3 Flashcards
1
Q
The nurse is reviewing the orders for a patient who was admitted for 24- hour observation of a leg fracture. The cast is in place. Which order does the nurse question?
A. Elevate the lower leg above the level of the heart
B. Perform Neuro-Circulatory checks every 8 hours
C. Apply ice packs for 24 hours
D. Provide a regular diet as tolerated
A
b
2
Q
A client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action?
A The client blood pressure is 136/72
B. Capillary refill time of the extremity is less than 3 seconds
C. Slight clear drainage is noted at the pin site
D. The traction weights are resting on the floor.
A
D. The traction weights are resting on the floor.
3
Q
. What is the rationale for elevating an extremity after a soft tissue injury such as a sprained ankle?
A. elevation increases the pain threshold
B. elevation increase metabolism in the tissues
C. elevation produces deep vasodilation
D. elevation reduces edema formation
A
D. elevation reduces edema formation
4
Q
The nurse is caring for a client with a fractured femur. Which factor in the client’s history may impede healing of the fracture?
A A sedentary lift style
B. History of smoking
C. Oral contraceptive use
D. Paget Disease
A
D. Paget Disease
5
Q
A Client sustains a fractured femur and pelvic fractures in a motor vehicle crash, for which signs and symptoms indicative of hypovolemic shock, does the nurse monitor the client closely? ( Select all that apply)
A fever
B oliguria
C Bradypnea
D. Tachycardia
E. Hypotension
A
bde
6
Q
A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse first intervention?
A Assess pedal pulses
B. Apply oxygen via nasal cannula
C. increase the IV flow rate
D Document the finding as this is normal result of the crush injury
A
a
7
Q
The nurses assesses a client with a below- Knee amputation. Which of the skin flap requires immediate action?
A pink and warm to touch
B Pale and cool to the touch
C Dark, pink, and dry to the touch
D Pink and slightly moist to the touch
A
b
8
Q
Which condition can result from the bone demineralization associated with immobility?
A. Osteoporosis
B. Urinary Retention
C. Pooling of blood
D. Susceptibility to infection
A
a
9
Q
The nurse is caring for several patients on an orthopedic trauma unit. Which conditions have a high risk for development of acute compartment syndrome? (SATA)
A. Lower legs caught between the bumpers of two cars
B. Massive infiltration of IV fluid into the forearm
C. bivalved cast on the leg
D. Severe burns to the upper extremities
F. Daily use of oral contraceptives
A
abd
10
Q
When assessing a female client the nurse learns that the client has several risk for osteoporosis. Which factor will the priority for the client teaching?
A Low calcium intake
B. Postmenopausal status
C. Positive family history
D. Previous use of steroids
A
a
11
Q
When assessing a female client the nurse learns that the client has several risk for osteoporosis. Which factor will the priority for the client teaching?
A Low calcium intake
B. Postmenopausal status
C. Positive family history
D. Previous use of steroids
A
a
12
Q
The nurse is performing a nursing history and assessment on an older patient. Which common findings in the older patient are related to the musculoskeletal system? (SATA)
A Decrease in bone density
B Decrease in falls due to lack of activity
C Atrophy of muscle tissue
D. Decrease in bone prominence
A
ac
13
Q
The nurse is caring for a patient with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (SATA).
A Capillary refill
B Palpable distal pulse
c. Severe pain not relieved by analgesics
D. Tingling of extremity
E inability to move extremity
A
cd
14
Q
The nurse is caring for a patient with an external fixation of bone fracture. What are the advantages of this type of treatment (SATA)
A. It is less painful than other treatments
B. it allows for earlier ambulation
C. it decreases the risk for infection
D. It maintains bone alignment
E. It stabilizes comminuted fractures that require bone grafting.
A
bde
15
Q
After an open reduction and internal fixation of a fractured hip. What assessments of the client’s affected leg should the nurse make? ( SATA)
A skin temperature
B. Mobility of the hip
C. Sensation in the toes
D. Condition of the pins
E. Presence of pedal pulse
A
ace
16
Q
In assessing the client with back pain, the nurse uses a paper clip bilaterally on each limb. what is the nurse assessing?
