TEST 12: The Client with Musculoskeletal Health Problems

Question 1

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

Answer 1

The Client with Rheumatoid Arthritis
1. 3. Initially, most clients with early symptoms of rheumatoid arthritis report early morning
stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include
limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules.
CN: Physiological adaptation;CL: Analyze

Question 2

2. A client with rheumatoid arthritis states, “I can’t do my household chores without becoming
   tired. My knees hurt whenever I walk.” Which goal for this client should take priority?.
3. Conserve energy.
4. Adapt self-care skills.
5. Develop coping skills.
6. Adapt body image.

Answer 2

2. 1. Based on the information from the client, the nurse should develop a plan with the client that
      will conserve energy and decrease episodes of fatigue. Although the client may develop a self-care
      deficit related to the increasing joint pain, the client is voicing concerns about household chores and
      difficulty around the house and yard, not self-care issues. Over time, the client may have difficulty
      coping or experience changes in body image as the disorder becomes chronic with increasing pain
      and fatigue, but the current priority is to conserve energy.
      CN: Basic care and comfort; CL: Analyze

Question 3

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

Answer 3

3. 1, 2, 4. RA affects women three times more often than men between the ages of 20 and 55
   years. Research has determined that RA occurs in clients who have had infectious disease, such as the
   Epstein-Barr virus. The genetic link, specifically HLA-DR4, has been found in 65% of clients with
   RA. People with osteoarthritis are not necessarily at risk for developing RA.
   CN: Reduction of risk potential;CL: Analyze

Question 4

4. A client is in the acute phase of rheumatoid arthritis. In which order of priority should the
   nurse establish the following goals?
5. Relieving pain.
6. Preserving joint function.
7. Maintaining usual ways of accomplishing tasks.
8. Preventing joint deformity.

Answer 4

4. 1, 4, 2, 3. Pain relief is the highest priority during the acute phase because pain is typically
   severe and interferes with the client’s ability to function. Preserving joint function is the next goal to
   set, followed by preventing joint deformity during the acute phase to promote an optimal level of
   functioning and reduce the risk of contractures. Maintaining usual ways of accomplishing tasks is the
   goal with the lowest priority during the acute phase. Rather, the focus is on developing less stressful
   ways of accomplishing routine tasks.
   CN: Physiological adaptation;CL: Synthesize

Question 5

5. The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the
   following client statements indicates that the client still has a knowledge deficit?.
6. “I can use heat and cold as often as I want.”
7. “With heat, I should apply it for no longer than 20 minutes at a time.”
8. “Heat-producing liniments can be used with other heat devices.”
9. “Ten to fifteen minutes per application is the maximum time for cold applications.”

Answer 5

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

Question 6

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

Answer 6

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

Question 7

7. The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the
   following would the nurse expect to instruct the client to avoid during rest periods?.
8. Proper body alignment.
9. Elevating the part.
10. Prone lying positions.
11. Positions of flexion.

Answer 7

7. 4. Positions of flexion should be avoided to prevent loss of functional ability of affected joints.
      Proper body alignment during rest periods is encouraged to maintain correct muscle and joint
      placement. Lying in the prone position is encouraged to avoid further curvature of the spine and
      internal rotation of the shoulders.
      CN: Physiological adaptation;CL: Synthesize

Question 8

8. After teaching the client with rheumatoid arthritis about measures to conserve energy in
   activities of daily living involving the small joints, which of the following, if stated by the client,
   would indicate the need for additional teaching?.
9. Pushing with palms when rising from a chair.
10. Holding packages close to the body.
11. Sliding objects.
12. Carrying a laundry basket with clinched fingers and fists.

Answer 8

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

Question 9

9. After teaching the client with severe rheumatoid arthritis about prescribed methotrexate, which
   of the following statements indicates the need for further teaching?.
10. “I will take my vitamins while I’m on this drug.”
11. “I must not drink any alcohol while I’m taking this drug.”
12. “I should brush my teeth after every meal.”
13. “I will continue taking my birth control pills.”

Answer 9

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

Question 10

10. A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports
    difficulty seeing out of the left eye. Correct interpretation of this assessment finding indicates which
    of the following?.
11. Development of a cataract.
12. Possible retinal degeneration.
13. Part of the disease process.
14. A coincidental occurrence.

Answer 10

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

Question 11

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

Answer 11

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

Question 12

12. Which of the following statements should the nurse include in the teaching session when
    preparing a client for arthrocentesis? Select all that apply.
13. “A local anesthetic agent may be injected into the joint site for your comfort.”
14. “A syringe and needle will be used to withdraw fluid from your joint.”
15. “The procedure, although not painful, will provide immediate relief.”
16. “We’ll want you to keep your joint active after the procedure to increase blood flow.”
17. “You will need to wear a compression bandage for several days after the procedure.”

Answer 12

12. 1, 2, 5. An arthrocentesis is performed to aspirate excess synovial fluid, pus, or blood from a
    joint cavity to relieve pain or to diagnosis inflammatory diseases such as rheumatoid arthritis. A local
    agent may be used to decrease the pain of the needle insertion through the skin and into the joint
    cavity. Aspiration of the fluid into the syringe can be very painful because of the size and
    inflammation of the joint. Usually a steroid medication is injected locally to alleviate the
    inflammation; a compression bandage is applied to help decrease swelling; and the client is asked to
    rest the joint for up to 24 hours afterward to help relieve the pain and promote rest to the inflamed
    joint. The client may experience pain during this time until the inflammation begins to resolve and
    swelling decreases.
    CN: Reduction of risk potential;CL: Create

Question 13

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

Answer 13

The Client with Osteoarthritis
13. 1, 4, 5. To prepare a client for an arthrocentesis, the nurse should tell the client that a local
anesthetic administered by the physician will decrease discomfort. There may be bleeding after the
procedure, so the nurse should check the dressing. The client may experience pain. The nurse should
offer pain medication and evaluate outcomes for pain relief. Because a local anesthetic is used, the
client will not require preoperative medication. The client will rest the knee for 24 hours and then
should begin range-of-motion and muscle-strengthening exercises.
CN: Management of care; CL: Create

Question 14

14. A postmenopausal client is scheduled for a bone-density scan. The nurse should instruct the
    client to:.
15. Remove all metal objects on the day of the scan.
16. Consume foods and beverages with a high content of calcium for 2 days before the test.
17. Ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test.
18. Report any significant pain to the physician at least 2 days before the test.

Answer 14

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

Question 15

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

Answer 15

15. 1. Shorter sessions will allow the client to rest between the sessions. Changing the physician’s
       prescription to a different examination will not provide the information needed for this client’s
       treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent.
       Thus, it would not help this client avoid the adverse effects of a lengthy x-ray examination. Although
       the x-ray table is hard, there are other options for making the client comfortable, rather than canceling
       the examination.
       CN: Management of care; CL: Synthesize

Question 16

16. Which of the following should the nurse assess when completing the history and physical
    examination of a client diagnosed with osteoarthritis?.
17. Anemia.
18. Osteoporosis.
19. Weight loss.
20. Local joint pain.

Answer 16

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

Question 17

17. Which of the following should be included in the teaching plan for a client with
    osteoporosis? Select all that apply.
18. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals.
19. Choose good calcium sources, such as figs, broccoli, and almonds.
20. Use alcohol in moderation because a moderate intake has no known negative effects.
21. Try swimming as a good exercise to maintain bone mass.
22. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods.

Answer 17

17. 1, 2, 3. A diet with adequate amounts of vitamin D aids in the regulation, absorption, and
    subsequent utilization of calcium and phosphorus, which are necessary for the normal calcification of
    bone. Figs, broccoli, and almonds are very good sources of calcium. Moderate intake of alcohol has
    no known negative effects on bone density but excessive alcohol intake does reduce bone density.
    Swimming, biking, and other non–weight-bearing exercises do not maintain bone mass. Walking and
    running, which are weight-bearing exercises, do maintain bone mass. The client should eat a balanced
    diet but does not need to avoid the use of high-fat foods.
    CN: Reduction of risk potential;CL: Create

Question 18

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

Answer 18

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

Question 19

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

Answer 19

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

Question 20

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

Answer 20

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

Question 21

21. After teaching a group of clients with osteoarthritis about using regular exercise, which of the
    following client statements indicates effective teaching?.
22. “Performing range-of-motion exercises will increase my joint mobility.”
23. “Exercise helps to drive synovial fluid through the cartilage.”
24. “Joint swelling should determine when to stop exercising.”
25. “Exercising in the outdoors year-round promotes joint relaxation.”

Answer 21

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

Question 22

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

Answer 22

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

Question 23

23. A client has an intracapsular hip fracture. The nurse should conduct a focused assessment to
    detect: .
24. Internal rotation.
25. Muscle flaccidity.
26. Shortening of the affected leg.
27. Absence of pain in the fracture area.

Answer 23

23. 3. With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because
       of the muscle spasms and external rotation. The client also experiences severe pain in the region of
       the fracture.
       CN: Physiological adaptation;CL: Analyze

Question 24

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

Answer 24

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

Question 25

25. A client with an extracapsular hip fracture returns to the nursing unit after internal fixation
    and pin insertion with a drainage tube at the incision site. Her husband asks, “Why does she have this
    tube inserted in her hip?” Which of the following responses would be best?.
26. “The tube helps us to detect a wound infection early on.”
27. “This way we won’t have to irrigate the wound.”
28. “Fluid won’t be allowed to accumulate at the site.”
29. “We have a way to administer antibiotics into the wound.”

Answer 25

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

Question 26

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

Answer 26

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

Question 27

27. The nurse is caring for an older adult male who had open reduction internal fixation (ORIF)
    of the right hip 24 hours ago. The client is now experiencing shortness of breath and reports having
    “tightness in my chest.” The nurse reviews the recent lab results. The nurse should report which of the
    following lab results to the physician?.
28. Hematocrit (Hct): 40% (0.4).
29. Serum glucose: 120 mg/dL (6.7 mmol/L).
30. Troponin: 1.4 mcg/L (1.4 μg/L).4. Erythrocyte sedimentation rate (ESR): 22 mm/h.

