Exam 3 Prep U's Flashcards
A client with newly diagnosed hypertension asks what to do to decrease the risk for related cardiovascular problems. Which risk factor is not modifiable by the client?
Age
Explanation:
Age and family history for cardiovascular disease are risk factors that cannot be changed. Obesity, inactivity, and dyslipidemia are risk factors that can be improved by the client through dietary changes, exercise, and other healthy lifestyle choices.
A nurse is planning care for a client who will be arriving to the unit postoperatively from bariatric surgery. In an effort to decrease the risk of venous thromboembolism (VTE), which health care provider orders does the nurse anticipate?
Mechanical compression and prophylactic anticoagulation
Explanation:
Both mechanical compression (intermittent pneumatic compression devices) and prophylactic anticoagulation with low molecular weight heparin agents are prescribed in the client who is postoperative bariatric surgery. Early ambulation is encouraged; however, it is not the only intervention.
A client weighs 215 lbs and is 5’ 8” tall. The nurse calculate this client’s body mass index (BMI) as what?
32.7
Explanation:
Using the formula for BMI, the client’s weight in pounds (215) is divided by the height in inches squared (68 inches squared) and then multiplied by 703. The result would be 32.7.
A nurse cares for a female client of childbearing age who will undergo bariatric surgery. When teaching the client about precautions after surgery, which teaching will the nurse include that is specific to this population?
“You should avoid pregnancy for at least 18 months after surgery.”
Explanation:
When teaching a female of childbearing age regarding precautions after bariatric surgery, the nurse should instruct the client to avoid pregnancy for at least 18 months after surgery. The ability to conceive after weight loss surgery may improve more often than worsen. Contraceptives are no less effective after surgery than before.
A nurse epidemiologist examines the overall decrease in life expectancy related to obesity. What finding is true?
There is a 6-20 year decrease in overall life expectancy for those with obesity.
Explanation:
Overall, there is a 6-20 year decrease in overall life expectancy for those with obesity.
A nurse is educating a community group about coronary artery disease. One member asks about how to avoid coronary artery disease. Which of the following items are considered modifiable risk factors for coronary artery disease? Choose all that apply. Hyperlipidemia Gender Obesity Race Tobacco use
Hyperlipidemia
Obesity
Tobacco use
What pathophysiological concept is related to the increase in the hormone leptin, as it relates to satiety and hunger?
Increased adipose stores
Explanation:
Increased fat stores increases the level of leptin in the bloodstream.
A nurse cares for clients with obesity. Which clinical measurements use quantified measurements to diagnose obesity? Select all that apply. Blood pressure Total cholesterol Weight BMI Waist circumference
Weight
BMI
Waist circumference
A client with obesity is prescribed orlistat for weight loss. The client asks the nurse, “I understand the medication prevents digestion of fat, but what happens if I eat fat?” What is the nurse’s best response?
“The fat is passed in your stools.”
Explanation:
Orlistat (Xenical) prevents the absorption of 30% of fat, decreasing caloric intake. Undigested fat is passed in the stools. The undigested fat is not excreted in the urine, absorbed in the intestines, or left undigested in the stomach.
A nurse cares for a client who is obese. The health care provider prescribes orlistat in an effort to help client lose weight, along with diet and exercise. When teaching the client about this medication, what will the nurse include?
“It binds with enzymes to help prevent digestion of fat.”
Explanation:
Orlistat (Xenical) works to bind to gastric and pancreatic lipase to prevent the digestion of 30% of ingested fat, thereby decreasing caloric intake.
The nurse provides care to a menopausal client, who states, “I read a news article that says I am at risk for coronary vascular disease due to inflammation.” Which method should the nurse suggest to the client to aid in the prevention of inflammation that can lead to atherosclerosis?
Addressing obesity
Explanation:
The 2019 ACC/AHA Guideline on the Primary Prevention of Coronary Vascular Disease (CVD) indicates a relationship between body fat and the production of inflammatory and thrombotic (clot-facilitating) proteins. This information suggests that decreasing obesity and body fat stores via exercise, dietary modification, or developing drugs that target proinflammatory proteins may reduce risk factors for heart disease. The risk for CVD accelerates for clients after menopause due to withdrawal of endogenous estradiol levels, which can worsen many traditional CVD risk factors, including body fat distribution. Avoiding the use of caffeine, using a multivitamin, and drinking at least 2 liters of water a day are not actions that will address the prevention of inflammation that can lead to atherosclerosis.
The nurse is teaching injection techniques for a client prescribed liraglutide for the treatment of obesity. Which areas of the body will the nurse suggest for injection sites? Select all that apply. Upper thigh Abdomen Upper arm Buttocks Lower thigh
Upper thigh
Abdomen
Upper arm
Lower thigh
A client with obesity is prescribed lorcaserin for weight loss. The client reports dry mouth. What is the nurse’s best response?
“This is an expected finding with this medication.”
Explanation:
Lorcaserin (Belviq), a selective serotonergic 5-HT2C receptor agonist, causes dry mouth. This is an expected and normal finding. Increasing fluid intake does not make this symptom go away. The other answer choices are incorrect.
The nurse is teaching a group of clients with obesity about the risks of disease associated with obesity. Which respiratory conditions or diseases will the nurse include in the teaching, which are associated with obesity? Select all that apply. Asthma Infection Obstructive sleep apnea Central sleep apnea Emphysema
Asthma
Infection
Obstructive sleep apnea
A nurse cares for an obese client taking phentermine for weight loss. What client teaching will the nurse include when discussing precautions about the medication?
“Do not drink alcohol while taking this medication.”
Explanation:
The nurse should tell the client to avoid drinking alcohol while taking this medication. The other answer choices are not as important as avoiding the drug/alcohol interaction associated with this medication.
The nurse observes that a client’s medical report indicates that the client has Cushing syndrome. During inspection, the nurse notes that the client’s BMI is 31, waist circumference is 40 inches, and localized fat pads exist around the neck and upper part of the back. Which of the following must the nurse keep in mind while planning the client’s care?
The nurse recognizes that the client’s obesity may be specifically related to the endocrine disorder. The nurse performs a thorough nutritional assessment.
Explanation:
Certain signs and symptoms that suggest possible nutritional deficiency, such as muscle wasting, poor skin integrity, loss of subcutaneous tissue, and obesity, are easy to note because they are specific; these symptoms should be studied further. Food records, 24-hour diet recall, and dietary education directed at weight loss do not account for the client’s medical condition as a factor in the client’s weight or nutritional status, although each method helps estimate whether food intake is adequate and appropriate.
A client with obesity is diagnosed with type 2 diabetes. In order to promote weight loss in the client and aid in glucose management, which medication will the nurse anticipate the health care provider ordering?
Metformin
Explanation:
Metformin (Glucophage) is a diabetes medication that also promotes weight loss. The other medications are diabetes medications; however, these promote weight gain, not weight loss.
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
“I should become involved in a weight loss program.”
Explanation:
Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won’t alleviate sleep apnea, and the physician probably wouldn’t order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren’t treatment factors associated with sleep apnea.