Gait
Mobility
Sensation
Strength
A
sensation
17
Q
A patient comes the to the ED after accidently puncturing his hand with an automatic nail gun. Which disorder is this patient primarily at risk for?
A Osteoporosis
B. Osteomyelitis
C. Osteocalcin
D. Dupuytren’s contracture
A
b
18
Q
A patient comes to the ED with crush syndrome from a crush injury to his right upper extremity and right lower extremity when heavy equipment fell on him at a construction site. The patient has signs and symptoms of hypovolemia, hyperkalemia, and compartment syndrome. Management of care for this patient will focus on preventing which complications? (Select all)
a) Sepsis
b) Cardiac dysrithmias
c) Respiratory failure
d) Acute kidney failure
e) Fluid overload
A
bd
19
Q
Which clinical findings does the nurse assess in the affected area of a patient with osteomyelitis (SATA)
A Erythema
B. Tenderness
C. Numbness and tinging
D Swelling
E Constant bone pain
A
abde
20
Q
A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states:
A. its important for me to drink a lot of fluids
B. a fad diet or starvation diet can cause an acute attack
C. I don’t need medication unless I’m having a severe attack
D. Physical and emotional stress can cause an attack
A
c
21
Q
Which factors affect bone healing after a fracture has occurred? (SATA)
A patient’s age
B Patient occupation
C. Type of bone injured
D. How the fracture was managed
E Presence of infection at the fracture site
A
acde
22
Q
A patient in a body case reports nausea vomiting and epigastric pain. The nurse notifies the physician for orders. Which interventions is the most conservative. and therefore the first thing to try to address the patients symptoms?
A insert a nasogastric tube and attach to low wall suction
B Cut a window over the abdominal area of the cast
C Obtain an order for an x-ray to diagnose a paralytic ileus
D Administer PRN Antiemetic and PRN pain medication
A
b
23
Q
The nurse is assessing a patient with an injury to the shoulder and upper arm after being thrown from their bicycle. What is the best position for this patient assessment?
A Supine so the extremity can be elevated
B. Low fowlers on an exam table for patient comfort
C. Slow ambulation to observe for natural arm movement
D Sitting to observe for shoulder droop
A
d
24
Q
A 39-year-old patient who is hospitalized for repair of a fractured tibia and fibula reports shortness of breath. Which complication related to the injury might the patient be experiencing?
A hypovolemic shock
B Fat Embolism
C. Acute compartment Syndrome
D Pneumonia
A
b
25
. The nurse is caring for a patient immobilized by a fractured hip. Which complication should the nurse monitor related to the patient’s immobilization status?
A. Metabolic rate increases
B. Increased joint mobility leading to contractures
C. Bone calcium increases releasing excess calcium into the body
D. Venous stasis leading to thrombi or Emboli formation
d
26
Which term is used to describe a type of fracture that produces a break in the skin?
A. Compound
B. Complicated
C. Greenstick
D. Spiral
a
27
Which should cause a nurse to suspect that an infection has developed under a cast?
A Complaint of paresthesia
B. cold toes
C increased reparations
D Hot Spots felt on the cast surface
d
28
The nurse is educating a patient who will have external fixation for treatment of a compound tibial fracture. What information does the nurse include in the teaching session?
A. The device allows for early ambulation
B. There is some danger for blood loss, but no danger of infection
C. The device is substitute therapy for a cast
D. The advantage of the device is rapid bone healing
a
29
Which is a potentially fatal complication of acute compartment syndrome(SATA)
A Myoglobinuric renal failure
B Ischemic heart failure
C Sepsis from Gangrene
D Hypovolemic shock
ac
30
Calculate the IV flow rate for 1200ml of NS to be infused in 6 hours. The infusion set is calibrated for a drop factor of 15gtts/ml
50
31
Dietary management of Gout includes which measures (SATA)
A Weight Reduction
B Salt Restriction
C High caloric intake
D Avoiding foods high in purine
E High carbohydrate diet
ad
32
Which is the prority nursing intervention for a patient with primary adrenal cortex dysfunction?
A weigh the patient daily
B closely measure fluid intake and output
C Monitor vital signs and the patient’s physiologic response to stress
D provide emotional support during stressful situations
c
33
. The nurse is caring for a patient diagnosed with small cell lung cancer. The nurse understands the patient may also present with which endocrine disorder?
