
D. "When I can walk without my walker, I can stop attending physical therapy." Perfect!
To prevent dislocation, the client must avoid flexing 90° at the waist. Using a device that allows the client to pick up objects from the floor without bending will help avoid this type of flexion.
A nurse is caring for a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is disoriented to time and place and has an SaO2 of 87%. The nurse notes generalized petechiae on the client’s skin. Which of the following complications should the nurse suspect?
A. Hypovolemic shock
B. Fat embolism syndrome
C. Thrombophlebitis
D. Osteomyelitis
The nurse should identify the triad of neurologic changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and fracture of a long bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude small blood vessels.
Fortified milk provides 2.45 mcg of vitamin D, which promotes calcium absorption from the gastrointestinal tract. Adults up to age 70 need 600 international units of vitamin D per day and 800 international units thereafter. Therefore, fortified milk is a good source of vitamin D.
A nurse is reinforcing nutrition education to a client who has osteomalacia. The nurse should identify that osteomalacia is caused by a deficiency of which of the following nutrients?
A. Fluoride
B. Vitamin A
C. Vitamin D
D. Phosphorus
Osteomalacia, a softening of the bones due to defective bone mineralization, results from a deficiency of vitamin D.
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and anxiety. The nurse should notify the charge nurse that this client is experiencing which of the following complications?
A. Pneumonia
B. Pulmonary embolus
C. Tension pneumothorax
D. Tuberculosis Correct
Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary embolus. The client might also exhibit tachycardia and chest petechiae and have a decreased SaO2. The nurse should notify the rapid response team immediately.
A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. The nurse should identify the fracture to be located by which of the following bones?
A. Sphenoid
B. Occipital
C. Parietal
D. Frontal
The parietal bones form the larger part of the upper and side wall of the cranium.
A nurse in an acute care clinic is talking with a client who reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss non-pharmacological approaches that will help relieve her pain. Which of the following interventions should the nurse suggest?
A. Apply warm compresses to sore joints
B. Decrease the daily intake of dietary protein
C. Keep joints in extension during rest periods
D. Limit sleep to 6 to 7 hours per night
Warm packs or warm soaks, such as in a bath or hot tub, are often effective for relieving arthritic pain. The nurse should encourage the client to avoid temperatures hot enough to cause burns. She should use a temperature just a little warmer than body temperature for optimal comfort.
A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?
A. Decreased intake of sodium
B. Spending several hours in the sun daily
C. Increased estrogen levels
D. History of anorexia nervosa
The nurse should identify anorexia nervosa as a risk factor for osteoporosis. Inadequate protein intake can lead to decreased bone density, increasing the risk of fractures.
A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction? (Select all that apply.)
A. "You'll have considerably less pain with the traction in place."
B. "You'll have the traction in place for a week or so."
C. "The traction will help decrease muscle spasms."
D. "The weights act as a pulling force to keep your leg and hip still."
E. "We have to make sure the weights are just barely touching the floor."
Buck's extension traction uses weights to help decrease muscle spasms. Pain is usually more severe without the traction. Typically, 2.3 to 5.5 kg (5 to 10 lb) of force helps stabilize the hip and leg preoperatively.
A nurse is reinforcing teaching with a client who has arthritis and is experiencing joint pain that impairs mobility. Which of the following instructions should the nurse include?
A. "Engage your joints in resistance exercises."
B. "Avoid using assistive devices when walking."
C. "Perform passive exercises."
D. "Apply heat to your joints prior to exercise."
The nurse should instruct the client to apply heat to the joints prior to exercise to increase mobility and reduce pain.
A nurse is assisting in the preparation of a community education program about reducing the risks of osteoporosis. Which of the following pieces of information should the nurse include?
A. Avoid sun exposure.
B. Take a calcium supplement once each day if at risk for osteoporosis.
C. Walking is the preferred exercise to maintain strong bones.
D. Caffeine intake minimizes the risk of developing osteoporosis.
The nurse should emphasize that regular walks are the preferred weight-bearing exercise to build and maintain strong bones.
A nurse is collecting data from a client who is 24 hours postoperative following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority?
A. Report of muscle spasms
B. Inability to get dressed without assistance
C. Report of feelings of anger
D. Refusal to look at the affected limb
The nurse should consider Maslow’s hierarchy of needs, which includes 5 levels of priority: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential and the ability to problem-solve and cope with life situations. When applying Maslow’s hierarchy of needs in a priority-setting framework, the nurse should review physiological needs first and then follow the remaining hierarchical levels. However, the nurse should consider all contributing client factors, as higher levels of the pyramid can compete with the lower levels, depending on the specific client situation. Therefore, the nurse should identify the report of muscle spasms—a physiological need—as the priority client finding.