A nurse cares for a client who is post op bariatric surgery. Which position will the nurse place the client in order to best promote comfort?
Low Fowler’s
Explanation:
Positioning the client in low Fowler’s position best promotes comfort in the client who is post op bariatric surgery. In addition to decreasing incisional pain, this position also promotes gastric emptying.
A nurse cares for clients who undergo bariatric surgery due to obesity. When teaching the client on the most successful surgery in clients with very high BMI’s, which procedure will the nurse mention?
Biliopancreatic diversion with duodenal switch
Explanation:
The biliopancreatic diversion with duodenal switch is the most successful bariatric surgery for clients with the highest BMI’s. The other answer choices represent additional bariatric surgeries; however, these are not the most successful in clients with the highest BMI’s.
Which hormones released throughout the gastrointestinal tract promote satiety? Select all that apply. Somatostatin Cholecystokinin Insulin Ghrelin Neuropeptide y
Somatostatin, cholecystokinin, and insulin are all hormones released throughout the gastrointestinal tract that promote satiety. Ghrelin and neuropeptide y are orexigenic, and stimulate hunger.
A nurse researches the cost and financial impact of obesity in America. What is the annual health care cost tied to obesity?
$147 billion
Explanation:
The estimated annual health care costs in America tied to obesity is $147 billion.
A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse’s understanding of the primary reason for this finding?
Rapid gastric dumping
Explanation:
Rapid gastric dumping may lead to steatorrhea, excessive fat in the feces. The primary cause of this finding is rapid gastric dumping. Excessive fat intake can make the problem worse; however, this is not the primary cause of the symptoms. Steatorrhea results from increased motility, not decreased and the size of the stomach does not contribute to this finding.
A nurse researcher studies the pathophysiology and etiology of obesity. What does the nurse discover is true regarding the “thrifty gene” theory of obesity?
Over time, we have become efficient in food storage and deposition of fat stores.
Explanation:
According to the “thrifty gene” theory, hunting for scarce food sources during prehistoric times consumed a lot of energy, and food sources were not abundant. Storing fat to provide energy sources during times of food scarcity was a physiologic adaptive response to these environmental challenges and over time, we became more efficient in food storage and fat deposition.
A client who is obese and the nurse have established a goal for the client to achieve a weight loss of 1 pound each week. One month later, the nurse evaluates that the client has lost 2 pounds. The nurse first states
“You have succeeded in making positive progress.”
Explanation:
In the evaluation stage of the nursing process, the nurse validates even small increments toward goal achievement, as reflected in statement b. This is important for enhancement of client self–esteem and reinforcing client behavior. Change is a slow process, and success may be defined as making some progress. The nurse and client will then need to re–evaluate the goal, as in statement d, and either continue with the current goal, change the goal, or discontinue the goal. Statements a and c are negative criticisms and would diminish client self–esteem.
A client who is 6 months postoperative bariatric surgery tells the nurse, “I hate what my body looks like now. All these skin folds really bother me.” What is the nurse’s best response?
“You are not alone in having these feelings.”
Explanation:
A client who is postoperative from bariatric surgery may share that they are dissatisfied with their appearance, often due to loose skin folds from excessive weight loss. It is the nurse’s role to validate the client’s feelings and to make sure the client understands that these feelings are normal. Asking the client why he or she is dissatisfied put the client in a defensive space and is not therapeutic. The client needs validation for his or her feelings; not being told that he or she can change. This may worsen the client’s body image.
A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse’s understanding of how the procedure works?
Restricts the client’s ability to eat.
Explanation:
Bariatric surgical procedures work by restricting a patient’s ability to eat (restrictive procedure), interfering with ingested nutrient absorption (malabsorptive procedures), or both. Bariatric procedures do not impair caloric absorption; rather, nutrients are impaired by malabsorption.
A nurse cares for a client with a BMI of 36 kg/m2 and nonalcoholic fatty liver disease. The client asks the nurse if he is a candidate for bariatric surgery. How should the nurse respond to the client?
“Yes, your BMI and chronic condition meets the criteria for bariatric surgery.”
Explanation:
The client’s BMI of > 35 kg/m2 and a more severe obesity-associated comorbid condition, makes the client a candidate for bariatric surgery.
Place the pathophysiological steps in order of how a client with obesity is at greater risk for venous thromboembolism in comparison to the general population.
Increased adipose tissue
Impairment of peripheral blood flow
Blood stasis
Formation of a thrombus
A nurse working in a cardiac health care office notes increased risk of certain cardiac conditions as a result of obesity. Which conditions can be associated with obesity? Select all that apply. Hypertension Coronary artery disease Heart failure Myocardial infarction Heart murmur
Hypertension
Coronary artery disease
Heart failure
Myocardial infarction
Understanding the definition of eating disorders is important in communicating facts while managing these conditions. Which is not an eating disorder?
obesity
Explanation:
Anorexia nervosa, bulimia nervosa, binge eating, and compulsive overeating are eating disorders. Obesity is a consequence of overeating.
A nurse cares for a client who is 5 feet 11 inches tall and weighs 225 pounds. What statement describes the client’s BMI?
Class I obesity
Explanation:
To calculate BMI, multiply weight in pounds by 703 and then divide that by height in inches squared. The client’s BMI is 31.4 kg/m2. This falls under the Class I obesity category. Normal weight BMI is 18.5-25 kg/m2. Overweight BMI is 25-30 kg/m2. Class II obesity is a BMI 35-40 kg/m2.
The nurse plans care for a client with obesity. What does the nurse recognize is the primary pathophysiological reason clients with obesity are at greater risk for developing thromboembolism?
Compromised peripheral blood flow
Explanation:
A client with obesity is at increased risk for developing thromboembolism due to compromised blood flow and resulting venous stasis. Although the client with obesity is at risk for high cholesterol levels, increased fat in the blood does not directly impact the risk for developing thromboembolism. Increased blood viscosity and impaired clotting do not typically occur in obesity and are not the reason a client with obesity would be at greater risk for developing thromboembolism.
A nurse cares for a client who is post op from bariatric surgery. Once able, the nurse encourages oral intake for what primary purpose?
Stimulate GI peristalsis
Explanation:
Early oral hydration stimulates GI peristalsis. The nurse would not give a client oral hydration to assess for intact swallowing as this may lead to aspiration. There is no reason to assume a client would have gastric perforation and this would not be appropriate. Digestive hormones are stimulated once peristalsis begins; however, this is not the primary purpose of early oral hydration.
The nurse establishes a learning contract with an overweight client. The contract is best if it
includes an incremental goal of 1–2 pound weight loss this week
Explanation:
The learning contract is recorded in writing. It is to be clear and describe what is to be achieved. A well–balanced diet is too vague. The nurse provides frequent and positive reinforcement as the client moves from one goal to the next. It is easier for the client to achieve a smaller, obtainable goal, such as 1–2 pound weight loss in one week, versus 30 pounds in 6 months.
A nurse researcher is reviewing data obtained from a developing nation on nutrition and metabolism issues facing that country. What is the nurse’s understanding of the “double-burden” many developing nations now face?