A Adrenal Crisis
B Crushing syndrome
C Diabetes insipidus
D Syndrome of inappropriate antidiuretic hormone
d
34
The nurse is teaching a patient with type 1 diabetes about exercise. The nurse understands the patient should avoid exercise during what time?
A during colder months
B when serum glucose is less than 150
C when ketones are present in the urine
D when emotional stressors are high for the patient
c
35
. The nurse knows that a patient with crush injuries to the lower extremities is at high risk for what complication?
A Bradycardia
B Hypotension
C Acute kidney injury
D spinal nerve injury
c
36
35. A 54 year old man presents to the ED with a deformed right ankle. He states that he was jogging close to the edge of a hillside and that he tripped and fell down the hill. There are No openings in the skin. A pulse cannot be obtained by touch to the right foot, Which is pale and cool to palpation. The patient rates his pain as an “8” on a scale of zero to 10. What is the priority nursing action at this time?
A. Administer pain medication.
B. Prepare for reduction.
C. Obtain a Doppler of the right foot pulse.
D. Notify the physician of the lack of a pulse in the right foot.
c
37
36. Which discharge instructions are appropriate for a patient diagnosed with Hepatitis A?
A Follow a gluten free diet
B avoid crowed settings
C do not share personal hygiene items
D May use acetaminophen for headaches and mild pain
c
38
For a patient dignosed with Hep A what are the recommendations for her family members
A Immune Globulin
B Interferon
C A Histamine 2 antagonist
D An anticholinergic
a
39
37. What priority laboratory analysis should the nurse review when caring for a patient with Crohn Disease?
A Potassium
B Hemoglobin
C Serum Albumin
D C- reactive protein
b
40
38. A patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the patients laboratory results for evidence of which condition?
A. Hyperkalemia
B. Hypernatremia
C. Hypercalcemia
D. Hyperglycemia
d
41
39. An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nasea and vomiting and fatigue for the past 24 hours. The nurse should monitor the patients for what prior assessment?
A Dehydration
B Hyperkalemia
C Hypernatremia
D Perineal skin breakdown
a
42
40. Which does the nurse recognize as a possible outcome for the patient experiencing an age related decrease in antidiuretic hormone.
A Diluted urine and dehydration
B Yeast infection and polydipsia
C Greater then idea body weight
D constipation lethargy and dry skin
a
43
41. When caring for a patient having a hypoglycemic episode the nurse knows which symptom requires immediate intervention?
Hunger
Confusion
Headache
Tachycardia
confusion
44
42. As the nurse assessing a patient with Grave disease which finding requires immediate attention?
Elevated temperature
Elevated blood pressure
Change in Respiratory Rate
Irregular heart rate and rhythm
Elevated temperature
45
43. When developing a postoperative plan care for a patient after a total thyroidectomy the nurse knows the plan should include which intervention?
Avoiding extending the patient’s neck
Assessing the patients voice once per shift
Encouraging the patients to be out of bed in a chair
Administering oxygen via nasal cannula as needed
Avoiding extending the patient’s neck
46
44. Prior to the liver biopsy. It is most important for the nurse to be aware of which lab test result
Serum Creatinine
Prothrombin time
Alkaline phosphatase
Serum calcium
prothrombin
47
45. Anya is a 25-year-old immigrant who had a diagnosis of Diabetes from her country. Upon presenting to the health clinic which symptoms are concerning to the intake nurse?
Tympanic membranes that are pearly grey with translucent appearance
Vision results of 20/50
White blood cell count of 6.4
Ketones +2 in the urine
Serum glucose of 210mg/dl
v
k
s
48
Anya becomes ill and presents to the ED dehydrated. After blood work-up, Anya is diagnosed as being in a state of Ketoacidosis and is admitted to the hospital. Which assessments findings are consistent with this diagnosis?