Answer 27

27. 3. Troponin is a cardiac biomarker and is normally almost undetectable in the blood. A level
       of 1.4 means there has likely been some damage to the heart muscle. Though serum glucose (normal
       60 to 100 mg/dL [3.3 to 5.5 mmol/L]) and ESR (normal is less than 20 for males greater than 50 years
       old) are slightly elevated, this could be explained by normal stress and inflammatory response tosurgery. The hematocrit is low (normal 40 to 45 [0.4 to 0.5] for men) but also not unexpected for a
       client following surgery.
       CN: Physiological adaption;CL: Synthesize

Question 28

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

Answer 28

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

Question 29

29. The nurse is to apply a sequential compression device (intermittent pneumatic compression).
    Identify the area of the compression device that is placed on the client’s calf.

Answer 29

29. The aircell should be centered on the back of the client’s calf.
    CN: Safety and infection control;CL: Apply

Question 30

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

Answer 30

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

Question 31

The Client Having Hip or Knee Replacement
Surgery
31. A frail elderly client with a hip fracture is to use an alternating air pressure mattress to
prevent pressure ulcers while recovering. The nurse is assisting the client’s family to place the
mattress (see below). The nurse should instruct the family to:
1. Turn the mattress over so the air cells face the mattress of the bed, and cover the mattress with
a bed sheet.
2. Put a thick pad over the pressure mattress to prevent soiling, and place the bed sheet on top of
the pad.
3. Make the bed with the bed sheet on top of the pressure mattress.
4. Make the bed, and then remove the pillow to allow full use of the mattress on the neck.

Answer 31

The Client Having Hip or Knee Replacement Surgery
31. 3. To obtain best results, one sheet should be used to cover the mattress. The air cells should
be facing up as shown. Thick pads should not be used; if the client is incontinent, a “breathable”
incontinent pad can be added. The client can use a pillow as needed.

Question 32

32. A client had a posterolateral total hip replacement 2 days ago. What should the nurse include
    in the client’s plan of care? Select all that apply.
33. When using a walker, encourage the client to keep the toes pointing inward.
34. Position a pillow between the legs to maintain abduction.
35. Allow the client to be in the supine position or in the lateral position on the unoperated side.
36. Do not allow the client to bend down to tie or slip on shoes.
37. Place ice on the incision after physical therapy.

Answer 32

32. 2, 3, 4, 5. A client who has had a posterolateral total hip replacement should not adduct the
    hip joint, which would lead to dislocation of the ball out of the socket; therefore, the client should be
    encouraged to keep the toes pointed slightly outward when using a walker. An abduction pillow
    should be kept between the legs to keep the hip joint in an abducted position. The client should rotate
    between lying supine and lateral on the unoperated side, but not on the operated side. Ice is used to
    reduce swelling on the operative side. The client should not flex the operated hip beyond a 90-degreeangle, such as when bending down to tie or slip on shoes. Doing so could lead to joint dislocation.
    CN: Reduction of risk potential;CL: Create

Question 33

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

Answer 33

33. 1, 3, 4. A client who has had a total hip replacement via an anterolateral approach has almost
    the opposite precautions as those for a client who has had a total hip replacement through the
    posterolateral approach. The hip joint should not be actively abducted. The client should avoid
    turning the toes or knee outward. The client should keep the legs side by side without a pillow or
    wedge. The client should use an elevated toilet seat and shower chair and should not extend the
    operative leg backward. The client should perform range-of-motion exercises as directed by the
    physical therapist.
    CN: Reduction of risk potential;CL: Create

Question 34

34. The nurse is assessing a client for neurologic impairment after a total hip replacement. Which
    of the following would indicate impairment in the affected extremity?.1. Decreased distal pulse.
35. Inability to move.
36. Diminished capillary refill.
37. Coolness to the touch.

Answer 34

34. 2. Being unable to move the affected leg suggests neurologic impairment. A decrease in the
       distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest
       vascular compromise.
       CN: Reduction of risk potential;CL: Analyze

Question 35

35. In preparation for total knee surgery, a 200-lb (90.7-kg) client with osteoarthritis must lose
    weight. Which of the following exercises should the nurse recommend as best if the client has no
    contraindications?.
36. Weight lifting.
37. Walking.
38. Aquatic exercise.
39. Tai chi exercise.

Answer 35

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

Question 36

36. Prior to surgery, the nurse is instructing a client who will have a total hip replacement
    tomorrow. Which of the following information is most important to include in the teaching plan at this
    time?.
37. Teaching how to prevent hip flexion.
38. Demonstrating coughing and deep-breathing techniques.
39. Showing the client what an actual hip prosthesis looks like.
40. Assessing the client’s fears about the procedure.

Answer 36

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

Question 37

37. The client has just had a total knee replacement for severe osteoarthritis. Which of the
    following assessment findings should lead the nurse to suspect possible nerve damage?.
38. Numbness.
39. Bleeding.
40. Dislocation.
41. Pinkness.

Answer 37

37. 1. The nurse should suspect nerve damage if numbness is present. However, whether the
       damage is short term and related to edema or long term and related to permanent nerve damage would
       not be clear at this point. The nurse needs to continue to assess the client’s neurovascular status,
       including pain, pallor, pulselessness, paresthesia, and paralysis (the five P’s). Bleeding would
       suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would
       suggest adequate circulation to the area. Numbness would suggest neurologic damage.
       CN: Reduction of risk potential;CL: Analyze

Question 38

38. After surgery and insertion of a total hip prosthesis, a client develops severe sudden pain and
    an inability to move the extremity. The nurse interprets these findings as indicating which of the
    following?.
39. A developing infection.
40. Bleeding in the operative site.
41. Joint dislocation.
42. Glue seepage into soft tissue.

Answer 38

38. 3. The joint has dislocated when the client with a total joint prosthesis develops severe
       sudden pain and an inability to move the extremity. Clinical manifestations of an infection would
       include inflammation, redness, erythema, and possibly drainage and separation of the wound.
       Bleeding could be external (eg, blood visible from the wound or on the dressing) or internal and
       manifested by signs of shock (eg, pallor, coolness, hypotension, tachycardia). The seepage of glueinto soft tissue would have occurred in the operating room, when the glue is still in the liquid form.
       The glue dries into the hard, fixed form before the wound is closed.
       CN: Reduction of risk potential;CL: Analyze

Question 39

39. A client who had a total hip replacement 2 days ago has developed an infection with a fever
    and profuse diaphoresis. The nurse establishes a goal to reduce the fluid deficit. Which of the
    following is the most appropriate outcome?.
40. The client drinks 2,000 mL of fluid per day.
41. The client understands how to manage the incision.
42. The client’s bed linens are changed as needed.
43. The client’s skin remains cool throughout hospitalization.

Answer 39

39. 1. An average adult requires approximately 1,100 to 1,400 mL of fluids per day. In some
       instances, such as when a person has an increase in body temperature or has increased perspiration,
       additional water may be necessary. With an increase in body temperature, there is also an increase in
       insensible fluid loss. The increased loss of fluid causes an increased need for fluid replacement. If
       the loss is significant and/or goes untreated, an individual’s intake will not be balanced with output.
       Managing the incision, changing the bed linens, or keeping the client’s skin cool are not outcomes
       indicative of resolution of a fluid volume deficit.
       CN: Physiological adaptation;CL: Synthesize

Question 40

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

Answer 40

40. 4. After knee arthroplasty, the knee will be extended and immobilized with a firm
       compression dressing and an adjustable soft extension splint in place. An SCD will be applied. The
       SCD can be discontinued when the client is ambulatory, but while the client is in bed the SCD needs
       to be maintained to prevent thromboembolism. The SCD should be positioned on the bed, but not on
       two pillows. Settings for the SCD are prescribed by the orthopedic surgeon. Initial dressing changes
       are completed by the orthopedic surgeon and changed as needed per physician prescription.
       CN: Reduction of risk potential;CL: Synthesize

Question 41

41. A client returns from the first session of scheduled physical therapy sessions following total
    knee replacement surgery. The nurse assesses that the client’s knee is swollen, slightly erythematous,
    and painful. The client rates the pain as 7 out of 10 and has not had any scheduled or PRN pain
    medication today. Which of the following are appropriate nursing interventions? Select all that apply.
42. Gently massage the area to increase circulation to reduce pain.
43. Administer pain medication as prescribed.
44. Elevate the leg and apply a cold pack.
45. Notify the physician.
46. Call physical therapy to cancel the next treatment.

Answer 41

41. 2, 3. It is anticipated that there might be some swelling, redness, and discomfort immediately
    after activity, including physical therapy. Ideally, pain medication could be offered or given prior to
    therapy to reduce posttreatment pain, but should be administered now. Elevation and cold packs can
    also reduce swelling and decrease pain. It is not appropriate to notify the physician as pain and
    swelling are normal after therapy. It is also not appropriate to massage the area. This will increase
    circulation and therefore increase swelling and pain.
    CN: Management of care; CL: Synthesize

Question 42

42. The nurse is preparing a client who has had a knee replacement with a metal joint to go home.
    The nurse should instruct the client about which of the following? Select all that apply.
43. Notify health care providers about the joint prior to invasive procedures.
44. Avoid use of magnetic resonance imaging (MRI) scans.
45. Notify airport security that the joint may set off alarms on metal detectors.
46. Refrain from carrying items weighing more than 5 lb (2.3 kg).
47. Limit fluid intake to 1,000 mL/day.