Both undernutrition and obesity
Explanation:
The WHO mentions that many developing nations now face a double-burden of both undernutrition and obesity. Both of these issues occur simultaneously and create a public health burden to developing nations.
A client is scheduled for a Roux-en-Y bariatric surgery. When teaching the client about the surgical procedure, which statement will the nurse use?
“The stomach is stapled to create a very small pouch and part of the small intestine is rerouted.”
Explanation:
In Roux-en-Y bariatric surgery, a horizontal row of staples across the fundus of the stomach creates a pouch with a capacity of 20 to 30 mL. The jejunum is divided distal to the ligament of Treitz, and the distal end is anastomosed to the new pouch. The proximal segment is anastomosed to the jejunum.
A nurse caring for adults with obesity recognizes that obesity is classified based on BMI. Which BMI does the nurse recognize as Class II obesity?
35 kg/m2
Explanation:
Class I obesity is defined as 30-34.9 kg/m2. Class II obesity is defined as a BMI of 35-39.9 kg/m2. A BMI of 40 kg/m2 or greater defines Class III obesity.
A nurse is providing discharge instruction for a client who is postoperative bariatric surgery. What statement will the nurse include when providing teaching aimed at decreasing the risk of gastric ulcers?
“Avoid taking non-steroidal anti-inflammatory drugs.”
Explanation:
The only statement that aids in avoiding gastric ulcers is the statement instructing the client to avoid taking non-steroidal anti-inflammatory (NSAID) drugs. Sitting in a semi-recumbent of low Fowler’s position aids in digestion but does not aid in the prevention of gastric ulcers. Propping the head of the bed would be beneficial for a client report GERD or acid reflux. antacid drugs do not increase the risk of gastric ulcers.
A nurse reviews a client’s medication list and notes the client takes orlistat for the treatment of obesity and to promote weight loss. Which client teaching will the nurse include that best promotes health in the client taking this medication?
“Make sure and take a daily multivitamin.”
Explanation:
The nurse should advise the client taking orlistat (Xenical) to take a daily multivitamin (not just calcium) as the client is at risk for malabsorption of nutrients.
A client with obesity reports pain in the joints. Which musculoskeletal condition related to obesity does the nurse suspect the client has?
Osteoarthritis
Explanation:
Osteoarthritis is an obesity-related musculoskeletal condition. Rheumatoid arthritis, inflammatory arthritis, and necrotizing arthritis are not obesity-related conditions.
What is a characteristic of the intrarenal category of acute renal failure?
Increased BUN
Explanation:
The intrarenal category of acute renal failure encompasses an increased BUN, increased creatinine, a low specific gravity of urine, and increased urine sodium.
Which nursing assessment finding indicates that the client who has undergone renal transplant has not met expected outcomes?
Fever
Explanation:
Fever is an indicator of infection or transplant rejection.
The client with polycystic kidney disease asks the nurse, “Will my kidneys ever function normally again?” The best response by the nurse is:
“As the disease progresses, you will most likely require renal replacement therapy.”
Explanation:
There is no cure for polycystic kidney disease. Medical management includes therapies to control blood pressure, urinary tract infections, and pain. Renal replacement therapy is indicated as the kidneys fail.
A patient undergoing a CT scan with contrast has a baseline creatinine level of 3 mg/dL, identifying this patient as at a high risk for developing kidney failure. What is the most effective intervention to reduce the risk of developing radiocontrast-induced nephropathy (CIN)?
Hydrating with saline intravenously before the test
Explanation:
Radiocontrast-induced nephropathy (CIN) is a major cause of hospital-acquired AKI. This is a potentially preventable condition. Baseline levels of creatinine greater than 2 mg/dL identify patients at high risk. Limiting the patient’s exposure to contrast agents and nephrotoxic medications will reduce the risk of CIN (Murphy & Byrne, 2010; Rank, 2013). Administration of N-acetylcysteine and sodium bicarbonate before and during procedures reduces risk, but prehydration with saline is considered the most effective method to prevent CIN (Murphy & Byrne, 2010; Rank, 2013).
The nurse is caring for a client with chronic kidney disease. The patient has gained 4 kg in the past 3 days. In milliliters, how much fluid retention does this equal? Enter your response as a whole number.
4000
Explanation:
A 1-kg weight gain is equal to 1,000 mL of retained fluid. 4 kg × 1,000 = 4,000. The most accurate indicator of fluid loss or gain in an acutely ill patient is weight. An accurate daily weight must be obtained and recorded.
After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?
“It is appropriate to warm the dialysate in a microwave.”
Explanation:
The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.
The nurse is able to identify which condition as uremia?
An excess of urea in the blood
Explanation:
Uremia is an excess of urea and other nitrogenous wastes in the blood. Azotemia is the concentration of nitrogenous wastes in the blood. Hematuria is blood in the urine. Proteinuria is protein in the urine. Hyperproteinemia is an excess of protein in the blood.
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hypovolemic shock caused by hemorrhage
Explanation:
If bleeding goes undetected or is not detected promptly, the patient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack.
The nurse is reviewing the potassium level of a patient with kidney disease. The results of the test are 6.5 mEq/L, and the nurse observes peaked T waves on the ECG. What priority intervention does the nurse anticipate the physician will order to reduce the potassium level?
Administration of sodium polystyrene sulfonate [Kayexalate])
Explanation:
The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.
The nurse on a telemetry unit is caring for a 54-year-old male client, admitted with chest pain, who has an arteriovenous (AV) fistula in the left arm for hemodialysis secondary to chronic kidney disease.
When a client has an arteriovenous (AV) fistula for hemodialysis, the nurse must provide interventions to protect the fistula and assess its patency.
The nurse auscultates the AV fistula with a stethoscope to detect a bruit, a sound generated by turbulent blood flow. The absence of a bruit may indicate blockage or clotting of the fistula. Likewise, the nurse palpates the AV fistula for a thrill (vibration), indicating turbulent blood flow through the fistula. The absence of a thrill can indicate a blockage or clotting of the fistula. The nurse also assesses for redness, swelling, or drainage at the AV fistula that might indicate infection. Blood pressures should not be taken in the arm with an AV fistula. Inflation of the blood pressure cuff can reduce the flow of blood, resulting in the clotting of blood in the fistula. Likewise, a tourniquet should not be placed around the arm to draw blood and the AV fistula should not be wrapped with a compression dressing as these procedures decrease blood flow to the fistula and increase the risk of clot formation.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?
Start IV fluids with a normal saline solution bolus followed by a maintenance dose.
Explanation:
The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn’t be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn’t fluid-overloaded so his urine output won’t increase with furosemide, which would actually worsen the client’s condition. The client doesn’t require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration.
A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?
Increase carbohydrates and limit protein intake.
Explanation:
Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood.
Diet modifications are part of nutritional therapy for the management of ARF. Select the high-potassium food that should be restricted.
Citrus fruits
Explanation:
Dietary restrictions include foods and fluids containing potassium, such as bananas, citrus, tomatoes, melons, or those with phosphorus, which is found in dairy, beans, nuts legumes, and carbonated beverages. Caffeine is also restricted.
A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client’s risk of:
water and sodium retention secondary to a severe decrease in the glomerular filtration rate.