Nausea, fruity breath ketonuria
Nausea blood glucose level 120mg/dl ketonuria
Vomiting trembling blood glucose level at 200mg/dl
Vomiting paleness abdominal pain
Nausea, fruity breath ketonuria
49
46. What does hypothyroidism casue?
General slowing of the metabolic rate
Thyroid serum leading to thyrotoxicosis
Acromegaly
Diabetes insipidus
general slownig
50
A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority?
a. Client with an hour car commute on the freeway each day
b. Client who rides a motorcycle to work 20 minutes each way
c. Client who sat in the back row at a rock concert recently
d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day
ANS: D
A chainsaw becomes dangerous to hearing after 2 hours of exposure without hearing protection. This client needs to be referred as the priority. Normal car traffic is safe for more than 8 hours. Motorcycle noise is safe for about 8 hours. The safe exposure time for a front-row rock concert seat is 3 minutes, but this client was in the back, and so had less exposure. In addition, a one-time exposure is less damaging than chronic exposure.
51
A patient in a cast reporsts a painful "hot spot" underneath the cast, and the nurse notices an unpleasant odor. Which intervention is the nurse most likely to perform first?
a. offer the patient a prn pain medication.
b. help the patient with hygiene around the cast
c. take the patient's temperature and other vital signs
d. call the orthopedic technician to change the cast
c
52
the nurse will infuse 1 ½ L of NS in over 7 hours. Drop factor: 15 gtt/ml. what is the flow rate (ml/hr) will the nurse set on the IV infusion pump?
53.6
53
the health care provider is educating a 65-year-old patient on a new diagnosis of primary open-angle glaucoma (POAG). Which statement by the patient shows
"I will need to follow my treatment plan to prevent damage to the optic nerve."
54
The student nurse is caring for a patient with an acute attack of Ménière's disease. Which finding indicates a need for further teaching of the student nurse?
1) The patient's urine output is measured.
2) An emesis basin is kept on the bedside table.
3) The patient is placed in the dayroom to watch a favorite action movie.
4) Three side rails on the patient's bed are placed in the upright position.
3) The patient is placed in the dayroom to watch a favorite action movie.
- When caring for a patient with an acute attack of Ménière's disease, the nurse should plan interventions that minimize vertigo and provide for patient safety. Avoiding fluorescent or flickering lights or a television will minimize the attack and/or symptoms.
55
6. The patient is diagnosed with osteoporosis. Which intervention by the nurse would be appropriate?
A. Teach her to cut down on her cigarette smoking.
B. Recommend walking for 30 minutes 3 to 5 times a week. Physical activity is important
C. Suggest a diet that is high in protein and calcium but low in vitamin D (want to increase vitamin D). chest largest area to absorb sunlight for vit d
D. Tell her to include high-impact activities, such as running, in her exercise regimen.
b
56
On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. An appropriate action by the nurse is to
a. administer prescribed opioids to relieve the pain.
b. explain the reasons for phantom limb pain.
c. loosen the compression bandage to decrease incisional pressure.
d. remind the patient that this phantom pain will diminish over time.
Correct Answer: A
Rationale: Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.
57
Which statements about retinal detachment are accurate? Select all that apply.
Retinal detachments are classified by the cause.
Restricting head movement can prevent further detachment.
Spontaneous reattachment of a totally detached retina is rare.
58
_____ drug therapy is administered to a patient with meniere's disease to decrease
Diuretic
59
An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate?
a. Assess for cerumen buildup.
b. Facilitate audiological testing.
c. Perform tuning fork tests.
d. Review the medication list.
ANS: A
All options are possible actions for the client with hearing loss. The first action the nurse should take is to look for cerumen buildup, which can decrease hearing in the older adult. If this is normal, medications should be assessed for ototoxicity. Further auditory testing may be needed for this client.
60
An older adult patient has skin traction in place for a hip fracture. Which outcome statement reflects that the goal of the therapy is successful?
Patient reports a decrease in pain for muscle spasms
61
The nurse is admitting a patient with a history of a herniated lumbar disc and low back pain. Which action would most likely aggravate the pain?
Bending or lifting
Back pain related to a herniated lumbar disc is aggravated by events and activities that increase stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.
62
The client is being assessed for rotator cuff injury. Which physical assessment finding is consistent with this type of injury?
a. The client is unable to maintain adduction of the affected arm at the shoulder for longer than 30 seconds.
b. The client is able to raise the affected arm to shoulder height but feels pain on doing this maneuver.
c. The client is unable to initiate or maintain abduction of the affected arm at the shoulder.
d. The client has referred pain to the shoulder and arm opposite the affected shoulder.