Answer 42

42. 1, 2, 3. The nurse should instruct the client to notify the dentist and other health care providers
    of the need to take prophylactic antibiotics if undergoing any procedure (eg, tooth extraction) due to
    the potential of bacteremia. The nurse should also advise the client that the metal components of the
    joint may set off the metal-detector alarms in airports. The client should also avoid MRI studies
    because the implanted metal components will be pulled toward the large magnet core of the MRI. Any
    weight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to
    5 lb (2.3 kg). Post-surgery, the client can resume a normal diet with regular fluid intake.
    CN: Health promotion and maintenance; CL: Create

Question 43

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

Answer 43

43. 4. After total hip replacement, proper positioning by the nurse prevents dislocation of the
       prosthesis. The nurse should place the client in a supine position and keep the affected extremity in
       slight abduction using an abduction splint or pillows or Buck’s extension traction. The client must not
       abduct or flex the operated hip because this may produce dislocation.
       CN: Reduction of risk potential;CL: Synthesize

Question 44

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

Answer 44

44. 2, 4, 5. Following total hip replacement, the client should use the overhead trapeze to assist
    with position changes. The head of the bed should not be elevated more than 45 degrees; any height
    greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracturebedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing
    exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and
    potential emboli. The prone position is avoided shortly after a total hip replacement.
    CN: Reduction of risk potential;CL: Synthesize

Question 45

45. A client is to have a total hip replacement. The preoperative plan should include which of the
    following? Select all that apply.
46. Administer antibiotics as prescribed to ensure therapeutic blood levels.
47. Apply leg compression device.
48. Request a trapeze be added to the bed.
49. Teach isometric exercises of quadriceps and gluteal muscles.
50. Demonstrate crutch walking with a 3-point gait.
51. Place Buck’s traction on the bed.

Answer 45

45. 1, 3, 4. Administration of antibiotics as prescribed will aid in the acquisition of therapeutic
    blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that
    a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also
    demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and
    gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will
    initially assist the client with walking by using a walker. The client will not use Buck’s traction. The
    client will require antiembolism stockings and use of a leg compression device to minimize the risk
    of thrombus formation and potential emboli; the leg compression device is applied during surgery and
    maintained per physician prescription.
    CN: Physiological adaptation; CL: Create

Question 46

46. The laboratory notifies the nurse that a client who had a total knee replacement 3 days agoand is receiving heparin has an activated partial thromboplastin time (aPTT) of 75 seconds. After
    verifying the values, the nurse calls the physician. The nurse should anticipate receiving a
    prescription for:.
47. Protamine sulfate.
48. Vitamin K.
49. Warfarin (Coumadin).
50. Packed red blood cells.

Answer 46

46. 1. The aPTT is at a critical value, and the client should receive protamine sulfate as the
       antidote for heparin. Vitamin K is the antidote for warfarin. Packed red blood cells are administered
       to increase the hematocrit.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 47

47. The nurse is teaching the client to administer enoxaparin (Lovenox) following a total hip
    replacement. The nurse should instruct the client about which of the following? Select all that apply.
48. Report promptly any difficulty breathing, rash, or itching.
49. Notify the health care provider of unusual bruising.
50. Avoid all aspirin-containing medications.
51. Wear or carry medical identification.
52. Expel the air bubble from the syringe before the injection.
53. Remove needle immediately after medication is injected.

Answer 47

47. 1, 2, 3, 4. Client/family teaching should include advising the client to report any symptoms of
    unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to health
    care provider immediately. Instruct the client not to take aspirin or nonsteroidal anti-inflammatory
    drugs without consulting the health care provider while on therapy. A low-molecular-weight heparin
    is considered to be a high-risk medication and the client should wear or carry medical identification.
    The air bubble should not be expelled from the syringe because the bubble ensures the client receives
    the full dose of the medication. The client should allow 5 seconds to pass before withdrawing the
    needle to prevent seepage of the medication out of the site.
    CN: Pharmacological and parenteral therapies; CL: Create

Question 48

48. A client who had a total hip replacement 4 days ago is worried about dislocation of the
    prosthesis. The nurse should respond by saying which of the following?.
49. “Don’t worry. Your new hip is very strong.”
50. “Use of a cushioned toilet seat helps to prevent dislocation.”
51. “Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid
    them. ”
52. “Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation.”

Answer 48

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

Question 49

49. The nurse is assessing a client who had a left hip replacement 36 hours ago. Which of the
    following indicates the prosthesis is dislocated? Select all that apply.
50. The client reported a “popping” sensation in the hip.
51. The left leg is shorter than the right leg.
52. The client has sharp pain in the groin.
53. The client cannot move the right leg.
54. The client cannot wiggle the toes on the left leg.

Answer 49

49. 1, 2, 3. Dislocation of a hip prosthesis may occur with positioning that exceeds the limits of
    the prosthesis. The nurse must recognize dislocation of the prosthesis. Signs of prosthesis dislocation
    include: acute groin pain in the affected hip, shortening of the affected leg, restricted ability or
    inability to move the affected leg, and reported “popping” sensation in the hip. Toe wiggling is not a
    test for potential hip dislocation.
    CN: Reduction of risk potential;CL: Analyze

Question 50

50. A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse
    should first:
51. Stabilize the leg with Buck’s traction.
52. Apply an ice pack to the affected hip.
53. Position the client toward the opposite side of the hip.
54. Notify the orthopedic surgeon.

Answer 50

50. 4. If a prosthesis becomes dislocated, the nurse should immediately notify the surgeon. This is
       done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintaincirculation. After closed reduction, the hip may be stabilized with Buck’s traction or a brace to
       prevent recurrent dislocation. If prescribed by the surgeon, an ice pack may be applied post-reduction
       to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic
       surgeons may prescribe the client be turned toward the side of the reduced hip, but that is not the
       nurse’s first response.
       CN: Reduction of risk potential;CL: Synthesize

Question 51

51. The nurse is planning care for a group of clients who have had total hip replacement. Of the
    clients listed below, which is at highest risk for infection and should be assessed first?.
52. A 55-year-old client who is 6 feet (180 cm) tall and weighs 180 lb (81.7 kg).
53. A 90-year-old who lives alone.
54. A 74-year-old who has periodontal disease with periodontitis.
55. A 75-year-old who has asthma and uses an inhaler.

Answer 51

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

Question 52

52. The nurse has established a goal with a client to improve mobility following hip replacement.Which of the following is a realistic outcome at the time of discharge from the surgical unit?.
53. The client can walk throughout the entire hospital with a walker.
54. The client can walk the length of a hospital hallway with minimal pain.
55. The client has increased independence in transfers from bed to chair.
56. The client can raise the affected leg 6 inches (15.2 cm) with assistance

Answer 52

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

Question 53

53. The nurse is assessing a client’s left leg for neurovascular changes following a total left knee
    replacement. Which of the following are expected normal findings? Select all that apply.
54. Reduced edema of the left knee.
55. Skin warm to touch.
56. Capillary refill response.
57. Moves toes.
58. Pain absent.
59. Pulse on left leg weaker than right leg.

Answer 53

53. 1, 2, 3, 4. Postoperatively, the knee in a total knee replacement is dressed with a compression
    bandage and ice may be applied to control edema and bleeding. Recurrent assessment by the nurse for
    neurovascular changes can prevent loss of limb. Normal neurovascular findings include color normal,
    extremity warm, capillary refill less than 3 seconds, moderate edema, tissue not palpably tense, pain
    controllable, normal sensations, no paresthesia, normal motor abilities, no paresis or paralysis, and
    pulses strong and equal.
    CN: Reduction of risk potential;CL: Analyze

Question 54

54. On the evening of surgery for total knee replacement, a client wants to get out of bed. To
    safely assist the client, the nurse should do which of the following?.
55. Encourage the client to apply full weight bearing.
56. Prescribe a walker for the client.
57. Place a straight-backed chair at the foot of the bed.
58. Apply a knee immobilizer.

Answer 54

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

Question 55

55. When preparing a client for discharge from the hospital after a total knee replacement, the
    nurse should include which of the following information in the discharge plan? Select all that apply.
56. Report signs of infection to health care provider.
57. Keep the affected leg and foot on the floor when sitting in a chair.
58. Remove antiembolism stockings when sleeping.
59. The physical therapist will encourage progressive ambulation with use of assistive devices.
60. Change the dressing daily.

Answer 55

55. 1, 4. After a total knee replacement, efforts are directed at preventing complications, such as
    thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should
    instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the
    affected leg must remain elevated when the client sits in a chair. After discharge, the client may
    undergo physical therapy on an outpatient basis per physician prescription. The client should leave
    the dressing in place until the follow-up visit with the surgeon.
    CN: Reduction of risk potential;CL: Create

Question 56

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

Answer 56

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

Question 57

The Client with a Herniated Disk
57. The nurse is observing a client who is recovering from back strain lift a box as shown below.
What should the nurse do?
1. Praise the client for using correct body mechanics.
2. Suggest to the client that she put both knees on the floor before attempting to lift the box.
3. Advise the client to bend from the waist rather than stretching her back in this position.
4. Inform the client that she should keep her back straight by squatting with both knees parallel.

Answer 57

The Client with a Herniated Disk
57. 1. The client is using correct body mechanics for lifting because she is keeping her back as
straight as possible and is holding the box close to her body. She is using her large leg muscles to lift
the box. She is using a broad base of support by placing her feet as wide apart as possible. The other
suggestions would cause the client to put a strain on her back.
CN: Reduction of risk potential;CL: Synthesize

Question 58

58. Which of the following activities should the nurse instruct the client with low back pain to
    avoid?.
59. Keeping light objects below the level of the elbows when lifting.
60. Leaning forward while bending the knees.
61. Exceeding the prescribed exercise program.
62. Sleeping on the side with legs flexed.