Explanation:
The client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys’ inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.
The nurse is providing supportive care to a client receiving hemodialysis in the management of acute kidney injury. Which statement from the nurse best reflects the ability of the kidneys to recover from acute kidney injury?
The kidneys can improve over a period of months.
Explanation:
The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. As long as recovery is continuing, there is no need to consider transplant or permanent hemodialysis. Acute kidney injury can progress to chronic renal failure.
A nurse assesses a client shortly after living donor kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
Urine output of 20 ml/hour
Explanation:
Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client’s urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. A serum potassium level of 4.9 mEq/L, a serum sodium level of 135 mEq/L, and a temperature of 99.2° F are normal assessment findings.
A nurse is caring for a client who’s ordered continuous ambulatory peritoneal dialysis (CAPD). Which finding should lead the nurse to question the client’s suitability for CAPD?
The client has a history of diverticulitis.
Explanation:
A history of diverticulitis contraindicates CAPD because CAPD has been associated with the rupture of diverticulum. A history of severe anemia while on hemodialysis or being on the transplant waiting list doesn’t contraindicate CAPD. The client who’s blind or partially blind can still learn to perform CAPD.
When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate?
Cola-colored urine
Explanation:
Cola-colored urine is a typical symptom of glomerulonephritis. Flank pain on the affected side, not left upper quadrant pain, would be present. Pyuria is a symptom of pyelonephritis, not glomerulonephritis. Blood pressure typically elevates in glomerulonephritis.
A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?
Recent history of streptococcal infection
Explanation:
Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client’s risk for chronic pyelonephritis.
What is used to decrease potassium level seen in acute renal failure?
Sodium polystyrene sulfonate
Explanation:
The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract.
A child is brought into the clinic with symptoms of edema and dark brown rusty urine. Which nursing assessment finding would best assist in determining the cause of this problem?
Sore throat 2 weeks ago
Explanation:
Acute glomerulonephritis usually occurs as a result of bacterial infection such as seen with a beta-hemolytic streptococcal infection or impetigo. Red blood cells and protein found in the urine and elevated blood pressure are symptoms associated with glomerulonephritis.
What is a hallmark of the diagnosis of nephrotic syndrome?
Proteinuria
Explanation:
Proteinuria (predominantly albumin) exceeding 3.5 g per day is the hallmark of the diagnosis of nephrotic syndrome. Hypoalbuminemia, hypernatremia, and hyperkalemia may occur.
Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?
Glomerulonephritis
Explanation:
Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis.
A client who suffered hypovolemic shock during a cardiac incident has developed acute kidney injury. Which is the best nursing rationale for this complication?
Decrease in the blood flow through the kidneys
Explanation:
Acute kidney injury can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.
A client with chronic kidney disease weighs 209 lbs (95 kg) and is prescribed 1.2 grams of protein per kg per day. Which amount of protein will the client ingest per day?
114
Explanation:
To calculate the amount of protein the client is to ingest per day, first determine the client’s weight in kg by dividing the weight in lbs by 2.2 or 209/2.2 = 95 kg. Then multiply the client’s weight in kg by 1.2 or 95 x 1.2 = 114 grams. The client is to ingest 114 grams of protein per day.
The nurse weighs a patient daily and measures urinary output every hour. The nurse notices a weight gain of 1.5 kg in a 74-kg patient over 48 hours. The nurse is aware that this weight gain is equivalent to the retention of:
1,500 mL of fluid
Explanation:
A 1-kg weight gain is equal to 1,000 mL of retained fluid.
Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. Hyperkalemia Metabolic alkalosis Anemia Hyperalbuminemia Hypocalcemia
Hyperkalemia is due to decreased potassium excretion and excessive potassium intake. Metabolic acidosis results from decreased acid secretion by the kidney. A damaged glomerular membrane causes excess protein loss.
Hyperkalemia is a serious side effect of acute renal failure. Identify the electrocardiogram (ECG) tracing that is diagnostic for hyperkalemia.
Tall, peaked T waves
Explanation:
Characteristic ECG signs of hyperkalemia are tall, tented, or peaked T waves, absent P waves, and a widened QRS complex.
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
Urine output of 250 ml/24 hours
Explanation:
ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is characterized by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn’t diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn’t result from this disorder.
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?
Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20.
Explanation:
The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.
The client with prostatitis presents with low back pain, dysuria, and unusual sensation following ejaculation. Which treatment(s) does the nurse anticipate being prescribed? Select all that apply. Analgesics Sitz baths Antibiotics Abstinence Treatment of sexual partner
Prostatitis is an inflammation of the prostate gland that is most often caused by microorganisms. Treatment consists of up to 30 days of antibiotic therapy, mild analgesics, and sitz baths. Sexual partners also need to be treated. Regular drainage of the prostate gland through masturbation or intercourse can be helpful in decreasing the inflammation and discomfort.
The client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education?
Brief, hot daily showers
Explanation:
Hot water removes more oils from the skin and can increase dryness and itching. Tepid water temperature is preferred in the management of pruritus. The use of moisturizing lotions and creams that do not contain perfumes can be helpful. Avoid scratching and keeping nails trimmed short is indicated in the management of pruritus.
A male client has doubts about performing peritoneal dialysis at home. He informs the nurse about his existing upper respiratory infection. Which of the following suggestions can the nurse offer to the client while performing an at-home peritoneal dialysis?
Wear a mask when performing exchanges.
Explanation:
The nurse should advise the client to wear a mask while performing exchanges. This prevents contamination of the dialysis catheter and tubing, and is usually advised to clients with upper respiratory infection. Auscultation of the lungs will not prevent contamination of the catheter or tubing. The client may also be advised to perform deep-breathing exercises to promote optimal lung expansion, but this will not prevent contamination. Clients with a fistula or graft in the arm should be advised against carrying heavy items.
The nurse is caring for a patient in the oliguric phase of acute kidney injury (AKI). What does the nurse know would be the daily urine output?
Less than 400 mL
Explanation:
The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 mL. In this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop.
The nurse helps a client to correctly perform peritoneal dialysis at home. The nurse must educate the client about the procedure. Which educational information should the nurse provide to the client?
Keep the dialysis supplies in a clean area, away from children and pets
Explanation:
It is important to keep the dialysis supplies in a clean area, away from children and pets, because the supplies may be dangerous for them. A mask is generally worn only while performing exchanges, especially when a client has an upper respiratory infection. The catheter insertion site should be cleaned daily with an antiseptic such as povidone-iodine, not with soap. In addition, the catheter should be stabilized to the abdomen above the belt line, not below the belt line, to avoid constant rubbing.
The nurse is administering calcium acetate (PhosLo) to a patient with end-stage renal disease. When is the best time for the nurse to administer this medication?
With food
Explanation:
Hyperphosphatemia and hypocalcemia are treated with medications that bind dietary phosphorus in the GI tract. Binders such as calcium carbonate (Os-Cal) or calcium acetate (PhosLo) are prescribed, but there is a risk of hypercalcemia. The nurse administers phosphate binders with food for them to be effective.
What is a characteristic of the intrarenal category of acute kidney injury (AKI)?