ANS: C
Clients with a rotator cuff tear are unable to initiate or maintain abduction of the affected arm at the shoulder. This is known as the drop arm test. The other options are not descriptive of a rotator cuff injury.
63
. a patient is receiving 250 ml normal saline IV over 4 hours, using tubing with a drip factor of 10 drops/ml. how many drops per minute should be delivered.
64
After a motor vehicle accident, a patient presents with a deformity to the leg with decreased pedal pulses. The fibula protrudes from the lateral aspect of the leg. How should the nurse classify the fracture?
Open
The patient has an open fracture because the fibula protrudes through the skin.
Spiral
Without an X-ray, it is not possible to determine if the patient has a spiral fracture. Spiral fractures occur when the fracture extends in a spiral direction along the bone shaft.
Closed
The patient does not have a closed fracture because there is a break in the skin.
Displaced
The patient has a displaced fracture because one portion of the fibula protrudes through the skin and the ends of the bone are separated and out of their normal position.
Incomplete
Because the fibula protrudes through the skin, this is not an incomplete fracture. Incomplete fractures are fractures that occur partly across the bone, with the bone still in alignment.
open , displaced
65
a teenager is brought to the emergency department by a group of excited friends. he is dazed and unable to answer questions. the nurse observes deformity to the right forearm and ecchymosis over the right lateral chest and abdomen. what is the most important reason to ask the friends about mechanism of injury?
to aid in making the diagnosis of other types of injuries.
66
. Which information from the client's history would the nurse identify as a risk factor for developing osteoporosis. Which information from the client's history would the nurse identify as a risk factor for developing osteoporosis?
Receives long-term steroid therapy
67
. A patient is informed by the health care provider that a fiberglass cast must be applied to the lower extremity. What does the nurse teach the patient about the procedure before the cast is applied?
a. "the stockinette should be changed once a week."
b. "the cast material will dry and become rigid in a few minutes."
c. "the cast will increase your risk for skin breakdown"
d. "The fiberglass is not waterproof, so avoiding getting it wet."
b
68
____is a side effect of taking calcium and cause serious damage to the urinary system
Hypercalcemia
69
doctors order: zosyn IV antibiotic is ordered to be administered Q8.
Dose: 40 mg/kg/day. The patient weighs 167lbs.
How much zosyn is administered at each scheduled dose?
1012
70
Tinnitus may be caused by which factors? (Select all that apply.)
b. Otosclerosis
c. Continuous exposure to loud noise
d. Medications
e. Ménière's disease
71
During the intake assessment and interview, what information indicates that patient has an increased risk for osteoporosis? (Select all that apply).
-Body mass index of 19
- Excessive alcohol use.
A thin body build,
evidenced by a body was index of 19, is a risk factor for osteoporosis. Additional risk factors include being female and of Caucasian or Asian ethnicity. Consuming greater than 2 alcoholic beverages daily is a risk factor for osteoporosis.
72
Which precautions does the nurse instruct a patient to follow after having ear surgery? (Select all that apply.)
b. "Stay away from people with colds."
c. "Do not drink through a straw for 2 to 3 weeks."
d. "Keep your ear dry for 6 weeks."
e. "Avoid straining when having a bowel movement."
73
A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals: (select all that apply)
A. hypotension
B. warm, reddened areas in her leg
C. parasthesia
D. petechiae of the neck and anterior chest wall
E. restlessness and confusion
de
74
_____ can result from the bone demineralization
osteoporosis
75
The nurse gently taps over the patient's mastoid process and the patient reports tenderness. This finding may indicate which condition?
a. Excessive cerument
b. Hyperacusis
c. Ruptured eardrum
d. Inflammatory process
d
76
A nurse is caring for a patient who reports loss of peripheral vision that developed over time. Which diagnostic tests would the nurse anticipate the patient to undergo?
Tonometry
Gonioscopy
77
The patient is admitted to the acute medical unit. Which medication would the nurse question?
A. Ibuprofen (Motrin):
B. Mesalamine (Asacol)
C. Prednisone (Deltasone)
D. Loperamide (Imodium)
a
78
The nurse is caring for a client with a fractured femur. Which factor in the client's history may impede healing of the fracture?
a. A sedentary lifestyle
b. A history of smoking
c. Oral contraceptive use
d. Paget's disease
ANS: D
Paget's disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks.