Answer 58

58. 3. The client with low back pain should not exceed the prescribed exercises even though they
       may think, “If this will make me well, double will make me well quicker.” When exceeding
       prescribed exercise programs, the client’s muscle may be unconditioned and easily tired, leading to
       injury and increased pain. To use proper body mechanics when lifting light objects, the client should
       bring the item close to the center of gravity, which occurs when the object is kept below the level of
       the elbows. Leaning forward while bending the knees allows for the muscles of the thigh to be used
       instead of those of the lower back. Sleeping on the side with the legs flexed is appropriate because
       the spine is kept in a neutral position without twisting or pulling on muscles.
       CN: Reduction of risk potential;CL: Synthesize

Question 59

59. A client attempting to get out of bed stops midway because of low back pain radiating down
    to the right heel and lateral foot. What should the nurse do in order of priority from first to last?
60. Apply a warm compress to the client’s back.
61. Notify the physician.
62. Assist the client to lie down.
63. Administer the prescribed celecoxib (Celebrex).

Answer 59

59.
3. Assist the client to lie down.
4. Administer the prescribed celecoxib (Celebrex).
1. Apply a warm compress to the client’s back.
2. Notify the physician.
When the client is not entirely able to get out of bed, the nurse should first assist the client to lie
down for comfort/safety before administering the prescribed Celebrex. Applying a warm compress
will further promote relaxation of skeletal muscles. The physician should be kept informed of the
client’s status and nursing actions already taken.
CN: Basic care and comfort;CL: Synthesize

Question 60

60. A client with a ruptured intervertebral disc at L4–L5 stands with a flattened spine slightly
    tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating
    which of the following?.
61. Motor changes.
62. Postural deformity.
63. Alteration of reflexes.
64. Sensory changes.

Answer 60

60. 2. Standing with a flattened spine slightly tilted forward and slightly flexed to the affected
       side indicates a postural deformity. Motor changes would include findings such as hypotonia or
       muscle weakness. Absent or diminished reflexes related to the level of herniation would indicatealteration in reflexes. Sensory changes would include findings such as paresthesia and numbness
       related to the specific tract of the herniation.
       CN: Physiological adaptation;CL: Analyze

Question 61

61. Which of the following positions would be most comfortable for a client with a ruptured disc
at L5–S1 right?.
1. Prone.
2. Supine with the legs flexed.
3. High Fowler's.
4. Right Sims'.

Answer 61

60. 2. Standing with a flattened spine slightly tilted forward and slightly flexed to the affected
       side indicates a postural deformity. Motor changes would include findings such as hypotonia or
       muscle weakness. Absent or diminished reflexes related to the level of herniation would indicatealteration in reflexes. Sensory changes would include findings such as paresthesia and numbness
       related to the specific tract of the herniation.
       CN: Physiological adaptation;CL: Analyze

Question 62

62. The client with a herniated intervertebral disc scheduled for a myelogram asks the nurse
    about the procedure. The nurse explains that radiographs will be taken of the client’s spine after an
    injection of which of the following?.
63. Sterile water.
64. Normal saline solution.
65. Liquid nitrogen.
66. Radiopaque dye.

Answer 62

62. 4. Myelography, used to determine the exact location of a herniated disk, involves the use of a
       radiopaque dye (usually an iodized oil, but in some instances a water-soluble compound). In some
       instances, air is used for an air-contrast study.
       CN: Reduction of risk potential;CL: Apply

Question 63

63. Which of the following would not be appropriate to include when preparing a client for
    magnetic resonance imaging (MRI) to evaluate a ruptured disc?.
64. Informing the client that the procedure is painless.
65. Taking a thorough history of past surgeries.
66. Checking for previous claustrophobia.
67. Starting an IV line at keep-open rate.

Answer 63

63. 4. An IV line is not required for an MRI. If a client has an IV line, it is usually converted to an
       intermittent infusion device, such as a saline lock, to avoid infiltration during transport of the client
       and completion of the procedure. When a contrast agent is used, the client is moved out of the
       cylinder, the contrast material is injected, and the client is moved back in. An MRI scan is painless.
       Typically the staff positions the client with pillows, blankets, earplugs, and music, to ensure client
       comfort, before the procedure is started. A history of past surgeries is important, especially if the
       surgery involved implantation of any metallic devices (eg, implants, clips, pacemakers).
       Additionally, the nurse needs to assess for hearing aids, electronic devices, shrapnel, bra hooks,
       necklaces, jewelry, credit cards, zippers, or any type of metal that the magnet of the MRI unit would
       attract. Although open MRI units are now available, they are not in widespread use. Therefore, the
       nurse needs to determine whether the client is claustrophobic because the unit is a closed cylinder in
       which the client hears pops of noise. A number of clients develop claustrophobia that causes the
       procedure to be canceled. If the client is claustrophobic, the procedure may need to be rescheduled
       after an open MRI unit is located or made available.
       CN: Reduction of risk potential;CL: Synthesize

Question 64

64. A client who has numbness from the back of the left buttock to the dorsum of the foot and big
    toe is scheduled to undergo a laminectomy. The operative consent form states “a left lumbar
    laminectomy of L3–L4.” Which of the following should the nurse do next?.
65. Have the client sign the consent form.
66. Call the surgeon.
67. Change the consent form.
68. Review the client’s history.

Answer 64

64. 2. Based on the client’s comments, the nurse should call the surgeon to verify the location of
       the surgery. The client’s comments indicate radiculopathy of L4–L5, but the consent form states L3–
       L4. Radiculopathy of L3–L4 involves pain radiating from the back to the buttocks to the posterior
       thigh to the inner calf. The nurse must act as a client advocate and not ask the client to sign the consent
       until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority
       or responsibility to change the consent. The history is a source of information, but when the client is
       coherent and the history is contradictory, the physician should be contacted to clarify the situation.
       Ultimately, it is the surgeon’s responsibility to identify the site of surgery specified on the surgical
       consent form.CN: Management of care; CL: Synthesize

Question 65

65. Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride
    (Zofran) to the client as prescribed. The nurse determines that the drug is effective when which of the
    following is controlled?.
66. Muscle spasms.
67. Nausea.
68. Shivering.
69. Dry mouth.

Answer 65

65. 2. Ondansetron hydrochloride (Zofran) is a selective serotonin receptor antagonist that acts
       centrally to control the client’s nausea in the postoperative phase. It does not control muscle spasms,
       shivering, or dry mouth.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 66

66. After a laminectomy, the client states, “The physician said that I can do anything I want to.”Which of the following client-stated activities indicates the need for further teaching?.
67. Drying the dishes.
68. Sitting outside on firm cushions.
69. Making the bed walking from side to side.
70. Sweeping the front porch.

Answer 66

66. 4. Sweeping causes a twisting motion, which should be avoided because twisting can cause
       undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture.
       Although the client should not bend at the waist, such as when washing dishes at the sink, the client
       can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back
       anatomically aligned. The client should not twist and pull, so when making the bed, the client should
       pull the covers up on one side and then walk around to the other side before trying to pull the covers
       up there.
       CN: Physiological adaptation;CL: Evaluate

Question 67

67. The nurse is developing the discharge teaching plan for a client after a lumbar laminectomy
    L4–L5 who will be returning to work in 6 weeks. Which of the following actions should the nurse
    encourage the client to avoid?.
68. Placing one foot on a step stool during prolonged standing.
69. Sleeping on the back with support under the knees.
70. Maintaining average body weight for height.
71. Sitting whenever possible.

Answer 67

67. 4. After a lumbar laminectomy L4–L5, a client who is returning to work should avoid sitting
       whenever possible. If the client must sit, he or she should sit only in chairs that allow the knees to be
       higher than the hips and support the arms to maintain correct body alignment and reduce undue stress
       on the spine. Maintaining good body postures is most important after a lumbar laminectomy L4–L5.
       By 6 weeks after the surgery, the client should have regained stamina. To maintain correct body
       posture, the client should also place one foot on a step stool during prolonged standing. Sleeping on
       the back with a support under the knees is effective in maintaining correct body posture. Maintaining
       an average weight for height is important in maintaining a healthy back because carrying extra weight
       causes undue stress on back muscles.
       CN: Physiological adaptation;CL: Synthesize

Question 68

68. A male client underwent a spinal fusion yesterday. Which of the following nursing
    assessments should alert the nurse to the development of a possible complication?.
69. Lateral rotation of the head and neck.
70. Clear yellowish fluid on the dressing.
71. Use of the standing position to void.
72. Nonproductive cough.

Answer 68

68. 2. Clear yellowish fluid on the dressing may be cerebrospinal fluid (CSF). This fluid must be
       tested for glucose to determine whether it is CSF. If so, the client is at great risk for an infection of the
       central nervous system, which has a high mortality rate. The client should be able to laterally rotate
       the head and neck, which is above the surgical site in the spinal column. During the nursing
       postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should
       find results consistent with the preoperative baseline status. Using the standing position to void is
       normal for a male client. Coughing is the body’s defense mechanism to help clear the lungs of the
       anesthetic agents and to ventilate the lungs in response to a sustained deep inspiration for ventilation
       of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should
       be avoided. Also, a productive cough of thick, yellow sputum would indicate the complication of a
       respiratory infection.
       CN: Reduction of risk potential;CL: Analyze

Question 69

69. The nurse is assisting a client who has had a spinal fusion apply a back brace. In which order
    of priority should the nurse assist the client applying the brace?
70. Have the client in a side-lying position.
71. Verify the prescriptions for the settings forthe brace.
72. Ask the client to stand with arms held away from the body.
73. Assist the client to log roll and rise to a sitting position.