Increased BUN
Explanation:
The intrarenal category of acute kidney injury (AKI) encompasses an increased BUN, increased creatinine, a low-normal specific gravity of urine, and increased urine sodium. Intrarenal AKI is the result of actual parenchymal damage to the glomeruli or kidney tubules. Acute tubular necrosis (ATN), AKI in which there is damage to the kidney tubules, is the most common type of intrinsic AKI. Characteristics of ATN are intratubular obstruction, tubular back leak (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and changes in glomerular permeability. These processes result in a decrease of GFR, progressive azotemia, and fluid and electrolyte imbalances.
Which of the following occurs late in chronic glomerulonephritis?
Peripheral neuropathy
Explanation:
Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
Risk for infection
Explanation:
The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. If the client experiences repeated peritoneal infections, continuous ambulatory peritoneal dialysis may no longer be effective in clearing waste products. Impaired urinary elimination, Toileting self-care deficit, and Activity intolerance may be pertinent but are secondary to the risk of infection.
A client with chronic kidney disease reports generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures?
Hyperphosphatemia
Explanation:
Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia. In an effort to raise blood calcium levels, the parathyroid glands secrete more parathormone. Elevated creatinine, urea, nitrogen, and potassium levels are expected in chronic renal failure and do not contribute to bone fractures.
After undergoing surgery the previous day for a total knee replacement, a client states, “I am not ready to ambulate yet.” What should the nurse do?
Discuss the complications that the client may experience if there is lack of cooperation with the care plan.
Explanation:
The nurse should discuss the care plan and its rationale with the client. Calling the health care provider to report the client’s noncompliance won’t alter the client’s degree of participation and shouldn’t be used to force the client to comply. Doing nothing isn’t acceptable. Although the client does have the right to make choices, it’s the nurse’s responsibility to provide education to help the client make informed decisions. Although the nurse should ultimately document the client’s refusal, the nurse should first discuss the care plan with the client.
A client has a plaster cast applied to the left leg. Which comment by the client following the procedure should the nurse address first?
“My toes are stiff.”
Explanation:
Compartment syndrome is characterized by neurovascular compromise. Stiffness of the toes may be a preliminary finding that the client is having trouble with motor function.
Which instruction should the nurse include when teaching the client following hip replacement surgery? (Select all that apply.)
“You may cross your legs at the ankles only.”
“Place pillows between your legs when you lay on your side.”
“Avoid bending forward when sitting in a chair.”
“Use a raised toilet seat and high-seated chair.”
“It is okay to briefly flex the hip to put on your clothes.”
“Place pillows between your legs when you lay on your side.”
“Avoid bending forward when sitting in a chair.”
“Use a raised toilet seat and high-seated chair.”
The client following post hip replacement should not cross the legs, even at the ankle. He or she should avoid bending forward when sitting in a chair, avoid flexing the hip when dressing, and use a raised toilet seat. A pillow should be placed between the legs when side-lying.
A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?
Elevate the affected extremity and use cold applications.
Explanation:
Elevating the affected extremity and using cold applications reduce swelling. Deep breathing and coughing helps with maintenance of effective respiratory rate and depth. ROM exercises maintain full ROM of unaffected joints. Antiembolism stockings help prevent deep vein thrombosis (DVT).
A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal, it is important for the nurse to assure:
the client that he or she won’t be cut
Casts are removed with a mechanical cast cutter. Cast cutters are noisy and frightening but the blade does not penetrate deep enough to cut the client. The client needs reassurance that the machine will not cut into the skin. The other options are either irrelevant or not something the nurse knows for certain at this time.
The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?
Pulmonary embolism
Explanation:
Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.
A client undergoes an open reduction of a femur fracture, and returns to the orthopedic unit with a cast in place. What is the rationale for frequently assessing the client’s pedal pulses?
maintaining adequate circulation
Explanation:
Circulation, sensation, and mobility of exposed fingers or toes must be assessed every 1 to 2 hours to ensure neurovascular status is not compromised.
A client with a long arm cast continues to complain of unrelieved throbbing pain even after receiving opioid pain medication. Which is the priority action by the nurse?
Assess for complications.
Explanation:
Unrelieved pain can be an indicator of a complication, such as compartment syndrome. Previous opioid drug use should not influence a complete and thorough assessment. Repositioning the client for comfort may be appropriate once all indications of a complication are ruled out. It is appropriate to teach relaxation techniques to help ease the pain, but assessing for a complication remains the highest priority.
The nurse is checking the traction apparatus for a client in skin traction. Which finding would require the nurse to intervene?
Weights hanging and touching the floor
Explanation:
When checking traction equipment, the weights should be freely hanging. Weights that touch the floor require the nurse to intervene. The body should be aligned in an opposite line to the pull of the traction. The ropes should be freely moving over unobstructed pulleys.
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?
Total arthroplasty
Explanation:
A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone’s alignment, thereby improving function and relieving pain.
Which objective symptom of a UTI is most common in older adults, especially those with dementia?
Change in cognitive functioning
Explanation:
The most common objective finding is a change in cognitive functioning, especially in those with dementia, because these clients usually exhibit even more profound cognitive changes with the onset of a UTI. Incontinence, hematuria, and back pain are not the most common presenting objective symptoms.
Which metabolic defects are associated with stone formation?
Hyperparathyroidism
Explanation:
Metabolic defects such as hyperparathyroidism and hyperuricemia (gout) are associated with stone formation. Hypoparathyroidism, hyperthyroidism, and hypouricemia are not associated with stone formation.
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence?
Decreased pelvic muscle tone due to multiple pregnancies
Explanation:
Stress incontinence is due to decreased pelvic muscle tone, which is associated with multiple pregnancies, obstetric injuries, obesity, menopause, or pelvic disease. Transient incontinence is due to increased urine production related to metabolic conditions. Urge incontinence is due to bladder irritation related to urinary tract infections, bladder tumors, radiation therapy, enlarged prostate, or neurologic dysfunction. Overflow incontinence is due to obstruction from fecal impaction or enlarged prostate.
Patients with urolithiasis need to be encouraged to:
Increase their fluid intake so that they can excrete up to 4 liters every day.
Explanation:
Fluids need to be increased up to 4 L/day to increase hydrostatic pressure within the urinary tract and thereby promote passage of the stone. This volume of fluid intake also helps prevent additional stone formation.
The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client?
Coffee in the morning
Explanation:
The nurse would discourage drinking coffee. Coffee, tea, alcohol, and colas are urinary tract irritants. Fruit juice, milk, and ginger ale are appropriate for drinking and counted toward the daily fluid total.
A patient who has been treated for uric acid stones is being discharged from the hospital. What type of diet does the nurse discuss with the patient?
Low-purine diet
Explanation:
For uric acid stones, the patient is placed on a low-purine diet to reduce the excretion of uric acid in the urine. Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided, and other proteins may be limited.
The nurse is caring for several older clients. For which client would the nurse be especially alert for signs and symptoms of pyelonephritis?
A client with urinary obstruction
Explanation:
The client with urinary obstruction is at the highest risk of developing pyelonephritis because a urinary obstruction is the most common cause of pyelonephritis in older adults. Acute glomerulonephritis usually occurs in older adults with preexisting chronic glomerulonephritis. Older clients with acute renal failure or urinary tumor are not at high risk for developing pyelonephritis.
A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. The nurse’s postoperative plan of care should include which action?
Maintain skin and stomal integrity.
Explanation:
The most important postoperative nursing management is to maintain skin and stomal integrity to avoid further complications, such as skin infections and urinary odor. Determining the client’s ability to manage stoma care, showing photographs, and suggesting a visit to a local ostomy group would be a part of the preoperative procedure.
Which term refers to inflammation of the renal pelvis?
Pyelonephritis
Explanation:
Pyelonephritis is an upper urinary tract inflammation, which may be acute or chronic. Cystitis is inflammation of the urinary bladder. Urethritis is inflammation of the urethra. Interstitial nephritis is inflammation of the kidney.
The nurse is assisting in the development of a protocol for bladder retraining following removal of an indwelling catheter. Which item should the nurse include?
Implement a 2- to 3-hour voiding schedule
Explanation:
Immediately after the removal of the indwelling catheter, the client is placed on a voiding schedule, usually 2 to 3 hours. At the given time, the client is instructed to void. Immediate voiding is not usually encouraged.
The nurse is assigned to care for a client who has had a total knee arthroplasty yesterday. What type of pharmacologic therapy does the nurse anticipate administering to this client to prevent complications related to the surgery?
Anticoagulation therapy
Explanation:
Anticoagulation therapy and early ambulation are very important for clients who have knee or hip replacement to prevent thrombus formation. The other therapy is not indicated solely for the knee or hip arthroplasty.
A nurse would most likely expect the need for open reduction for a client with which of the following?
Joint fracture
Explanation:
An open reduction is required when soft tissue is caught between the ends of the broken pieces of bone, the bone has a wide separation, open fractures are evident, comminuted fractures are present, and the patella or other joints are fractured. It is also done when wound debridement or internal fixation is needed.
Which term describes a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure?
Fasciotomy
Explanation:
A fasciotomy is a surgical procedure to release constricting muscle fascia so as to relieve muscle tissue pressure. An osteotomy is a surgical cutting of bone. An arthroplasty is a surgical repair of a joint. Arthrodesis is a surgical fusion of a joint.
A client with a right leg fracture is returning to the orthopedist to have the cast removed. What would the physician prescribe as further treatment?
physical therapy
Explanation:
For some time, the limb will need support. An elastic bandage may be wrapped on a leg, the client may use a cane, and an arm may be kept in a sling until progressive active exercise and physical therapy help the client regain normal strength and motion.
A nurse is caring for a client who recently underwent a total hip replacement. What is the best action by the nurse for client care?
Limit hip flexion of the client’s hip when the client sits up.
Explanation:
The nurse should instruct the client to limit hip flexion to 90 degrees when sitting. The nurse should supply an elevated toilet seat so that the client can sit without having to flex the hip more than 90 degrees. The nurse should instruct the client not to cross legs to avoid dislodging or dislocating the prosthesis. The nurse should caution the client against sitting in chairs that are too low or too soft; these chairs increase flexion, which is undesirable.
A client is seen in the emergency department for an injury acquired from falling off of a bicycle and fracturing the arm. The client also has a long laceration that has been sutured in the same area. The client asks the nurse why a splint is applied and not a cast. What is the best explanation by the nurse?
“We will need to monitor the status of the laceration to be sure it does not get infected.”
Explanation:
A splint would be used when there is special skin treatment or observation that is required. The arm fracture would require the same form of immobilization that a leg fracture does. The length of time the splint can be worn is equal to that of a cast to immobilize the fracture. The cost of the splint and cast would be similar.
Conservative treatment of a compressed nerve root is first line treatment. What conservative treatment is used to increase the distance between vertebrae and decrease severe muscle spasm?
Skin traction
Explanation:
Skin traction, which can be applied in the home, is used to decrease severe muscle spasm as well as increase the distance between adjacent vertebrae, keep the vertebrae correctly aligned, and, in many instances, relieve pain. Treatment relieves symptoms for an extended period.
A client’s cast is removed. The client is worried because the skin appears mottled and is covered with a yellowish crust. What advice should the nurse give the client to address the skin problem?
Apply lotions and take warm baths or soaks.
Explanation:
The client should be advised to apply lotions and take warm baths or soaks. This will help in softening the skin and removing debris. The client usually sheds this residue in a few days so the client need not consult a skin specialist. It is not advisable to scrub the area vigorously. The client need not avoid exposure to direct sunlight because the area is not photosensitive.
A client has a Fiberglass cast on the right arm. Which action should the nurse include in the care plan?
Assessing movement and sensation in the fingers of the right hand
Explanation:
The nurse should assess a casted arm every 2 hours for finger movement and sensation to make sure the cast isn’t restricting circulation. To reduce the risk of skin breakdown, the nurse should leave a casted arm uncovered, which allows air to circulate through the cast pores to the skin below. Unlike a plaster cast, a Fiberglass cast dries quickly and can be handled without damage soon after application. The nurse should assess the brachial and radial pulses distal to the cast — not the pedal and posterior tibial pulses, which are found in the legs.
The nurse is assigned to care for a client who has had an open reduction and internal fixation of a fractured right femur 2 days ago. The nurse is listening to the client’s lungs and, when moving the gown, observes petechial hemorrhages on the skin of the chest. What is the first action by the nurse?
Call the physician to inform them of the findings.
Explanation:
The findings of the nurse indicate that the client may have a fat embolus, and the physician should be informed immediately. Administration of pain medication is not indicated at this time. The rash is not indicative of an allergic reaction. There is no indication that the rash is related to hemorrhage, and there is no need to increase the IV fluids.
The nurse is caring for a patient who had a total hip replacement. What lethal postoperative complication should the nurse closely monitor for?
Pulmonary embolism
Explanation:
Patients having orthopedic surgery are particularly at risk for venous thromboembolism, including deep vein thrombosis and pulmonary embolism.
Following a total knee replacement, the surgeon orders a continuous passive motion (CPM) device. The client asks about the purpose of this treatment. What is the best response by the nurse?
“CPM increases range of motion of the joint.”
Explanation:
CPM increases circulation and range of motion of the knee joint.
A client has severe osteoarthritis in the left hip and is having surgery to replace both articular surfaces of the hip. What type of surgical procedure will the nurse prepare the client for?
Total arthroplasty
Explanation:
A total arthroplasty is a replacement of both articular surfaces within one joint. An arthrodesis is a fusion of a joint for stabilization and pain relief and is usually done on a wrist or knee. A hemiarthroplasty is the replacement of one of the articular surfaces in a joint, such as the femoral head but not the acetabulum. An osteotomy is the cutting and removal of a wedge of bone to change the bone’s alignment, thereby improving function and relieving pain.
A 68-year-old female client who had a below-the-knee amputation is to be discharged because her healing is almost complete. Which of the following would be most important for the nurse to discuss with this client?