79
Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma?
1. Dilating the pupil
2. Resting the eye muscles
3. Preventing secondary infection
4. Controlling intraocular pressure
Controlling intraocular pressure
Glaucoma is a disease in which there is increased intraocular pressure resulting from narrowing of the aqueous outflow channel (canal of Schlemm). This can lead to blindness, caused by compression of the nutritive blood vessels supplying the rods and cones. Pupil dilation increases intraocular pressure because it narrows the canal of Schlemm. Intraocular pressure is not affected by activity of the eye. Although secondary infections are not desirable, the priority is to maintain vision by controlling the pressure.
80
The nurse assesses a client with a below-knee amputation. Which assessment of the skin flap requires immediate action?
a. Pink and warm to the touch
b. Pale and cool to the touch
c. Dark pink and dry to the touch
d. Pink and slightly moist to the touch
ANS: B
The skin flap should appear pink in a light-skinned person and not discolored in a darker-skinned person. The area should feel warm but not hot. Pale and cool skin could indicate inadequate blood flow to the area. The nurse would notify the provider.
81
A client sustains a fractured femur and pelvic fractures in a motor vehicle crash. For which signs and symptoms, indicative of hypovolemic shock, does the nurse monitor the client closely? Select all that apply.
1. Tachycardia
2.Fever
3. Hypotension
4. Oliguria
5. Bradypnea
Tachycardia
hypotension
oliguria
82
A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states:
A: "I don't need medication unless I'm having a severe attack."
B: “a fad diet or starvation can cause an acute attack”
C: “It is important for me to drink a lot of fluids”
D: “Physical and emotional stress can cause an attack.”
a
83
A client with an anxiety disorder who has been prescribed an antibiotic for otitis media asks the nurse, "Why'd the doctor tell me not to discontinue the medication until the pills are gone?" Which response by the nurse is appropriate?
B "Completing the medication ensures that the infection will be resolved."
84
A patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the patient's laboratory results for evidence of which condition?
A. Hyperkalemia
B. Hypernatremia
C. Hypercalcemia
D. Hyperglycemia
Answer: D
Rationale: Long-term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease, and increased risk for infection.
85
the nurse performing a nursing history and assessment on an older patient. which common findings in the older patient are related to the musculoskeletal system? SATA
A: atrophy of muscle tissue
B: degeneration of cartilage
C: decrease in bone density
D: decrease in falls due to lack of activity
E: decrease in bone prominence
ac
86
An adult patient has been diagnosed with Ménière's disease. Which points does the nurse include in the teaching plan for this patient? (Select all that apply.)
a. Make slow head movements.
b. Reduce the intake of salt.
c. Stop smoking.
d. take vitamin supplements
e.avoid red meat
f. irrigate the ears frequently to decrease cerumen
a. Make slow head movements.
b. Reduce the intake of salt.
c. Stop smoking.
87
What priority laboratory analysis should the nurse review when caring for a patient with Crohn Disease?
A Potassium
B Hemoglobin
C Serum Albumin
D C- reactive protein
b
88
The nurse will infuse 1 ½ L of NS in over 12 hours. What flow rate will the nurse set on the IV pump?
a. 150 ml/h
b. 42 ml/h
c. 83.3 ml/h
d. 125 ml/
d. 125 ml/
89
A 54 year old man presents to the ED with a deformed right ankle. He states that he was jogging close to the edge of a hillside and that he tripped and fell down the hill. There are No openings in the skin. A pulse cannot be obtained by touch to the right foot, Which is pale and cool to palpation. The patient rates his pain as an “8” on a scale of zero to 10. What is the priority nursing action at this time?
A. Administer pain medication.
B. Prepare for reduction.
C. Obtain a Doppler of the right foot pulse.
D. Notify the physician of the lack of a pulse in the right foot
c
90
The nurse is educating a patient who will have external fixation for treatment of a compound tibial fracture. What information does the nurse include in the teaching session?