Answer 69

69.
2. Verify the prescription for the settings for the brace.
1. Have the client in a side-lying position.3. Assist the client to log roll and rise to a sitting position.
4. Ask the client to stand with arms held away from the body.
The nurse should first verify the settings for the brace and activity prescriptions. Next, the client
should be in a side-lying position; explain that the spine should be kept aligned and in a neutral
position, and the client should not pull on objects with arms. For getting out of bed, log roll client to
side, splint back, and rise to a sitting position by pushing against the mattress while swinging legs
over the side of the bed. Finally, the client should stand with the arms outstretched so the nurse can
apply the brace.
CN: Physiological adaptation;CL: Synthesize

Question 70

70. After the nurse teaches a client about wearing a back brace after a spinal fusion, which of the
    following client statements indicates effective teaching?.
71. “I will apply lotion before putting on the brace.”
72. “I will be sure to pad the area around my iliac crest.”
73. “I can use baby powder under the brace to absorb perspiration.”4. “I should wear a thin cotton undershirt under the brace.”

Answer 70

70. 4. The client should wear a thin cotton undershirt under the brace to prevent the brace from
       abrading directly against the skin. The cotton material also aids in absorbing any moisture, such as
       perspiration, that could lead to skin irritation and breakdown. Applying lotion is not recommended
       before applying the brace because further skin breakdown can result (related to the collection of
       moisture where microorganisms can grow) and irritants from the lotion can cause further irritation.
       Applying extra padding (eg, to the iliac crests) is not recommended because the padding can become
       wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder is not
       recommended because the irritation from the talcum also can cause irritation and skin breakdown.
       CN: Reduction of risk potential;CL: Evaluate

Question 71

71. The nurse develops a teaching plan for a client scheduled for a spinal fusion. Which of the
    following should the nurse include?.
72. The client typically experiences more pain at the donor site than at the fusion site.
73. The surgeon will apply a simple gauze dressing to the donor site.
74. Neurovascular checks are unnecessary if the fibula is the donor site.
75. The client’s level of activity restriction is determined by the amount of pain.

Answer 71

71. 1. Typically, the donor site causes more pain than the fused site does because inflammation,
       swelling, and venous oozing around the nerve endings in the donor site, where the subcutaneous tissue
       was removed, occur during the first 24 to 48 hours postoperatively. After surgery, the surgeon applies
       a pressure dressing to the donor site to compress the veins that were transected for the removal of
       subcutaneous tissue but that did not stop oozing blood after surgical cauterization during the surgical
       procedure. Pressure on a transected vein, which is low pressure, stops the oozing and loss of blood
       from the venous site. When the donor site is the fibula, neurovascular checks must be performed every
       hour to ensure adequate neurologic function of and circulation to the area. The surgeon, not the degree
       or amount of pain, specifies activity restrictions.
       CN: Physiological adaptation;CL: Synthesize

Question 72

72. A client who has had a lumbar laminectomy with a spinal fusion is sitting in a chair. Which of
    the following is the correct position for this client?.
73. On the floor with the feet flat.
74. On a low footstool.
75. In any comfortable position with legs uncrossed.
76. On a high footstool so the feet are level with the chair seat.

Answer 72

72. 1. A client who has had back surgery should place his feet flat on the floor to avoid strain on
       the incision. Placing the feet on a low or high footstool or in any other position of comfort with the
       legs uncrossed increases the pressure on the suture line and increases the inflammation around the
       involved nerve root, thereby increasing the risk of possible rerupture of the disc site.
       CN: Reduction of risk potential;CL: Evaluate

Question 73

73. The nurse develops a plan of care for a client in the initial postoperative period following a
    lumbar laminectomy. Which of the following activities is contraindicated?.
74. Assisting with daily hygiene activities.
75. Lying flat in bed.
76. Walking in the hall.
77. Sitting all afternoon in her room.

Answer 73

73. 4. After a lumbar laminectomy, a client should not sit for prolonged periods in a chair because
       of the increased pressure against the nerve root and incision site. Assisting with daily hygiene is an
       appropriate activity during the initial postoperative period because, as with any surgical procedure,
       the client needs to return to an optimal level of functioning as soon as possible. There is no limitation
       on the client’s participation in daily hygiene activities except for individual responses of pain, nausea,
       vomiting, or weakness. Lying flat in bed is appropriate because it does not cause stress on the spinalcolumn where the laminectomy was performed and the disc tissue was removed. Positions that should
       be avoided are those that would cause twisting and flexion of the spine. Walking in the hall is an
       acceptable activity. It promotes good postoperative ventilation, circulation, and return of peristalsis,
       which are needed for all surgical clients. In addition, walking provides the postoperative lumbar
       laminectomy client an opportunity to build up endurance and muscle strength and to promote
       circulation to the operative and incision sites for healing without twisting or stressing them.
       CN: Physiological adaptation;CL: Synthesize

Question 74

74. Which of the following exercises should the nurse advise the client to avoid after a lumbar
laminectomy?.
1. Knee-to-chest lifts.
2. Hip tilts.
3. Sit-ups.
4. Pelvic tilts.

Answer 74

74. 3. Sit-ups are not recommended for the client who has had a lumbar laminectomy because
       these exercises place too great a stress on the back. Knee-to-chest lifts, hip tilts, and pelvic tilt
       exercises are recommended to strengthen back and abdominal muscles.
       CN: Reduction of risk potential;CL: Synthesize

Question 75

The Client with an Amputation due to Peripheral
Vascular Disease
75. Which of the following factors contributes to a risk for amputation in a client with peripheral
vascular disease? Select all that apply.
1. Uncontrolled diabetes mellitus for 15 years.
2. A 20-pack-year history of cigarette smoking.
3. Current age of 39 years.
4. A serum cholesterol concentration of 275 mg/dL (15.3 mmol/L).
5. Work that requires prolonged standing.

Answer 75

The Client with an Amputation due to Peripheral Vascular
Disease
75. 1, 2, 4. Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular
disease because of the macroangiopathic and microangiopathic changes that result from poor blood
glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease; nicotine is
a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/dL (11.1 mmol/L) are
considered a risk factor for peripheral vascular disease. Typically, peripheral vascular disease is
considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be
considered as a risk factor contributing to the development of peripheral vascular disease. Prolonged
standing is a risk factor for venous stasis and varicose veins.
CN: Health promotion and maintenance; CL: Analyze

Question 76

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

Answer 76

76. 2. The client with severe arterial occlusive disease and gangrene of the left great toe would
       have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and
       lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (ie, not
       thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the
       extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.
       CN: Physiological adaptation;CL: Analyze

Question 77

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

Answer 77

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

Question 78

78. Which of the following is most helpful to promote circulation for the client with peripheral
    arterial disease?.
79. Resting with the legs elevated above the level of the heart.
80. Walking slowly but steadily for 30 minutes twice a day.
81. Minimizing activity as much and as often as possible.
82. Wearing antiembolism stockings at all times when out of bed.

Answer 78

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

Question 79

79. Which of the following should the nurse include in the teaching plan for a client with arterial
    insufficiency to the feet that is being managed conservatively?.
80. Daily lubrication of the feet.
81. Soaking the feet in warm water.
82. Applying antiembolism stockings.
83. Wearing firm, supportive leather shoes.

Answer 79

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

Question 80

80. A client says, “I hate the idea of being an invalid after they cut off my leg.” Which of the
    following would be the nurse’s most therapeutic response?.
81. “At least you will still have one good leg to use.”
82. “Tell me more about how you’re feeling.”
83. “Let’s finish the preoperative teaching.”
84. “You’re lucky to have a wife to care for you.”

Answer 80

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

Question 81

81. The client asks the nurse, “Why can’t the physician tell me exactly how much of my leg he’s
    going to take off? Don’t you think I should know that?” On which of the following should the nurse
    base the response?.
82. The need to remove as much of the leg as possible.
83. The adequacy of the blood supply to the tissues.
84. The ease with which a prosthesis can be fitted.
85. The client’s ability to walk with a prosthesis.

Answer 81

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

Question 82

82. A client who has had an above-the-knee amputation develops a dime-sized bright red spot on
    the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should:.
83. Elevate the stump.
84. Reinforce the dressing.
85. Call the surgeon.
86. Draw a mark around the site.

Answer 82

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

Question 83

83. A client in the postanesthesia care unit with a left below-the-knee amputation has pain in the
    left big toe. Which of the following should the nurse do first?.
84. Tell the client it is impossible to feel the pain.
85. Show the client that the toes are not there.
86. Explain to the client that the pain is real.
87. Give the client the prescribed opioid analgesic.

Answer 83

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

Question 84

84. The client with an above-the-knee amputation is to use crutches while the prosthesis is being
    adjusted. Which of the following exercises will best prepare the client for using crutches?.
85. Abdominal exercises.
86. Isometric shoulder exercises.
87. Quadriceps setting exercises.
88. Triceps stretching exercises.

Answer 84

84. 4. Use of crutches requires significant strength from the triceps muscles. Therefore, efforts are
       focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-
       ups are excellent exercises targeted at the triceps muscles. Abdominal exercises, range-of-motion and
       isometric exercises of the shoulders, and quadriceps and gluteal setting exercises are not helpful in
       preparing for crutch walking.
       CN: Reduction of risk potential;CL: Synthesize

Question 85

85. The nurse teaches a client about using crutches, instructing the client to support the weight
    primarily on which of the following body areas?.
86. Axillae.
87. Elbows.
88. Upper arms.
89. Hands.

Answer 85

85. 4. When using crutches, the client is taught to support weight primarily on the hands.
       Supporting body weight on the axillae, elbows, or upper arms must be avoided to prevent nerve
       damage from excessive pressure.
       CN: Reduction of risk potential;CL: Synthesize

Question 86

86. The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the
    following should be the nurse’s first step in planning the dietary instructions?.
87. Determining the client’s knowledge level about cholesterol.
88. Asking the client to name foods that are high in fat, cholesterol, and salt.
89. Explaining the importance of complying with the diet.
90. Assessing the client’s and family’s typical food preferences.