Exploring factors related to the client’s home environment
Explanation:
Exploring factors related to the older adult client’s home environment and determining a plan for continued rehabilitation before discharge is most important. The client should be encouraged to eat foods rich in protein, calcium, and vitamin D. Because the healing is almost complete, the client need not always keep the affected limb elevated unless prescribed to do so. Because the client is in her late 60s, she is most likely to have already undergone menopause. Therefore, educating her about the effects of menopause is not as important.
Which is not a guideline for avoiding hip dislocation after replacement surgery.
The hip may be flexed to put on clothing such as pants, stockings, socks, or shoes.
Explanation:
Guidelines for avoiding hip dislocation after replacement surgery specify that the hip should not be flexed to put on clothing such as pants, stockings, socks, or shoes. Clients should keep the knees apart at all times, put a pillow between the legs when sleeping, and never cross the legs when seated.
A client is reporting pain following orthopedic surgery. Which intervention will help relieve pain?
Elevate the affected extremity and use cold applications.
Explanation:
Elevating the affected extremity and using cold applications reduce swelling. Deep breathing and coughing helps with maintenance of effective respiratory rate and depth. ROM exercises maintain full ROM of unaffected joints. Antiembolism stockings help prevent deep vein thrombosis (DVT).
A patient in pelvic traction needs circulatory status assessed. How should the nurse assess for a positive Homans’ sign?
Have the patient extend each leg and dorsiflex each foot to determine if pain or tenderness is present in the lower leg.
Explanation:
The nurse should assess for pain on passive flexion of each foot, which could indicate deep vein thrombosis.
The nurse is caring for a client who had a total knee replacement 3 days ago. Which nursing assessment finding requires immediate attention by the nurse?
Drainage from wound suction device = 100 ml
Explanation:
Drainage from a wound suction device should be less than 25 ml 48 hours after surgery; 100 ml is an excessive amount and may necessitate opening of the wound to remove the blood.
A client who is undergoing skeletal traction reports pressure on bony areas. Which action would be most appropriate to provide comfort for the client?
Changing the client’s position within prescribed limits.
Explanation:
Changing the position of a client within prescribed limits helps relieve pressure on bony areas and promotes comfort. Analgesics help to relive pain but may not help relieve pressure on bony areas. Warm compresses aid blood circulation. The client should not exercise while on traction unless prescribed to regain strength in the affected limb.
A client is being discharged home with a long arm cast. What education should the nurse include to prevent disuse syndrome in the arm?
Use of isometric exercises
Explanation:
Isometric exercises allow for use of the muscle without moving the bone. Doing isometric exercises every hour while the client is awake will help prevent disuse syndrome. Proper use of a sling does not prevent disuse syndrome. The client should not attempt to reposition the arm in the cast. Abduction and adduction of the shoulder will help the shoulder joint but does not require the use of muscles in the lower arm.
A client in the emergency department is being treated for a wrist fracture. The client asks why a splint is being applied instead of a cast. What is the best response by the nurse?
“A splint is applied when more swelling is expected at the site of injury.”
Explanation:
Splints are noncircumferential and will not compromise circulation when swelling is expected. A splint is applied to support and immobilize the injured joint. A fracture will swell as part of the inflammation process. The client would not have to stay longer if a fiberglass cast is applied. Fiberglass cast dry in approximately 30 minutes. An orthopedic doctor is not needed to apply the cast. Many nurses and technicians are trained in proper application of a cast. Some fractures may not be treated with a cast but it would not be appropriate to answer with this response because it does not reflect the actual reason for a splint being applied.
Which nursing action would help prevent deep vein thrombosis in a client who has had an orthopedic surgery?
Apply antiembolism stockings
Explanation:
Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a client who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain, while ROM exercises help maintain muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling; cold does not prevent deep vein thrombosis.
Which is a benefit of a continuous passive motion (CPM) device when applied after knee surgery?
It promotes healing by increasing circulation and movement of the knee joint.
Explanation:
A CPM device applied after knee surgery promotes healing by increasing circulation and movement of the knee joint.
A client with a fractured femur is placed in skeletal traction. Which intervention will increase client independence when moving in bed?
Apply a trapeze to the bed frame.
Explanation:
To encourage movement, an assistive device called a trapeze can be suspended overhead within easy reach of the client. The trapeze helps the client move about in bed and move on and off the bedpan. The client’s elbows frequently become sore, and nerve injury may occur if the client repositions by pushing on the elbows. Clients frequently push on the heel of the unaffected leg when they raise themselves. This digging of the heel into the mattress may injure the tissues. It is important to instruct clients not to use their heels or elbows to push themselves up in bed. The weights should not be removed to reposition the client or for any other reason.
A client is brought to the emergency department by a softball team member who states the client and another player ran into each other, and the client is having severe pain in the right shoulder. What symptoms of a fractured clavicle does the nurse recognize?
Right shoulder slopes downward and droops inward.
Explanation:
The client with a fractured clavicle has restricted motion, and the affected shoulder appears to slope downward and droop inward. The client will have pain, not typically tingling and numbness in the right shoulder. Pain is not felt in the unaffected shoulder.
The nurse is caring for a client with an external fixator that requires pin care twice a day. The nurse observes that there is a new purulent drainage around one of the pins. What intervention should the nurse anticipate doing?
Obtaining a culture
Explanation:
A culture should be obtained if purulent drainage is present. Drainage should be gently removed, not scrubbed. Iodine-based products interfere with tissue healing and are not recommended for cleaning pin sites. Ointment should not be applied to the pin site unless specifically ordered.
Which is an inaccurate principle of traction?
The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely. The client must be in good alignment in the center of the bed. Skeletal traction is interrupted to turn and reposition the client.
Skeletal traction is interrupted to turn and reposition the client.
Explanation:
Skeletal traction is never interrupted. The weights are not removed unless intermittent treatment is prescribed. The weights must hang freely, with the client in good alignment in the center of the bed.
The nurse is caring for a client who lives alone and had a total knee replacement. An appropriate nursing diagnosis for the client is:
Risk for ineffective therapeutic regimen management
Explanation:
The client without adequate support and resources is at risk for ineffective therapeutic regimen management. A total knee replacement may be used to treat avascular necrosis. While an orthopedic client is at risk for disturbed body image and situational low self-esteem, there is no evidence that these exist for this client.
A variety of complications can occur after a leg amputation. Which is not a possibility in the immediate postoperative period?
osteomyelitis
Explanation:
Chronic osteomyelitis may occur after persistent infection in the late postoperative period. Hematoma, hemorrhage, and infection are potential complications in the immediate postoperative period.
A client has undergone an external fixation. Which actions would be the priority for this client?
Maintaining pin care.
Explanation:
Pin care is a priority for a client with external fixation, because pin sites are entry points for infection. The nurse should also monitor redness, drainage, and tenderness at the site. Planning the client’s diet and monitoring the client’s urine output and blood pressure, although necessary, are not as important as maintaining pin care.
The client displays manifestations of compartment syndrome. What treatment will the nurse expect the client to be scheduled for?
A fasciotomy
Explanation:
A treatment option for compartment syndrome is fasciotomy.
A nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?
Assessing the extremity for neurovascular integrity
Explanation:
Although all measures are correct, assessing neurovascular integrity takes priority because a decrease in neurovascular integrity could compromise the limb. The pull of the traction must be continuous to keep the client from sliding. Sufficient countertraction must be maintained at all times by keeping the ropes over the center of the pulley. The line of pull is maintained by allowing the weights to hang free.
An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker?
24 hours
Explanation:
Following hip arthroplasty (total hip replacement), patients begin ambulation with the assistance of a walker or crutches within a day after surgery.
A client’s left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client’s care plan?
Teach the client how to prevent problems caused by immobility.
Explanation:
By teaching the client about prevention measures, the nurse can help prevent problems caused by immobility, such as hypostatic pneumonia, muscle contracture, and atrophy. The nurse applies traction straps for skin traction — not skeletal traction. For a client in skeletal traction, the nurse should assess the affected limb, rather than assess the level of consciousness. Removing skeletal traction is the physician’s responsibility — not the nurse’s.
A client arrives in the emergency department with a suspected bone fracture of the right arm. How does the nurse expect the client to describe the pain?
Sharp and piercing
Explanation:
The nurse must carefully evaluate pain associated with the musculoskeletal condition, asking the client to indicate the exact site and to describe the character and intensity of the pain using a pain rating scale. Most pain can be relieved by elevating the involved part, applying ice or cold packs, and administering analgesic agents as prescribed. Pain associated with the underlying condition (e.g., fracture, which is sharp and piercing) is frequently controlled by immobilization. Pain due to edema that is associated with trauma, surgery, or bleeding into the tissues can frequently be controlled by elevation and, if prescribed, intermittent application of ice or cold packs. Ice bags (one third to one half full) or cold application devices are placed on each side of the cast, if prescribed, making sure not to indent or wet the cast. Unrelieved or disproportionate pain may indicate complications. Pain associated with compartment syndrome is relentless and is not controlled by modalities such as elevation, application of ice or cold, and usual dosages of analgesic agents. Severe burning pain over bony prominences, especially the heels, anterior ankles, and elbows, warns of an impending pressure ulcer. This may also occur from too-tight elastic wraps used to hold splints in place.
Which statement is accurate regarding care of a plaster cast?
The cast can be dented while it is damp.
Explanation:
The cast can be dented while it is damp. A dry plaster case is white and shiny. The cast will dry in 24 to 72 hours. A freshly applied cast should be exposed to circulating air to dry and should not be covered with clothing or bed linens or placed on plastic-coated mats or bedding.
Which would be contraindicated as a component of self-care activities for the client with a cast?
Cover the cast with plastic to insulate it
Explanation:
The cast should be kept dry, but do not cover it with plastic or rubber because this causes condensation, which dampens the cast and skin. The other activities are consistent with cast care.
Which type of cast encloses the trunk and a lower extremity?
Hip spica
Explanation:
A hip spica cast encloses the trunk and a lower extremity. A body cast encloses the trunk. A long-leg cast extends from the junction of the upper and middle third of the thigh to the base of the toes. A short-leg cast extends from below the knee to the base of the toes.
The nurse is caring for a patient postoperatively following orthopedic surgery. The nurse assesses an oxygen saturation of 89%, confusion, and a rash on the upper torso. What does the nurse suspect is occurring with this patient?
Fat emboli syndrome
Explanation:
Fat embolism syndrome (FES) (see Chapter 43) may occur with orthopedic surgery. The nurse must be alert to any signs and symptoms that may suggest the development of FES. These may include respiratory distress; onset of delirium or any acute change in level of consciousness; and development of unusual skin rashes, especially a papular rash on the upper torso.
A client is seen in the orthopedic clinic for complaints of severe pain in the left hip. After a series of diagnostic tests, the client is diagnosed with severe degenerative joint disease of the left hip and suggested to have the hip reconstructed. What procedure will the nurse schedule the client for?
Left hip arthroplasty
Explanation:
Clients with arthritis, trauma, hip fracture, or a congenital deformity may have an arthroplasty, or reconstruction of the joint. This procedure uses an artificial joint that restores previously lost function and relieves pain. An arthroscopy is not used to reconstruct a diseased hip. A closed reduction is not an invasive surgical procedure and would not be used to reconstruct the hip. An open reduction and internal fixation is not the treatment for reconstruction of the hip related to a diseased hip.
A client has a cast applied to the leg for treatment of a tibia fracture and also has a wound on the leg that requires dressing changes due to drainage. For what should the nurse prepare the client?
Cutting a cast window
Explanation:
After the cast dries, a cast window, or opening, may be cut. This usually is done when the client reports discomfort under the cast or has a wound that requires a dressing change. The window permits direct inspection of the skin, a means to check the pulse in a casted arm or leg, or a way to change a dressing. A bivalve cast is when the cast is cut in two if the leg swells or if the client is being weaned from a cast, when a sharp x-ray is needed, or as a splint for immobilizing painful joints when a client has arthritis. The cast should not be removed due to the instability of a fracture. The client’s condition does not indicate an external fixator is required.
Which device is designed specifically to support and immobilize a body part in a desired position?
Splint
Explanation:
A splint may be applied to a fractured extremity initially until swelling subsides. Splints are designed to provide stability for fractures that are unstable and to immobilize and support the body part in a functional position. A brace is an externally applied device to support a body part, control movement, and prevent injury; braces are used to enhance movement while preventing injury. A sling is a bandage used to support an arm temporarily while the client ambulates; it is not designed to immobilize the body part. Traction is the use of a pulling force on a body part and thus it is not designed to immobilize; the goal of traction is to achieve or maintain alignment, decrease muscle spasms and pain, or correct or prevent deformities.
The nurse is providing instructions to the client who is being prepared for skeletal traction. Which statement by the client indicates teaching was effective?
“Metal pins will go through my skin to the bone.”
Explanation:
In skeletal traction, metal rods or pins are used to apply continuous traction directly to the bone. Weights are used to apply the traction. Casts, external fixators, or splints are used when the traction is discontinued.
A group of students is reviewing information about cast composition in preparation for a discussion on the advantages and disadvantages of each. The students demonstrate understanding of the topic when they cite which of the following as an advantage of a plaster cast?
Better molding to the client
Explanation:
Plaster casts require a longer time for drying but mold better to the client and are initially used until the swelling subsides. Fiberglass casts dry more quickly, are lighter in weight, longer lasting, and breathable.
The nurse is caring for a client with a cystoscopy tube draining urine from the bladder. When reviewing the client’s history prior to administering care, which is of most concern?
New diagnosis of urosepsis
Explanation:
All of the options are typical risk factors for a client with a cystoscopy tube. The most concerning risk factor is of urosepsis, which is a serious systemic infection from microorganisms in the urinary tract invading the bloodstream.
Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply.
Urinary retention Deficient knowledge: management of urinary diversion Disturbed body image Risk for impaired skin integrity Chronic pain
Deficient knowledge, disturbed body image, and risk for impaired skin integrity are expected problems for the client with a new ileal conduit. Urinary retention and chronic pain are not expected client problems.