A. The device allows for early ambulation
B. There is some danger for blood loss, but no danger of infection
C. The device is substitute therapy for a cast
D. The advantage of the device is rapid bone healing
a
91
Which factors affect bone healing after a fracture has occurred? (SATA)
A patient’s age
B Patient occupation
C. Type of bone injured
D. How the fracture was managed
E Presence of infection at the fracture site
acde
92
After an open reduction and internal fixation of a fractured hip. What assessments of the client’s affected leg should the nurse make? ( SATA)
A skin temperature
B. Mobility of the hip
C. Sensation in the toes
D. Condition of the pins
E. Presence of pedal pulse
ace
93
. When assessing a female client the nurse learns that the client has several risk for osteoporosis. Which factor will the priority for the client teaching?
A Low calcium intake
B. Postmenopausal status
C. Positive family history
D. Previous use of steroids
a
94
. The nurse is caring for a patient with an external fixation of bone fracture. What are the advantages of this type of treatment (SATA)
A. It is less painful than other treatments
B. it allows for earlier ambulation
C. it decreases the risk for infection
D. It maintains bone alignment
E. It stabilizes comminuted fractures that require bone grafting.
bde
95
A patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the patients laboratory results for evidence of which condition?
A. Hyperkalemia
B. Hypernatremia
C. Hypercalcemia
D. Hyperglycemia
d
96
The nurse is caring for a client who is admitted with mastoiditis. Which assessment data obtained by the nurse requires the most immediate action?
a. The eardrum is red, thick-appearing, and immobile.
b. The lymph nodes are swollen and painful to touch.
c. The client reports a headache and a stiff neck.
d. The client's oral temperature is 100.1° F (37.8° C).
c
97
MD order reads. Administer ampicillin 25 mg/kg/day. The patient weights 176 lbs. what is the dose that the patient will receive Q6 hours?
A.250 mg
b. 500 mg
c. 1 gm
d. 2 gm
b
98
abd
99
Which clinical findings does the nurse assess in the affected area of a patient with osteomyelitis (SATA)
A Erythema
B. Tenderness
C. Numbness and tinging
D Swelling
E Constant bone pain
abde
100
. Calculate the IV flow rate for 1200ml of NS to be infused in 6 hours. The infusion set is calibrated for a drop factor of 15gtts/ml
50
101
before performing a physical examination. what assessments related to the patient's hearing can be done while observing the patient? SATA
a. observe if the patient is anxious or overly talkative
b. notice if the patient asks for questions to be repeated
c. notice the patient's response when not looking in the direction of sound
d. notice whether the patient tilts the head toward the examiner
e. observe the patient’s body posture and position
f. observe the patient’s clothes and hygiene
b,c,d,e
102
The pancreases performs which functions? Select All
A. breaks down amino acids
b. secretes enzymes fro digestion from the exocrine part of the gland
c. breaks down fatty acids and triglycerides
d. produces glucagon from the endocrine part of the organ
e. produces enzymes that digest carbs, fats, and proteins
f. detoxifies potentially harmful compounds.
bde
103
. A 39-year-old patient who is hospitalized for repair of a fractured tibia and fibula reports shortness of breath. Which complication related to the injury might the patient be experiencing?
A hypovolemic shock
B Fat Embolism
C. Acute compartment Syndrome
D Pneumonia
b
104
A myringotomy may need to be performed for______.
promote drainage and relieve pressure
105
A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?
Constriction of the peripheral vessels increases the force of flow.
Constriction of the peripheral blood vessels and the resulting increase in blood pressure impairs circulation and limits the amount of oxygen being delivered to body cells, particularly in the extremities. Nicotine constricts all peripheral vessels, not just superficial ones. Its primary action is vasoconstriction; it will not dilate deep vessels. Nicotine constricts rather than dilates peripheral vessels.
106
The nurse is caring for a patient with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome (SATA).
A Capillary refill to extremity <3 seconds
B Palpable distal pulse
c. Severe pain not relived by analgesics
D. Tingling of extremity
E inability to move extremity
cd
107
Which signs and symptoms should a patient who has had cataract surgery report to the health care provider? (Select all that apply.)
a. Sharp, sudden pain in the eye
b. Decreased vision
d. Green or yellow thick discharge
e. Flashes of light
f. lid swelling
g. mild eye itching
abdef
108
. A patient comes to the ED with crush syndrome from a crush injury to his right upper extremity and right lower extremity when heavy equipment fell on him at a construction site. The patient has signs and symptoms of hypovolemia, hyperkalemia, and compartment syndrome. Management of care for this patient will focus on preventing which complications? (Select all)
a) Sepsis
b) Cardiac dysrithmias
c) Respiratory failure
d) Acute kidney failure
e) Fluid overload
bd
109
. An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nasea and vomiting and fatigue for the past 24 hours. The nurse should monitor the patients for what prior assessment?
A Dehydration
B Hyperkalemia
C Hypernatremia
D Perineal skin breakdown
a
110
The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?
a. "Do you feel like something is in your ear?"
b. "Do you have frequent ear infections?"
c. "Have you been exposed to loud noises?"
d. "Have you been told your ear bones don't move?"
ANS: C
Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.
111
A client has a fracture and is being treated with skeletal traction. Which assessment causes the nurse to take immediate action?
A The client blood pressure is 136/72
B. Capillary refill time of the extremity is less than 3 seconds
C. Slight clear drainage is noted at the pin site
D. The traction weights are resting on the floor.
d
112
. Dietary management of Gout includes which measures (SATA)
A Weight Reduction
B Salt Restriction
C High caloric intake
D Avoiding foods high in purine
E High carbohydrate diet
ad
113
A patient comes the to the ED after accidently puncturing his hand with an automatic nail gun. Which disorder is this patient primarily at risk for?
A Osteoporosis
B. Osteomyelitis
C. Osteocalcin
D. Dupuytren's contracture
b
114
A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity. The skin of the right leg appears pale. Which is the nurse first intervention?
A Assess pedal pulses
B. Apply oxygen via nasal cannula
C. increase the IV flow rate
D Document the finding as this is normal result of the crush injury
a
115
. MD order states: Administer Cefzol 240 mg IVPB Q6 hours x 7 days. The directions on the vial say: Add 5 mL NS to vial to a reconstitution ration of 500 mg/mL. how many mLs will you administer Q6 hours to nearest hundredth.
a. 10.48
b. 0.48
c. 2.48:
d. 4.8
c
116
The nurse is caring for a patient immobilized by a fractured hip. Which complication should the nurse monitor related to the patient’s immobilization status?
A. Metabolic rate increases
B. Increased joint mobility leading to contractures
C. Bone calcium increases releasing excess calcium into the body
D. Venous stasis leading to thrombi or Emboli formation
d
117
which statements about intra ocular pressure are true SATA
a. if the IOP is too low, the eyeball can collapse
b. the IOP is normally low in the eyeball
c. if. The IOP is too high, pressure is exerted on the blood vessels
d. high IOP can cause glaucoma
e. High IOP maintains an adequate blood flow to the retina
acd
118
Which condition can result from the bone demineralization associated with immobility?
A. Osteoporosis
B. Urinary Retention
C. Pooling of blood
D. Susceptibility to infection
a
119
The patient is admitted to the acute medical unit. Which medication would the nurse question?
A. Ibuprofen (Motrin)
B. Mesalamine (Asacol)
C. Prednisone (Deltasone)
D. Loperamide (Imodium)
a
120
The nurse is assessing a patient with an injury to the shoulder and upper arm after being thrown from their bicycle. What is the best position for this patient assessment?
A Supine so the extremity can be elevated
B. Low fowlers on an exam table for patient comfort
C. Slow ambulation to observe for natural arm movement
D Sitting to observe for shoulder droop
d
121
solumedrol 1.5 mg/kg is ordered for a child weighing 74.8 lb. solumedrol is available at 125 mg/2 ml. how many more mL must the nurse administer?
A. 0.4
b. 1.2
c. 1.5
d. 0.8
0.8
122
What is the rationale for elevating an extremity after a soft tissue injury such as a sprained ankle?
A. elevation increases the pain threshold
B. elevation increase metabolism in the tissues
C. elevation produces deep vasodilation
D. elevation reduces edema formation
D. elevation reduces edema formation
123
Which type of drug therapy does the nurse anticipate giving to a client with Ménière's disease to decrease endolymph volume?
a. Antihistamines
b. Antipyretics
c. Diuretics
d. Nicotinic acid
c