Answer 86

86. 4. Before beginning dietary instructions and interventions, the nurse must first assess the
       client’s and family’s food preferences, such as pattern of food intake, lifestyle, food preferences, and
       ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin
       teaching based on the client’s current knowledge level and then building on this knowledge base.
       CN: Physiological adaptation;CL: Synthesize

Question 87

The Client with Fractures
87. A client has a leg immobilized in traction. Which of the following activities demonstrated by
the client indicate that the client understands actions to take to prevent muscle atrophy?.
1. The client adducts the affected leg every 2 hours.
2. The client rolls the affected leg away from the body’s midline twice per day.
3. The client performs isometric exercises to the affected extremity three times per day.
4. The client asks the nurse to add a 5-lb (2.3-kg) weight to the traction for 30 min/day.

Answer 87

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

Question 88

88. The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the
    following indicate that the drug is having the intended effect?.
89. Lack of infection.
90. Reduction in itching.
91. Relief of muscle spasms.
92. Decrease in nervousness.

Answer 88

88. 3. Methocarbamol is a muscle relaxant and acts primarily to relieve muscle spasms. It has no
       effect on microorganisms, does not reduce itching, and has no effect on nervousness.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 89

89. When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for
    muscle pain, which information should the nurse expect to include? Select all that apply.
90. The drug can be used if the person is allergic to aspirin.
91. Acetaminophen does not affect platelet aggregation.
92. This drug causes little or no gastric distress.
93. Acetaminophen exerts a strong anti-inflammatory effect.
94. The client should have the international normalized ratio (INR) checked regularly.

Answer 89

89. 1, 2, 3. Acetaminophen is an alternative for a client who is allergic to aspirin. It does not
    affect platelet aggregation and the client does not need to have coagulation studies (such as INR).
    Acetaminophen causes little or no gastric distress. Acetaminophen exerts no anti-inflammatory
    effects.CN: Pharmacological and parenteral therapies; CL: Create

Question 90

90. A client who has been taking hydrocodone with acetaminophen at home for 6 weeks
    following a fractured tibia is admitted with a blood pressure of 80/50 mm Hg, a pulse rate of 115
    bpm, and respirations of 8 breaths per minute and shallow. The nurse interprets these findings as
    indicating which of the following?.
91. Expected common adverse effects of the hydrocodone.
92. Hypersensitivity reaction to the acetaminophen.
93. Possible habituating effect of the long-term drug use.
94. Hemorrhage from gastrointestinal irritation associated with the pain medication.

Answer 90

90. 3. Hypotension and depressed respirations are signs of high levels of ingestion of
       hydrocodone, and the client may be developing a habit of taking this drug for a prolonged period.
       Expected common adverse effects of hydrocodone and acetaminophen would include drowsiness,
       confusion, blurred vision, and constipation. Hemorrhage from gastrointestinal irritation is not
       associated with this drug. Hypersensitivity reactions would be manifested by pruritus and rashes.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 91

91. When admitting a client with a fractured extremity, the nurse should first focus the assessment
    on which of the following?.
92. The area proximal to the fracture.
93. The actual fracture site.
94. The area distal to the fracture.
95. The opposite extremity for baseline comparison.

Answer 91

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

Question 92

92. Which of the following client statements identifies a knowledge deficit about cast care?.
93. “I’ll elevate the cast above my heart initially.”
94. “I’ll exercise my joints above and below the cast.”
95. “I can pull out cast padding to scratch inside the cast.”
96. “I’ll apply ice for 10 minutes to control edema for the first 24 hours.”

Answer 92

92. 3. Clients should not pull out cast padding to scratch inside the cast because of the hazard of
       skin breakdown and subsequent potential for infection. Clients are encouraged to elevate the casted
       extremity above the level of the heart to reduce edema and to exercise or move the joints above and
       below the cast to promote and maintain flexibility and muscle strength. Applying ice for 10 minutes
       during the first 24 hours helps to reduce edema.
       CN: Reduction of risk potential;CL: Evaluate

Question 93

93. Which of the following interventions would be least appropriate for a client who is in adouble hip spica cast?.
94. Encouraging the intake of cranberry juice.
95. Advising the client to eat large amounts of cheese.
96. Establishing regular times for elimination.
97. Having the client dangle at the bedside.

Answer 93

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

Question 94

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

Answer 94

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

Question 95

95. A client returned from surgery with a debrided open tibial fracture and has a three-way
    drainage system. The nurse should first:.
96. Review the results of culture and sensitivity testing of the wound.
97. Look for the presence of a pressure dressing over the wound.
98. Determine if the client has increased pain from exposed nerve endings.
99. Check the client’s blood pressure for hypotension resulting from additional vessel bleeding.

Answer 95

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

Question 96

96. A client has a tibial fracture that required casting. Approximately 5 hours later, the client has
    increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes
    previously. Which of the following should be the nurse’s next assessment?.
97. Presence of a distal pulse.
98. Pain with a pain rating scale.
99. Vital sign changes.
100. Potential for drug tolerance.

Answer 96

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

Question 97

97. A client with a fracture develops compartment syndrome. Which of the following signs
    should alert the nurse to impending organ failure?.
98. Crackles.
99. Jaundice.
100. Generalized edema.
101. Dark, scanty urine.

Answer 97

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

Question 98

The Client with a Femoral Fracture
98. A client with a fractured right femur has not had any immunizations since childhood. Which of
the following biologic products should the nurse administer to provide the client with passive
immunity for tetanus?.
1. Tetanus toxoid.
2. Tetanus antigen.
3. Tetanus vaccine.
4. Tetanus antitoxin.

Answer 98

The Client with a Femoral Fracture
98. 4. Passive immunity for tetanus is provided in the form of tetanus antitoxin or tetanus immune
globulin. An antitoxin is an antibody to the toxin of an organism. Administering tetanus toxoid,
antigen, or vaccine would provide active immunity by stimulating the body to produce its own
antibodies.
CN: Pharmacological and parenteral therapies; CL: Apply

Question 99

99. After teaching the client with a femoral fracture about the purpose of treatment with skeletal
    traction, which of the following, if stated by the client, would indicate the need for additional
    teaching?.
100. To align injured bones.
101. To provide long-term pull.
102. To apply 25 lb (11.3 kg) of traction.
103. To pull weight with a boot.

Answer 99

99. 4. Skeletal traction is not used to pull weight with a boot. Skeletal traction involves the
       insertion of a wire or a pin into the bone to maintain a pull of 5 to 45 lb (2.3 to 20.4 kg) on the area,
       promoting proper alignment of the fractured bones over a long term.
       CN: Reduction of risk potential;CL: Evaluate

Question 100

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

Answer 100

100. 4. The client with a femoral fracture in balanced suspension traction should not be given a
        complete bed bath. Rather, the client is encouraged to participate in self-care and movement in bed,
        such as with a trapeze triangle. Use of a fracture bedpan is appropriate. A fracture bedpan is lower,
        and it is easier for the client to move on and off the bedpan without altering the line of traction.
        Checking for areas of redness or pressure over all areas in contact with the traction or bed, including
        the ischial tuberosity, is important to prevent possible skin breakdown. The client should be
        positioned so that the feet do not press against the footboard. Therefore, elevating the head of the bedno more than 25 degrees is recommended to keep the client from moving down in the bed.
        CN: Reduction of risk potential;CL: Synthesize

Question 101

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

Answer 101

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

Question 102

102. The client in balanced suspension traction is transported to surgery for closed reduction and
     internal fixation of a fractured femur. Which of the following should the nurse do when transporting
     the client to the operating room?.
103. Transfer the client to a cart with manually suspended traction.
104. Call the surgeon to request a prescription to temporarily remove the traction.
105. Send the client on the bed with extra help to stabilize the traction.
106. Remove the traction and send the client on a cart.

Answer 102

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

Question 103

103. A client has a Pearson attachment on the traction setup. Which of the following is the
     purpose of this attachment?.
104. To support the lower portion of the leg.
105. To support the thigh and upper leg.
106. To allow attachment of the skeletal pin.4. To prevent flexion deformities in the ankle and foot.

Answer 103

103. 1. The Pearson attachment supports the lower leg and provides increased stability in the
        overall traction setup. It also makes it easier to maintain correct alignment. It does not support the
        thigh and the upper leg or prevent flexion deformities in the ankle and foot. It is not attached to the
        skeletal pin.
        CN: Reduction of risk potential;CL: Apply

Question 104

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

Answer 104

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

Question 105

105. Which of the following is the priority for a client with a fractured femur who is in traction
     at this time?.
106. Prevent effects of immobility while in traction.
107. Develop skills to cope with prolonged immobility.
108. Choose appropriate diversional activities during the prolonged recovery.
109. Adapt to inactivity from the impaired mobility.

Answer 105

105. 1 The priority for this client is to prevent the effects of prolonged immobility, such as
     preventing skin breakdown and encouraging the client to take deep breaths, and use active range-of-
     motion exercises for the joints that are not immobilized. Although not the priority, the nurse also
     should seek ways to help the client adjust to and cope with the present state of immobility. Emphasis
     should be placed on what the client can do, such as participating in daily care and exercises to
     maintain muscle strength. Finding diversional activities is not a priority at this moment. Although theclient must adapt to the inactivity, helping the client develop coping skills is the priority at this time.
     CN: Psychosocial adaptation;CL: Analyze

Question 106

106. The client asks the nurse what the activity limitations are while in Buck’s traction. The nurse
     should tell the client:.
107. “You can sit up whenever you want.”
108. “You must lie flat on your back most of the time.”
109. “You can turn your body.”
110. “You must lie on your stomach.”

Answer 106

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

Question 107

107. When a client has a Thomas splint, the nurse should assess the client regularly for which of
     the following?.
108. Signs of skin pressure in the groin area.
109. Evidence of decreased breath sounds.
110. Skin breakdown behind the heel.
111. Urine retention.

Answer 107

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

Question 108

108. The client in traction for a fractured femur is having difficulty managing self-care activities.
     Which of the following would indicate a successful outcome of a goal of promoting independence for
     this client?.
109. The client assists as much as possible in care, demonstrating increased participation over time.
110. The client allows the nurse to complete care in an efficient manner without interfering.
111. The client allows the spouse to assume total responsibility for care.
112. The client accepts that self-care is not possible while in traction.

Answer 108

108. 1. The client’s assisting as much as possible in self-care and increasing participation over
        time indicate that the client has accomplished self-care by gaining a sense of control. If the client lets
        the nurse complete the care without interfering, the behavior would indicate passivity, possibly from
        denial or depression. If the client allows the spouse to assume total responsibility, a successful
        outcome has not been reached. The client is able to accomplish self-care activities within the limits
        of immobilization from the traction.
        CN: Basic care and comfort; CL: Evaluate

Question 109

109. The client with an open femoral fracture was discharged to the home and developed fever,
     night sweats, chills, restlessness, and restrictive movement of the fractured leg. Which of the
     following reflects the best interpretation of these findings?.
110. Pulmonary emboli.
111. Osteomyelitis.
112. Fat emboli.
113. Urinary tract infection.

Answer 109

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

Question 110

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

Answer 110

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

Question 111

The Client with a Spinal Cord Injury
111. A client is being admitted with a spinal cord transection at C7. Which of the following
assessments take priority upon the client's arrival? Select all that apply.
1. Reflexes.
2. Bladder function.
3. Blood pressure.
4. Temperature.
5. Respirations.

Answer 111

The Client with a Spinal Cord Injury
111. 3, 4, 5. The nurse should assess the client for spinal shock, which is the immediate response
to spinal cord transection. Hypotension occurs, and the body loses core temperature to environmental
temperature. The nurse must treat the client immediately to manage hypotension and hypothermia. The
nurse should also ensure that there is an adequate airway and respirations; there may be respiratory
compromise due to intercostal muscle involvement. Once the client is stable, the nurse should conduct
a complete neurologic check. The nurse should take all precautions to keep the client’s head, neck,
and spine position in straight alignment. If the client is conscious, the nurse should briefly assess
major reflexes, such as the Achilles, patellar, biceps, and triceps tendons, and sensation of the
perineum for bladder function.
CN: Management of care; CL: Analyze

Question 112

112. When planning to move a person with a possible spinal cord injury, the nurse should direct
     the team to:.
113. Limit movement of the arms by wrapping them next to the body.
114. Move the person gently to help reduce pain.
115. Immobilize the head and neck to prevent further injury.
116. Cushion the back with pillows to ensure comfort.

Answer 112

112. 3. The priority concern is to immobilize the head and neck to prevent further trauma when a
        fractured vertebra is unstable and easily displaced. Although wrapping and supporting the extremities
        is important, it does not take priority over immobilizing the head and neck. Pain usually is not a
        significant consideration with this type of injury. Cushioning is contraindicated. The neck should be
        kept in a neutral position and immobilized. Flexion of the neck is avoided.
        CN: Safety and infection control;CL: Synthesize

Question 113

113. The nurse is caring for a client with a spinal cord injury. The client is experiencing blurred
     vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first?.
114. Position the client on the left side.
115. Control the environment by turning the lights off and decreasing stimulation for the client.
116. Check the client’s bladder for distention.
117. Administer pain medications.

Answer 113

113. 3. The client is experiencing autonomic dysreflexia, which is a medical emergency. The
        nurse should immediately evaluate the client for bladder distention and be prepared to catheterize the
        client. Positioning the client on the left side, reducing environmental stimuli, and administering pain
        medications are not used to treat autonomic hyperreflexia.
        CN: Physiological adaptation;CL: Synthesize

Question 114

114. The nurse is taking care of a client with a spinal cord injury. The extent of the client’s injury
     is shown below. Which of the following findings is expected when assessing this client?
115. Inability to move his arms.
116. Loss of sensation in his hands and fingers.
117. Dysfunction of bowel and bladder.
118. Difficulty breathing.

Answer 114

114. 3. This client has a spinal cord injury of the sacral region of the spinal cord and will have
        bladder and bowel dysfunction, as well as loss of sensation and muscle control below the injury. The
        other options are true of a client who has quadriplegia.
        CN: Physiological adaptation;CL: Analyze

Question 115

115. When the client has a cord transection at T4, which of the following is the primary focus of
the nursing assessment?.
1. Renal status.
2. Vascular status.
3. Gastrointestinal function.
4. Biliary function.

Answer 115

115. 2. Although assessment of renal status, gastrointestinal function, and biliary function is
        important, with the spinal cord transection at T4 the client’s vascular status is the primary focus of the
        nursing assessment because the sympathetic feedback system is lost and the client is at risk for
        hypotension and bradycardia.
        CN: Physiological adaptation;CL: Analyze

Question 116

116. When assessing the client with a cord transection above T5 for possible complications,
     which of the following should the nurse expect as least likely to occur?.
117. Diarrhea.
118. Paralytic ileus.
119. Stress ulcers.
120. Intra-abdominal bleeding.

Answer 116

116. 1. The client with a spinal cord transection above T5 is least likely to develop diarrhea.
        Rather, constipation due to atonia would be possible. The client with a spinal cord transection above
        T5 is at risk for development of a paralytic ileus because the sympathetic nerve innervation to the
        vagus nerve, which dominates all the vessels and organs below T5 (eg, the intestinal tract), has beendisrupted and therefore so has movement or peristalsis. The client is at risk for development of stress
        ulcers because the sympathetic nerve innervation to the stomach has been disrupted, which results in
        an excessive release of hydrochloric acid in the stomach, allowing contact of hydrochloric acid with
        the stomach mucosa. The client does not feel subjective signs of stress ulcers (eg, pain, guarding,
        tenderness) and therefore is at increased risk for bleeding because complications of an ulcer can
        develop before early diagnosis.
        CN: Reduction of risk potential;CL: Synthesize

Question 117

117. The nurse is planning to teach the client with spinal cord injury and intermittent nasogastric
     suctioning about interventions to protect the integumentary system. The nurse should tell the client to:.
118. Eat enough calories to maintain desired weight.
119. Stay in cool environments to avoid sweating.
120. Stay in warm environments to avoid chilling.
121. Eat low-sodium foods to avoid edema.

Answer 117

117. 1. The client should eat enough calories to maintain the desired weight, a positive nitrogen
        balance, and enough protein to help decrease the rate of muscle atrophy and prevent skin breakdown
        and infection. The client with a spinal cord injury does not have poikilothermy, the ability to adjust
        body temperature to the environmental temperature. The client should add additional clothes or
        coverage below the level of transection in cool environments. The client does not sweat below the
        level of transection and should be sensitive to the possibility of overheating in extremely hot climates
        and the need for sprinkling or moving into an air-conditioned environment. The client with
        intermittent nasogastric suctioning is at risk for development of metabolic alkalosis and an electrolyte
        imbalance that leads to decreased tissue perfusion; therefore, the client needs to increase the sodium
        and potassium in the diet, not decrease the sodium.
        CN: Reduction of risk potential;CL: Synthesize

Question 118

118. Which of the following should the nurse use as the best method to assess for the
     development of deep vein thrombosis in a client with a spinal cord injury?.
119. Homans’ sign.
120. Pain.
121. Tenderness.
122. Leg girth.

Answer 118

118. 4. Measuring the leg girth is the most appropriate method because the usual signs, such as a
        positive Homans’ sign, pain, and tenderness, are not present. Other means of assessing for deep vein
        thrombosis in a client with a spinal cord injury are through a Doppler examination and impedance
        plethysmography.
        CN: Reduction of risk potential;CL: Analyze

Question 119

119. During the period of spinal shock, the nurse should expect the client's bladder function to be
which of the following?.
1. Spastic.
2. Normal.
3. Atonic.
4. Uncontrolled.

Answer 119

119. 3. During the period of spinal shock, the bladder is completely atonic and will continue to
        fill passively unless the client is catheterized. The bladder will not go into spasms or cause
        uncontrolled urination. Bladder function will not be normal during the period of spinal shock.
        CN: Reduction of risk potential;CL: Analyze

Question 120

120. After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in
     the legs, and calls the nurse in excitement to report the leg movement. Which of the following
     responses by the nurse would be the most accurate?.
121. “These movements indicate that the damaged nerves are healing.”
122. “This is a good sign. Keep trying to move all the affected muscles.”
123. “The return of movement means that eventually you should be able to walk again.”
124. “The movements occur from muscle reflexes that can’t be initiated or controlled by the brain.”

Answer 120

120. 4. The movements occur from muscle reflexes and cannot be initiated or controlled by the
        brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased
        sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing
        is taking place or that the client will walk again. The movement is not voluntary and cannot be
        brought under voluntary control.
        CN: Physiological adaptation;CL: Synthesize

Question 121

121. The client with a spinal cord injury asks the nurse why the dietitian has recommended to
     decrease the total daily intake of calcium. Which of the following responses by the nurse would
     provide the most accurate information?.
122. “Excessive intake of dairy products makes constipation more common.”
123. “Immobility increases calcium absorption from the intestine.”
124. “Lack of weight bearing causes demineralization of the long bones.”
125. “Dairy products likely will contribute to weight gain.”

Answer 121

121. 3. Long-bone demineralization is a serious consequence of the loss of weight bearing. An
        excessive calcium load is brought to the kidneys, and precipitation may occur, predisposing to stone
        formation. Excessive intake of dairy products may promote constipation. However, this is not the
        most accurate reason for decreasing calcium intake. Immobility does not increase calcium absorption
        from the intestine. Dairy products do not necessarily contribute to weight gain.
        CN: Basic care and comfort;CL: Synthesize

Question 122

122. As a first step in teaching a woman with a spinal cord injury and quadriplegia about her
     sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the
     following statements by the client indicates she understands her current ability?.
123. “I won’t be able to have sexual intercourse until the urinary catheter is removed.”
124. “I can participate in sexual activity but might not experience orgasm.”
125. “I can’t have sexual intercourse because it causes hypertension, but other sexual activity is
     okay.”
126. “I should be able to participate in sexual activity, but I will be infertile.”

Answer 122

122. 2. The woman with spinal cord injury can participate in sexual activity but might not
        experience orgasm. Cessation in the nerve pathway may occur in spinal cord injury, but this does notnegate the client’s mental and emotional needs to creatively participate with her partner in a sexual
        relationship and to reach orgasm. An indwelling urinary catheter may be left in place during
        intercourse and need not be removed because the indwelling urinary catheter is placed in the urethra,
        which is not the channel used for sexual intercourse. There are no contraindications, such as
        hypertension, to sexual activity in a woman with spinal cord injury. Sexual intercourse is allowed,
        and hypertension should be manageable. Because a spinal cord injury does not affect fertility, the
        client should have access to family planning information so that an unplanned pregnancy can be
        avoided.
        CN: Basic care and comfort; CL: Evaluate

Question 123

123. A client with a spinal cord injury who has been active in sports and outdoor activities talks
     almost obsessively about his past activities. In tears, one day he asks the nurse, “Why can’t I stop
     talking about these things? I know those days are gone forever.” Which of the following responses by
     the nurse conveys the best understanding of the client’s behavior?.
124. “Be patient. It takes time to adjust to such a massive loss.”
125. “Talking about the past is a form of denial. We have to help you focus on today.”
126. “Reviewing your losses is a way to help you work through your grief and loss.”
127. “It’s a simple escape mechanism to go back and live again in happier times.”

Answer 123

123. 3. Spinal cord injury represents a physical loss; grief is the normal response to this loss.
        Working through grief entails reviewing memories and eventually letting go of them. The process may
        take as long as 2 years. Telling the client to be patient and that adjustment takes time is a clichéd type
        of response, one that is not empathetic or responsive to the client’s needs. Telling the client to focus
        on today does not allow time for the grief process, which is necessary for the client to work through
        and adjust to the loss. The client is not escaping but is reminiscing on what is lost, to work through the
        grieving process.
        CN: Psychosocial adaptation;CL: Synthesize

Question 124

Managing Care Quality and Safety
124. Four days after surgery for internal fixation of a C3–C4 fracture, a nurse is moving a client
from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this
client. Which of the following features of the wheelchair are appropriate for the needs of this client?
Select all that apply.
1. Back at the level of the client’s scapula.
2. Back and head that are high.
3. Seat that is lower than normal.
4. Seat with firm cushions.
5. Chair controlled by the client’s breath.

Answer 124

Managing Care Quality and Safety
124. 2, 3, 5. The client with a C3–C4 fracture has neck control but may tire easily using sore
muscles around the incision area to hold up the head. Therefore, the head and neck of the wheelchair
should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the
bed to the wheelchair. When a client can use the hands and arms to move the wheelchair, the
placement of the back to the client’s scapula is necessary. This client cannot use the arms and will
need an electric chair with breath, chin, or voice control to manipulate movement of the chair. A firm
or hard cushion adds pressure to bony prominences; the cushion should instead be padded to reduce
the risk of pressure ulcers.
CN: Basic care and comfort;CL: Synthesize

Question 125

125. The nurse is documenting care of a client who is restrained in bed with bilateral wrist
     restraints. Following assessment of the restraints, the nurse’s documentation should include which of
     the following? Select all that apply.
126. Nutrition and hydration needs.
127. Capillary refill.
128. Continued need for restraints.
129. Need for medication.
130. Skin integrity.

Answer 125

125. 1, 2, 3, 5. A restraint is a method of involuntary physical restriction of a client’s freedom of
     movement, physical activity, or normal access to his/her body. The nurse must monitor and provide
     care to optimize the physical and psychological well-being of the client including, but not limited to,
     respiratory and circulatory status, skin integrity, and vital signs. With each assessment, the nurse
     needs to ascertain that restraints are still required for client safety. The least restrictive intervention
     based on an individualized assessment of the client’s medical or behavioral status or condition is
     needed.
     CN: Safety and infection control;CL: Analyze

Question 126

126. The nurse on an orthopedic unit is instituting a falls prevention program. Which of the
following personnel should be involved in the program? Select all that apply.
1. Registered nurses.
2. Physicians.
3. Unlicensed personnel.
4. Housekeeping services.
5. Family members.
6. Client.

Answer 126

126. 1, 2, 3, 4, 5, 6. Client safety is a priority for the client, the client’s family, and all of the
     personnel working on this unit. All of these persons must be engaged in using strategies to prevent
     falls.
     CN: Safety and infection control;CL: Create

Question 127

127. The nurse unit manager is making rounds on a team of clients and notices a client who is
     wearing red slipper socks and a color-coded armband that indicates the client is at risk for falling
     walking down the hall unassisted. The nurse should do which of the following first?.
128. Encourage the client to keep walking until he becomes tired.
129. Walk with the client back to his room and assist him to get in bed.
130. Accompany the client while using the lapel microphone to call for the unlicensed nursing
     personnel (UAP) to walk with the client.
131. Instruct the client to walk only in his room.

Answer 127

127. 3. The client is identified as being at risk for falling and a staff member or family member
        should accompany the client when walking. The nurse can delegate the task of ambulating the client tothe UAP, but should remain with the client until the UAP arrives. Walking only in the room will not
        provide an opportunity for the client to gain strength and improve ambulation. The client should not
        walk beyond the point of being fatigued; the UAP should observe for fatigue and the nurse should set
        appropriate goals for distance to be walked.
        CN: Reduction of risk potential;CL: Synthesize

Question 128

128. The physician has prescribed 5 mg Coumadin (warfarin) orally for a hospitalized client. In
     planning care for this client, the nurse should verify that which of the following services have been
     contacted? Check all that apply.
129. Pharmacy.
130. Dietary.
131. Laboratory.
132. Discharge planning.5. Chaplain.

Answer 128

128. 1, 2, 3. To assure client safety when using anticoagulants, the nurse should coordinate care at
     this time with the pharmacist, dietitian, and laboratory. The pharmacist will collaborate in teaching
     the client about using the drug; dietary services will plan a diet that limits foods that have high
     amounts of vitamin K (spinach, cabbage, blueberries) that will interfere with anticoagulation, and the
     laboratory will draw daily INR levels to assure accurate dosing. Although the nurse coordinates
     discharge planning at the time of admission to the hospital, at this point it is too soon for discharge
     planning services to be involved because it is not known if the client will continue to take the
     Coumadin when discharged. There is no indication a chaplain is needed at this time.
     CN: Management of care; CL: Synthesize

Question 129

129. The nurse on the orthopedic unit is going to lunch and is conducting a “hand-off” to the
     charge nurse. The goal of the “hand-off” communication is to do which of the following?.
130. To ensure the charge nurse understands that the nurse is going to lunch.
131. To be sure the charge nurse assigns someone else to take care of the client.
132. To provide accurate information about client’s care to the next caregiver.
133. To provide in-depth information about the client’s history.

Answer 129

129. 3. Hand-off communication is an interactive communication allowing the opportunity for
        questioning between the giver and receiver of client information including up-to-date information
        regarding the client’s care, treatment, and services; current condition; and any recent or anticipated
        changes. “Hand-off” communication does occur when a nurse is leaving the nursing unit, but the
        purpose is not to let the charge nurse know that the nurse is going to lunch or to have someone else
        assigned to care for the client. “Hand-off” communication focuses on current information, not the
        client’s history.
        CN: Management of care; CL: Synthesize

Question 130

130. The client has been diagnosed with septic arthritis in a hip joint. Which of the following are
     desired outcomes from a client-focused teaching plan? Select all that apply.
131. Report pain that is severe enough to limit activities.
132. Discuss how to take prescribed medications.
133. Describe how the application of a heating pad set on “high” readily resolves edema.
134. Describe the septic arthritis physiologic process.
135. Explain the importance of supporting the affected joint.
136. Describe how to use ambulatory aids and assistive devices.

Answer 130

130. 2, 4, 5, 6. The nurse should determine that a client with rheumatoid arthritis can describe the
     septic arthritis physiologic process and knows how to relieve pain using pharmacologic and
     nonpharmacologic interventions. Prolonged immobility and limited activity may promote formation of
     a deep vein thrombosis and possibly subsequent pulmonary emboli. The client should also understand
     the importance of supporting the affected joint, weight-bearing and activity restrictions, and how to
     use ambulatory aids and assistive devices safely to promote recovery of normal function. The local
     application of heat and cold to an injured body part can provide therapeutic benefits; however, “high”
     heat may cause a thermal injury and further promote edema formation. The client should inform the
     health care provider about pain that is not relieved by the current management plan.
     CN: Management of care; CL: Evaluate

Question 131

131. The nurse should perform passive range-of-motion (ROM) exercises on which of the
     following clients? A client: Select all that apply.
132. Who has septic joints.
133. Who has temporary loss of sensation.
134. Who is unconsciousness.
135. Who has plantar flexion of the foot.
136. Who has supination of the hand.

Answer 131

131. 2, 3. Passive ROM exercises are used to move the client’s joints through as full a ROM as
     possible. Passive ROM exercises improve or maintain joint mobility and help prevent contractures.
     These exercises are indicated for the client with temporary or permanent loss of mobility, sensation,
     or consciousness. Exercises help with joint mobility, strength, and endurance. Plantar flexion of the
     foot and supination of the hand may be normal joint movements if the client can do active ROM.
     Septic joints have infection that may be spread either hematogenously or through trauma.
     CN: Reduction of risk potential; CL: Apply