The nurse should turn the client every 2 hours to prevent skin breakdown. The nurse should also reposition the client during turning, which keeps the client's extremities from becoming stiff and promotes blood circulation of the extremities. Additionally, the nurse should monitor the client's pin sites for loosening. Loosening of the pins of the halo device can place the client's cervical or thoracic traction at risk; the provider should be notified immediately if this occurs. Finally, the nurse should check the client's skin for redness and ensure the vest is not rubbing against the client's skin, which can create a pressure ulcer. The nurse should check the client's skin to make sure it is dry and clean to prevent skin breakdown.
A nurse is caring for a client who is postoperative following a lumbar disk excision. Which of the following interventions should the nurse suggest for the client's plan of care?
A. Keep the client's legs flat with the knees extended
B. Encourage the client to sit in a chair for as long as possible
C. Logroll the client in bed for care procedures
D. Expect urinary retention for the first postoperative day
The client should receive instructions about logrolling preoperatively. It might be necessary for the nurse to engage other staff members in assisting with logrolling in order to maintain proper alignment of the client's spine at all times postoperatively.
A nurse is reinforcing teaching with a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include?
A. "You will need to apply a cold pack to the site three times per day."
B. "Your provider might ask you to walk frequently to increase circulation to the area."
C. "You will need to limit consumption of high-protein foods."
D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy. "
Osteomyelitis is an acute or chronic bone infection. The client will require weeks to months of IV antibiotic therapy for treatment. Therefore, the nurse should discuss the need for long-term IV access for antibiotic therapy.
A nurse is assisting with the care of a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively?
A. With the leg on the affected side adducted
B. With the hip externally rotated on the affected side
C. With the leg on the affected side abducted
D. With the hip flexed at 90° on the affected side
With the leg on the affected side abducted The nurse should plan to place the client with the leg abducted on the affected side postoperatively. Adduction or external rotation of the leg will cause the hip to dislocate.
A nurse is determining a client's risk of developing osteoporosis. The nurse should identify which of the following are risk factors for bone loss? (Select all that apply.)
A. Small body frame
B. Hypertension
C. African-American ethnicity
D. Low vitamin D intake
E. Smoking
Females have a higher risk of developing osteoporosis than males. Family history, a low body mass index, and a small body frame are risk factors for developing osteoporosis, as well as inadequate levels of calcium and vitamin D, smoking, alcohol intake, and caffeine intake.
A nurse is reinforcing discharge teaching with a client who has osteoarthritis. Which of the following instructions should the nurse provide?
A. "Rest frequently after periods of activity."
B. "Perform exercise only on days that you feel well."
A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed, and the traction weight is resting on the floor. Which of the following actions should the nurse take?
A. Remove the weight temporarily to reposition the client in the correct alignment in bed
B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely
C. Lift the rope off the pulley while the client rocks back and forth to reposition
D. Lift the weight manually while another staff member moves up the client in bed
The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to maintain proper alignment of the extremity.
home health nurse is collecting data from a client who is 1 week postoperative following a total knee replacement. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will discontinue the blood thinner my doctor prescribed once I am at home."
B. "I will keep a pillow under my knee when I am in bed."
C. "I plan to use a walker to help me get around."
D. "I will discontinue using the CPM machine when I get home."
The client will receive a prescription for a walker, cane, or crutches to promote ambulation following a total knee replacement
A nurse is collecting data from a female client who reports severe joint pain. The nurse should identify that which of the following factors places the client at risk for gout?
A. Perimenopausal
B. Migraine headaches
C. Diuretic use
D. Irritable bowel syndrome
A client's use of diuretics is a risk factor for gout, which is a systemic disorder that affects the joints as a result of high uric acid levels in the blood.
A nurse is reinforcing teaching with a client who is on bed rest about preventing complications. Which of the following client statements indicates an understanding of the teaching?
A. "I should perform range-of-motion exercises once per day."
B. "I should cough and deep-breathe every hour."
C. "I should change my position every 4 hours."
D. "I should perform foot and ankle pumps every 3 hours."
The nurse should instruct the client to cough and deep-breathe every hour to promote lung expansion, maintain adequate gas exchange, and mobilize secretions
A nurse is collecting data from a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider as an indication of fat emboli?
A. Ecchymosis of the thigh
B. Serous drainage at the pin site
C. Chest petechiae
D. Muscle spasms in the left leg
The nurse should identify chest petechiae as an indication of a fat embolism. Clients who have fractures of the long bones such as the femur are at increased risk for fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure
