Exam 4 Flashcards
1. A nurse cares for a dying client. Which manifestation of dying
should the nurse treat first?
d. Hair loss
Only symptoms that cause distress for a dying client should be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the clients comfort. Even when symptoms, such as anorexia or hair loss, disturb the family, they should be treated only if the client is distressed by their presence. The nurse should treat the clients pain first.
2. A nurse plans care for a client who is nearing end of life. Which
question should the nurse ask when developing this clients plan of
a. Is your advance directive up to date and notarized?
b. Do you want to be at home at the end of your life?
c. Would you like a physical therapist to assist you with range-of-motion activities?
d. Have your children discussed resuscitation with your health care provider?
When developing a plan of care for a dying client, consideration should be given for where the client wants to die. Advance directives do not need to be notarized. A physical therapist would not be involved in end-of-life care. The client should discuss resuscitation with the health care provider and children; do-not-resuscitate status should be the clients decision, not the familys decision.
3. A nurse is caring for a client who has lung cancer and is dying.
Which prescription should the nurse question?
a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5
b. Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezes
c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions
d. Sodium biphosphate (Fleet) enema once a day PRN for impacted stool
Pain medications should be scheduled around the clock to maintain comfort and prevent reoccurrence of pain. The other medications are appropriate for this client.
4. A client tells the nurse that, even though it has been 4 months
since her sisters death, she frequently finds
herself crying uncontrollably. How should the nurse respond?
a. Most people move on within a few months. You should see a grief counselor.
b. Whenever you start to cry, distract yourself from thoughts of your sister.
c. You should try not to cry. Im sure your sister is in a better
d. Your feelings are completely normal and may continue for a long time.
Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the clients response.
5. After teaching a client about advance directives, a nurse assesses
the clients understanding. Which statement indicates the client
correctly understands the teaching?
a. An advance directive will keep my children from selling my home when Im old.
b. An advance directive will be completed as soon as Im incapacitated and cant think for myself.
c. An advance directive will specify what I want done when I can no longer make decisions about health care.
d. An advance directive will allow me to keep my money out of the reach of my family.
An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal
health care. It does not address issues such as the clients residence or financial matters.
6. A nurse teaches a client who is considering being admitted to
hospice. Which statement should the nurse include in this clients
a. Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge.
b. Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms.
c. Hospice care will not help with your symptoms of depression. I will refer you to the facilitys counseling services instead.
d. You seem to be experiencing some difficulty with this stage of the grieving process. Lets talk about your feelings.
As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client.
7. A nurse is caring for a dying client. The clients spouse states, I
think he is choking to death. How should the nurse respond?
a. Do not worry. The choking sound is normal during the dying process.
b. I will administer more morphine to keep your husband comfortable.
c. I can ask the respiratory therapist to suction secretions out through his nose.
d. I will have another nurse assist me to turn your husband on his side.
The choking sound or death rattle is common in dying clients. The nurse should acknowledge the spouses concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side
with a towel under the mouth to collect secretions is the best intervention. The nurse should not minimize the spouses concerns. Morphine will assist with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not appropriate in a dying client.
8. The nurse is teaching a family member about various types of
complementary therapies that might be effective for relieving the
dying clients anxiety and restlessness. Which statement made by the
family member indicates understanding of the nurses teaching?
a. Maybe we should just hire an around-the-clock sitter to stay with Grandmother.
b. I have some of her favorite hymns on a CD that I could bring for music therapy.
c. I dont think that shell need pain medication along with her herbal treatments.
d. I will burn therapeutic incense in the room so we can stop the anxiety pills.
Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a clients inner restlessness. Hiring an around-the-clock sitter does not demonstrate that the clients family understands complementary therapies. Complementary therapies are used in conjunction with traditional therapy. Complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications.
9. A nurse is caring for a terminally ill client who has just died in
a hospital setting with family members at the bedside. Which action
should the nurse take first?
a. Call for emergency assistance so that resuscitation procedures can begin.
b. Ask family members if they would like to spend time alone with the client.
c. Ensure that a death certificate has been completed by the physician.
d. Request family members to prepare the clients body for the funeral home.
Before moving the clients body to the funeral home, the nurse should ask family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a
death certificate has been completed before the client is moved to the mortuary, the nurse first should ask family members if they would like to be alone with the client. The clients family should not be expected to
prepare the body for the funeral home.
10. A nurse assesses a client who is dying. Which manifestation of a
dying client should the nurse assess to determine whether the client
is near death?
a. Level of consciousness
b. Respiratory rate
c. Bowel sounds
d. Pain level on a 0-to-10 scale
Although all of these assessments should be performed during the dying process, periods of apnea and Cheyne-Strokes respirations indicate death is near. As peripheral circulation decreases, the clients level of consciousness and bowel sounds decrease, and the client would be unable to provide a numeric number on a pain scale. Even with these other symptoms, the nurse should continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.
11. A nurse is caring for a client who is terminally ill. The clients
spouse states, I am concerned because he does not want to eat. How
should the nurse respond?
a. Let him know that food is available if he wants it, but do not insist that he eat.
b. A feeding tube can be placed in the nose to provide important nutrients.
c. Force him to eat even if he does not feel hungry, or he will die sooner.
d. He is getting all the nutrients he needs through his intravenous catheter.
When family members understand that the client is not suffering from hunger and is not starving to death, they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family.
12. A nurse discusses inpatient hospice with a client and the clients
family. A family member expresses concern that her loved one will
receive only custodial care. How should the nurse respond?
a. The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.
b. Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop.
c. A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given.
d. Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility.
Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.
13. An intensive care nurse discusses withdrawal of care with a
clients family. The family expresses concerns related to
discontinuation of therapy. How should the nurse respond?
a. I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia.
b. You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support.
c. I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death.
d. There is no need to worry. Most religious organizations support the clients decision to stop medical treatment.
The nurse should validate the familys concerns and provide accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about their purpose. If the clients family asks for specific information about euthanasia, legal, or religious issues, the nurse should provide unbiased information about these topics.
14. A hospice nurse is caring for a variety of clients who are dying.
Which end-of-life and death ritual is paired with the correct
a. Roman Catholic Autopsies are not allowed except under special circumstances.
b. Christian Upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth.
c. Judaism A person who is extremely ill and dying should not be left alone.
d. Islam An ill or dying person should receive the Sacrament of the Sick.
According to Jewish law, a person who is extremely ill or dying should not be left alone. Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon death. A Catholic priest performs the Sacrament of the Sick for ill or dying people.
1. A hospice nurse is caring for a dying client and her family
members. Which interventions should the nurse
implement? (Select all that apply.)
a. Teach family members about physical signs of impending death.
b. Encourage the management of adverse symptoms.
c. Assist family members by offering an explanation for their loss.
d. Encourage reminiscence by both client and family members.
e. Avoid spirituality because the clients and the nurses beliefs may not be congruent.
ANS: A, B, D
The nurse should teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the familys loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether the clients religion is the same.
2. A nurse admits an older adult client to the hospital. Which
criterion should the nurse use to determine if the client can make his
own medical decisions? (Select all that apply.)
a. Can communicate his treatment preferences
b. Is able to read and write at an eighth-grade level
c. Is oriented enough to understand information provided
d. Can evaluate and deliberate information
e. Has completed an advance directive
ANS: A, C, D
To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented 4); evaluate, deliberate, and mentally manipulate information; and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the clients level so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to.
3. A hospice nurse plans care for a client who is experiencing pain.
Which complementary therapies should the nurse incorporate in this
clients pain management plan? (Select all that apply.)
a. Play music that the client enjoys.
b. Massage tissue that is tender from radiation therapy.
c. Rub lavender lotion on the clients feet.
d. Ambulate the client in the hall twice a day.
e. Administer intravenous morphine.
ANS: A, C
Complementary therapies for pain management include massage therapy, music therapy, Therapeutic Touch, and aromatherapy. Nurses should not massage over sites of tissue damage from radiation therapy. Ambulation and intravenous morphine are not complementary therapies for pain management.
1. A nurse is working with a community group promoting healthy aging.
What recommendation is best to help prevent osteoarthritis
a. Avoid contact sports.
b. Get plenty of calcium.
c. Lose weight if needed.
d. Engage in weight-bearing exercise.
Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and
weight-bearing exercise are both important for osteoporosis.
2. A nurse in the family clinic is teaching a client newly diagnosed
with osteoarthritis (OA) about drugs used to treat the disease. For
which medication does the nurse plan primary teaching?
a. Acetaminophen (Tylenol)
b. Cyclobenzaprine hydrochloride (Flexeril)
c. Hyaluronate (Hyalgan)
d. Ibuprofen (Motrin)
All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a
nonsteroidal anti-inflammatory drug.
3. The clinic nurse assesses a client with diabetes during a checkup.
The client also has osteoarthritis (OA). The nurse notes the clients
blood glucose readings have been elevated. What question by the nurse
is most appropriate?
a. Are you compliant with following the diabetic diet?
b. Have you been taking glucosamine supplements?
c. How much exercise do you really get each week?
d. Youre still taking your diabetic medication, right?
All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them.Compliant is a word associated with negative images, and the client may deny being noncompliant. Asking how much exercise the client really gets is accusatory. Asking if the client takes his or her medications right? is patronizing.
4. The nurse working in the orthopedic clinic knows that a client
with which factor has an absolute contraindication for having a total
a. Needs multiple dental fillings
b. Over age 85
c. Severe osteoporosis
d. Urinary tract infection
Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age
greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.
5. An older client has returned to the surgical unit after a total
hip replacement. The client is confused and restless. What
intervention by the nurse is most important to prevent injury?
a. Administer mild sedation.
b. Keep all four siderails up.
c. Restrain the clients hands.
d. Use an abduction pillow.
Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the clients mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.
6. What action by the perioperative nursing staff is most important
to prevent surgical wound infection in a client having a total joint
a. Administer preoperative antibiotic as ordered.
b. Assess the clients white blood cell count.
c. Instruct the client to shower the night before.
d. Monitor the clients temperature postoperatively.
To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The
other options are processes to monitor for infection, not prevent it.
7. The nurse on the postoperative inpatient unit assesses a client
after a total hip replacement. The clients surgical leg is visibly
shorter than the other one and the client reports extreme pain. While
a co-worker calls the
surgeon, what action by the nurse is best?
a. Assess neurovascular status in both legs.
b. Elevate the affected leg and apply ice.
c. Prepare to administer pain medication.
d. Try to place the affected leg in abduction.
This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The
nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.
8. A client has a continuous passive motion (CPM) device after a
total knee replacement. What action does the nurse delegate to the
unlicensed assistive personnel (UAP) after the affected leg is placed
in the machine while
the client is in bed?
a. Assess the distal circulation in 30 minutes.
b. Change the settings based on range of motion.
c. Raise the lower siderail on the affected side.
d. Remind the client to do quad-setting exercises.
Because the clients leg is strapped into the CPM, if it falls off the bed due to movement, the clients leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.
9. After a total knee replacement, a client is on the postoperative
nursing unit with a continuous femoral nerve blockade. On assessment,
the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is
pale pink, warm,
and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?
a. Document the findings and monitor as prescribed.
b. Increase the frequency of monitoring the client.
c. Notify the surgeon or anesthesia provider immediately.
d. Palpate the clients bladder or perform a bladder scan.
With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.
10. A nurse is discharging a client to a short-term rehabilitation
center after a joint replacement. Which action by the nurse is most
a. Administering pain medication before transport
b. Answering any last-minute questions by the client
c. Ensuring the family has directions to the facility
d. Providing a verbal hand-off report to the facility
As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.
11. A nurse works in the rheumatology clinic and sees clients with
rheumatoid arthritis (RA). Which client should the nurse see
a. Client who reports jaw pain when eating
b. Client with a red, hot, swollen right wrist
c. Client who has a puffy-looking area behind the knee
d. Client with a worse joint deformity since the last visit
All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.
12. A client with rheumatoid arthritis (RA) is on the postoperative
nursing unit after having elective surgery. The client reports that
one arm feels like pins and needles and that the neck is very painful
since returning from
surgery. What action by the nurse is best?
a. Assist the client to change positions.
b. Document the findings in the clients chart.
c. Encourage range of motion of the neck.
d. Notify the provider immediately.
Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.
13. The nurse working in the rheumatology clinic is seeing clients
with rheumatoid arthritis (RA). What assessment would be most
important for the client whose chart contains the diagnosis of Sjgrens
a. Abdominal assessment
b. Oxygen saturation
c. Renal function studies
d. Visual acuity
Sjgrens syndrome is seen in clients with RA and manifests with dryness of the eyes, mouth, and vagina in females. Visual disturbances can occur. The other assessments are not related to RA and Sjgrens syndrome.
14. The nurse is working with a client who has rheumatoid arthritis
(RA). The nurse has identified the priority problem of poor body image
for the client. What finding by the nurse indicates goals for this
client problem are being met?
a. Attends meetings of a book club
b. Has a positive outlook on life
c. Takes medication as directed
d. Uses assistive devices to protect joints
All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.
16. The nurse in the rheumatology clinic is assessing clients with
rheumatoid arthritis (RA). Which client should the nurse see
a. Client taking celecoxib (Celebrex) and ranitidine (Zantac)
b. Client taking etanercept (Enbrel) with a red injection site
c. Client with a blood glucose of 190 mg/dL who is taking steroids
d. Client with a fever and cough who is taking tofacitinib (Xeljanz)
Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib,
which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.
17. A client with rheumatoid arthritis (RA) has an acutely swollen,
red, and painful joint. What nonpharmacologic treatment does the nurse
a. Heating pad
b. Ice packs
d. Wax dip
Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.
18. The nurse on an inpatient rheumatology unit receives a hand-off
report on a client with an acute exacerbation of systemic lupus
erythematosus (SLE). Which reported laboratory value requires the
nurse to assess the client further?
a. Creatinine: 3.9 mg/dL
b. Platelet count: 210,000/mm3
c. Red blood cell count: 5.2/mm3
d. White blood cell count: 4400/mm3
Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.
19. A client who has had systemic lupus erythematosus (SLE) for many
years is in the clinic reporting hip pain with ambulation. Which
action by the nurse is best?
a. Assess medication records for steroid use.
b. Facilitate a consultation with physical therapy.
c. Measure the range of motion in both hips.
d. Notify the health care provider immediately.
Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough
information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.
20. A client with systemic lupus erythematosus (SLE) was recently
discharged from the hospital after an acute exacerbation. The client
is in the clinic for a follow-up visit and is distraught about the
possibility of another hospitalization disrupting the family. What
action by the nurse is best?
a. Explain to the client that SLE is an unpredictable disease.
b. Help the client create backup plans to minimize disruption.
c. Offer to talk to the family and educate them about SLE.
d. Tell the client to remain compliant with treatment plans.
SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.
24. A client in the orthopedic clinic has a self-reported history of
osteoarthritis. The client reports a low-grade fever that started when
the weather changed and several joints started acting up, especially
both hips and knees. What action by the nurse is best?
a. Assess the client for the presence of subcutaneous nodules or Bakers cysts.
b. Inspect the clients feet and hands for podagra and tophi on fingers and toes.
c. Prepare to teach the client about an acetaminophen (Tylenol) regimen.
d. Reassure the client that the problems will fade as the weather changes again.
Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and
Bakers cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.
25. A nurse is caring for a client after joint replacement surgery.
What action by the nurse is most important to prevent wound
a. Assess the clients white blood cell count.
b. Culture any drainage from the wound.
c. Monitor the clients temperature every 4 hours.
d. Use aseptic technique for dressing changes.
Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of
an infection that is already present.
26. A nurse is discharging a client after a total hip replacement.
What statement by the client indicates good potential for
a. I can bend down to pick something up.
b. I no longer need to do my exercises.
c. I will not sit with my legs crossed.
d. I wont wash my incision to keep it dry.
There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.
27. The nurse is caring for a client using a continuous passive
motion (CPM) machine and has delegated some tasks to the unlicensed
assistive personnel (UAP). What action by the UAP warrants
intervention by the nurse?
a. Checking to see if the machine is working
b. Keeping controls in a secure place on the bed
c. Placing padding in the machine per request
d. Storing the CPM machine under the bed after removal
For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.
28. A client recently diagnosed with systemic lupus erythematosus
(SLE) is in the clinic for a follow-up visit. The nurse evaluates that
the client practices good self-care when the client makes which
a. I always wear long sleeves, pants, and a hat when outdoors.
b. I try not to use cosmetics that contain any type of sunblock.
c. Since I tend to sweat a lot, I use a lot of baby powder.
d. Since I cant be exposed to the sun, I have been using a tanning bed.
Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.
29. A client is scheduled to have a hip replacement. Preoperatively,
the client is found to be mildly anemic and the surgeon states the
client may need a blood transfusion during or after the surgery. What
action by the preoperative nurse is most important?
a. Administer preoperative medications as prescribed.
b. Ensure that a consent for transfusion is on the chart.
c. Explain to the client how anemia affects healing.
d. Teach the client about foods high in protein and iron.
The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.
30. An older client is scheduled to have hip replacement in 2 months
and has the following laboratory values: white blood cell count:
8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL,
hematocrit: 32%. What intervention by the nurse is most
a. Instruct the client to avoid large crowds.
b. Prepare to administer epoetin alfa (Epogen).
c. Teach the client about foods high in iron.
d. Tell the client that all laboratory results are normal.
This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the clients red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This
colony-stimulating factor will encourage the production of red cells. The clients white blood cell count is normal, so avoiding infection is not the priority.
31. A client is getting out of bed into the chair for the first time
after an uncemented hip replacement. What action by the nurse is most
a. Have adequate help to transfer the client.
b. Provide socks so the client can slide easier.
c. Tell the client full weight bearing is allowed.
d. Use a footstool to elevate the clients leg.
The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the
leg greater than 90 degrees is not allowed.
32. A client has fibromyalgia and is prescribed duloxetine
hydrochloride (Cymbalta). The client calls the clinic and asks the
nurse why an antidepressant drug has been prescribed. What response by
the nurse is best?
a. A little sedation will help you get some rest.
b. Depression often accompanies fibromyalgia.
c. This drug works in the brain to decrease pain.
d. You will have more energy after taking this drug.
Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.
33. A client has been diagnosed with rheumatoid arthritis. The client
has experienced increased fatigue and worsening physical status and is
finding it difficult to maintain the role of elder in his cultural
community. The elder is expected to attend social events and make
community decisions. Stress seems to exacerbate the condition. What
action by the nurse is best?
a. Assess the clients culture more thoroughly.
b. Discuss options for performing duties.
c. See if the client will call a community meeting.
d. Suggest the client give up the role of elder.
The nurse needs a more thorough understanding of the clients culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.
34. A client has rheumatoid arthritis that especially affects the
hands. The client wants to finish quilting a baby blanket before the
birth of her grandchild. What response by the nurse is best?
a. Lets ask the provider about increasing your pain pills.
b. Hold ice bags against your hands before quilting.
c. Try a paraffin wax dip 20 minutes before you quilt.
d. You need to stop quilting before it destroys your fingers.
Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a hot or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.
35. A client has newly diagnosed systemic lupus erythematosus (SLE).
What instruction by the nurse is most important?
a. Be sure you get enough sleep at night.
b. Eat plenty of high-protein, high-iron foods.
c. Notify your provider at once if you get a fever.
d. Weigh yourself every day on the same scale.
Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily
weights may or may not be important depending on renal involvement.
37. A client takes celecoxib (Celebrex) for chronic osteoarthritis in
multiple joints. After a knee replacement, the health care provider
has prescribed morphine sulfate for postoperative pain relief. The
client also requests the celecoxib in addition to the morphine. What
action by the nurse is best?
a. Consult with the health care provider about administering both drugs to the client.
b. Inform the client that the celecoxib will be started when he or she goes home.
c. Teach the client that, since morphine is stronger, celecoxib is not needed.
d. Tell the client he or she should not take both drugs at the same time.
Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help
with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this
1. The nursing student studying rheumatoid arthritis (RA) learns
which facts about the disease? (Select all that
a. It affects single joints only.
b. Antibodies lead to inflammation.
c. It consists of an autoimmune process.
d. Morning stiffness is rare.
e. Permanent damage is inevitable.
ANS: B, C
RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation.
Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.
2. A nurse is teaching a female client with rheumatoid arthritis (RA)
about taking methotrexate (MTX) (Rheumatrex) for disease control. What
information does the nurse include? (Select all that apply.)
a. Avoid acetaminophen in over-the-counter medications.
b. It may take several weeks to become effective on pain.
c. Pregnancy and breast-feeding are not affected by MTX.
d. Stay away from large crowds and people who are ill.
e. You may find that folic acid, a B vitamin, reduces side effects.
ANS: A, B, D, E
MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.
3. A client has been diagnosed with fibromyalgia syndrome but does
not want to take the prescribed medications. What nonpharmacologic
measures can the nurse suggest to help manage this condition? (Select
all that apply.)
d. Tai chi
e. Vigorous aerobics
NS: A, B, D
There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.
4. The nurse working in the rheumatology clinic assesses clients with
rheumatoid arthritis (RA) for late manifestations. Which
signs/symptoms are considered late manifestations of RA? (Select all
b. Feltys syndrome
c. Joint deformity
d. Low-grade fever
e. Weight loss
ANS: B, C, E
Late manifestations of RA include Feltys syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.
5. An older client returning to the postoperative nursing unit after
a hip replacement is disoriented and restless. What actions does the
nurse delegate to the unlicensed assistive personnel (UAP)? (Select
all that apply.)
a. Apply an abduction pillow to the clients legs.
b. Assess the skin under the abduction pillow straps.
c. Place pillows under the heels to keep them off the bed.
d. Monitor cognition to determine when the client can get up.
e. Take and record vital signs per unit/facility policy.
ANS: A, C, E
The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurses responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.
9. A client has rheumatoid arthritis (RA) and the visiting nurse is
conducting a home assessment. What options can the nurse suggest for
the client to maintain independence in activities of daily living
(ADLs)? (Select all
a. Grab bars to reach high items
b. Long-handled bath scrub brush
c. Soft rocker-recliner chair
d. Toothbrush with built-up handle
e. Wheelchair cushion for comfort
ANS: A, B, D
Grab bars, long-handled bath brushes, and toothbrushes with
built-up handles all provide modifications for daily activities,
making it easier for the client with RA to complete ADLs
independently. The rocker-recliner
and wheelchair cushion are comfort measures but do not help increase independence.
10. A home health care nurse is visiting a client discharged home
after a hip replacement. The client is still on partial weight bearing
and using a walker. What safety precautions can the nurse recommend to
(Select all that apply.)
a. Buy and install an elevated toilet seat.
b. Install grab bars in the shower and by the toilet.
c. Step into the bathtub with the affected leg first.
d. Remove all throw rugs throughout the house.
e. Use a shower chair while taking a shower.
ANS: A, B, D, E
Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.
11. A client with fibromyalgia is in the hospital for an unrelated
issue. The client reports that sleep, which is always difficult, is
even harder now. What actions by the nurse are most appropriate?
(Select all that apply.)
a. Allow the client uninterrupted rest time.
b. Assess the clients usual bedtime routine.
c. Limit environmental noise as much as possible.
d. Offer a massage or warm shower at night.
e. Request an order for a strong sleeping pill.
ANS: A, B, C, D
Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the clients usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.
1. The nurse is caring for a client diagnosed with human immune
deficiency virus. The clients CD4+ cell count is 399/mm3. What action
by the nurse is best?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from
alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.
2. The nurse is presenting information to a community group on safer
sex practices. The nurse should teach that which sexual practice is
a. Anal intercourse
c. Oral sex
d. Vaginal intercourse
Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.
3. The nurse providing direct client care uses specific practices to
reduce the chance of acquiring infection with human immune deficiency
virus (HIV) from clients. Which practice is most effective?
a. Consistent use of Standard Precautions
b. Double-gloving before body fluid exposure
c. Labeling charts and armbands HIV+
d. Wearing a mask within 3 feet of the client
According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this
fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.
4. A client with human immune deficiency virus is admitted to the
hospital with fever, night sweats, and severe cough. Laboratory
results include a CD4+ cell count of 180/mm3 and a negative
tuberculosis (TB) skin test 4 days ago. What action should the nurse
a. Initiate Droplet Precautions for the client.
b. Notify the provider about the CD4+ results.
c. Place the client under Airborne Precautions.
d. Use Standard Precautions to provide care.
Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.
5. A nurse is talking with a client about a negative enzyme-linked
immunosorbent assay (ELISA) test for human immune deficiency virus
(HIV) antibodies. The test is negative and the client states Whew! I
worried about that result. What action by the nurse is most important?
a. Assess the clients sexual activity and patterns.
b. Express happiness over the test result.
c. Remind the client about safer sex practices.
d. Tell the client to be retested in 3 months.
The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the clients sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.
6. A client with human immune deficiency virus (HIV) has had a sudden
decline in status with a large increase in viral load. What action
should the nurse take first?
a. Ask the client about travel to any foreign countries.
b. Assess the client for adherence to the drug regimen.
c. Determine if the client has any new sexual partners.
d. Request information about new living quarters or pets.
Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this clients viral load has increased
dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.
7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The
client reports shortness of breath with activity and extreme fatigue.
What intervention is best to promote comfort?
a. Administer sleeping medication.
b. Perform most activities for the client.
c. Increase the clients oxygen during activity.
d. Pace activities, allowing for adequate rest.
This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the clients activity.
8. A client with HIV wasting syndrome has inadequate nutrition. What
assessment finding by the nurse best
ndicates that goals have been met for this client problem?
a. Chooses high-protein food
b. Has decreased oral discomfort
c. Eats 90% of meals and snacks
d. Has a weight gain of 2 pounds/1 month
The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.
9. A client with acquired immune deficiency syndrome is hospitalized
and has weeping Kaposis sarcoma lesions. The nurse dresses them with
sterile gauze. When changing these dressings, which action is most
a. Adhering to Standard Precautions
b. Assessing tolerance to dressing changes
c. Performing hand hygiene before and after care
d. Disposing of soiled dressings properly
All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.
10. A client has a primary selective immunoglobulin A deficiency. The
nurse should prepare the client for self management by teaching what
principle of medical management?
a. Infusions will be scheduled every 3 to 4 weeks.
b. Treatment is aimed at treating specific infections.
c. Unfortunately, there is no effective treatment.
d. You will need many immunoglobulin A infusions.
Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.
11. An HIV-positive client is admitted to the hospital with
Toxoplasma gondii infection. Which action by the nurse is most
a. Initiate Contact Precautions.
b. Place the client on Airborne Precautions.
c. Place the client on Droplet Precautions.
d. Use Standard Precautions consistently.
Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.
12. A client has just been diagnosed with human immune deficiency
virus (HIV). The client is distraught and does not know what to do.
What intervention by the nurse is best?
a. Assess the client for support systems.
b. Determine if a clergy member would help.
c. Explain legal requirements to tell sex partners.
d. Offer to tell the family for the client.
This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.
13. A nurse works on a unit that has admitted its first client with
acquired immune deficiency syndrome. The nurse overhears other staff
members talking about the AIDS guy and wondering how the client
contracted the disease. What action by the nurse is best?
a. Confront the staff members about unethical behavior.
b. Ignore the behavior; they will stop on their own soon.
c. Report the behavior to the units nursing management.
d. Tell the client that other staff members are talking about him or her.
The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.
14. A client has been hospitalized with an opportunistic infection
secondary to acquired immune deficiency syndrome. The clients partner
is listed as the emergency contact, but the clients mother insists
that she should be listed instead. What action by the nurse is
a. Contact the social worker to assist the client with advance directives.
b. Ignore the mother; the client does not want her to be involved.
c. Let the client know, gently, that nurses cannot be involved in these disputes.
d. Tell the client that, legally, the mother is the emergency contact.
The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.
15. A client with human immune deficiency virus infection is
hospitalized for an unrelated condition, and several medications are
prescribed in addition to the regimen already being used. What action
by the nurse is most important?
a. Consult with the pharmacy about drug interactions.
b. Ensure that the client understands the new medications.
c. Give the new drugs without considering the old ones.
d. Schedule all medications at standard times.
The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.
16. A client with acquired immune deficiency syndrome has been
hospitalized with suspected cryptosporidiosis. What physical
assessment would be most consistent with this condition?
a. Auscultating the lungs
b. Assessing mucous membranes
c. Listening to bowel sounds
d. Performing a neurologic examination
Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the clients mucous membranes for dryness.
The nurse will perform the other assessments as part of a comprehensive assessment.
17. A client with HIV/AIDS asks the nurse why gabapentin (Neurontin)
is part of the drug regimen when the client does not have a history of
seizures. What response by the nurse is best?
a. Gabapentin can be used as an antidepressant too.
b. I have no idea why you should be taking this drug.
c. This drug helps treat the pain from nerve irritation.
d. You are at risk for seizures due to fungal infections.
Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client.
18. A nurse is caring for four clients who have immune disorders.
After receiving the hand-off report, which client should the nurse
a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C)
b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching
c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion
d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.
19. An HIV-negative client who has an HIV-positive partner asks the
nurse about receiving Truvada (emtricitabine and tenofovir). What
information is most important to teach the client about this
a. Truvada does not reduce the need for safe sex practices.
b. This drug has been taken off the market due to increases in cancer.
c. Truvada reduces the number of HIV tests you will need.
d. This drug is only used for postexposure prophylaxis.
Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not
reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure
1. A student nurse is learning about human immune deficiency virus
(HIV) infection. Which statements about HIV infection are correct?
(Select all that apply.)
a. CD4+ cells begin to create new HIV virus particles.
b. Antibodies produced are incomplete and do not function well.
c. Macrophages stop functioning properly.
d. Opportunistic infections and cancer are leading causes of
e. People with stage 1 HIV disease are not infectious to others.
ANS: A, B, C, D
In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.
2. Which findings are AIDS-defining characteristics? (Select all that
a. CD4+ cell count less than 200/mm3 or less than 14%
b. Infection with Pneumocystis jiroveci
c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV)
d. Presence of HIV wasting syndrome
e. Taking antiretroviral medications
ANS: A, B, D
A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic
infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.
3. A nurse is traveling to a third-world country with a medical
volunteer group to work with people who are infected with human immune
deficiency virus (HIV). The nurse should recognize that which of the
might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.)
a. Clean drinking water
b. Cultural beliefs about illness
c. Lack of antiviral medication
d. Social stigma
e. Unknown transmission routes
ANS: A, B, C, D
Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.
4. A client with acquired immune deficiency syndrome (AIDS) is
hospitalized with Pneumocystis jiroveci pneumonia and is started on
the drug of choice for this infection. What laboratory values should
the nurse report to the provider as a priority? (Select all that
a. Aspartate transaminase, alanine transaminase: elevated
b. CD4+ cell count: 180/mm3
c. Creatinine: 1.0 mg/dL
d. Platelet count: 80,000/mm3
e. Serum sodium: 120 mEq/L
ANS: A, D, E
The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes,
low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal.
5. A client with acquired immune deficiency syndrome has oral thrush
and difficulty eating. What actions does the nurse delegate to the
unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Apply oral anesthetic gels before meals.
b. Assist the client with oral care every 2 hours.
c. Offer the client frequent sips of cool drinks.
d. Provide the client with alcohol-based mouthwash.
e. Remind the client to use only a soft toothbrush.
ANS: B, C, E
The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes
are harsh and drying and should not be used.
6. A client with acquired immune deficiency syndrome is in the
hospital with severe diarrhea. What actions does the nurse delegate to
the unlicensed assistive personnel (UAP)? (Select all that
a. Assessing the clients fluid and electrolyte status
b. Assisting the client to get out of bed to prevent falls
c. Obtaining a bedside commode if the client is weak
d. Providing gentle perianal cleansing after stools
e. Reporting any perianal abnormalities
ANS: B, C, D, E
The UAP can assist the client with getting out of bed, obtain a bedside commode for the clients use, cleanse the clients perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status.
7. A client with acquired immune deficiency syndrome and esophagitis
due to Candida fungus is scheduled for an endoscopy. What actions by
the nurse are most appropriate? (Select all that apply.)
a. Assess the clients mouth and throat.
b. Determine if the client has a stiff neck.
c. Ensure that the consent form is on the chart.
d. Maintain NPO status as prescribed.
e. Percuss the clients abdomen.
ANS: A, C, D
Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the clients mouth and throat beforehand, ensures valid consent is on the chart, and maintains the
client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure.
10. After teaching the wife of a client who has Parkinson disease,
the nurse assesses the wifes understanding. Which statement by the
clients wife indicates she correctly understands changes associated
with this disease?
a. His masklike face makes it difficult to communicate, so I will use a white board.
b. He should not socialize outside of the house due to uncontrollable drooling.
c. This disease is associated with anxiety causing increased perspiration.
d. He may have trouble chewing, so I will offer bite-sized portions.
Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the clients nutritional needs. A masklike face and drooling are common in clients with Parkinson
disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the clients masklike face can be misinterpreted and additional time may be
needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous systems response.
11. A nurse plans care for a client with Parkinson disease. Which
intervention should the nurse include in this clients plan of
a. Ambulate the client in the hallway twice a day.
b. Ensure a fluid intake of at least 3 liters per day.
c. Teach the client pursed-lip breathing techniques.
d. Keep the head of the bed at 30 degrees or greater.
Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of
the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the clients blood. Pursed-lip breathing increases exhalation of carbon dioxide.
21. A nurse delegates care for a client with Parkinson disease to an
unlicensed assistive personnel (UAP). Which statement should the nurse
include when delegating this clients care?
a. Allow the client to be as independent as possible with activities.
b. Assist the client with frequent and meticulous oral care.
c. Assess the clients ability to eat and swallow before each meal.
d. Schedule appointments early in the morning to ensure rest in the afternoon.
Clients with Parkinson disease do not move as quickly and can have functional problems. The client should be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse should assess the clients ability to eat and swallow; this should not be delegated. Appointments and activities should not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.
1. A nurse promotes the prevention of lower back pain by teaching
clients at a community center. Which instruction should the nurse
include in this education?
a. Participate in an exercise program to strengthen muscles.
b. Purchase a mattress that allows you to adjust the firmness.
c. Wear flat instead of high-heeled shoes to work each day.
d. Keep your weight within 20% of your ideal body weight.
Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.
2. A nurse plans care for a client with lower back pain from a
work-related injury. Which intervention should the nurse include in
this clients plan of care?
a. Encourage the client to stretch the back by reaching toward the toes.
b. Massage the affected area with ice twice a day.
c. Apply a heating pad for 20 minutes at least four times daily.
d. Advise the client to avoid warm baths or showers.
Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.
3. A nurse assesses a client who is recovering from a diskectomy 6
hours ago. Which assessment finding should the nurse address
a. Sleepy but arouses to voice
b. Dry and cracked oral mucosa
c. Pain present in lower back
d. Bladder palpated above pubis
A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to provide care but are not the priority or a complication of the procedure.
4. A nurse assesses clients at a community center. Which client is at
greatest risk for lower back pain?
a. A 24-year-old female who is 25 weeks pregnant
b. A 36-year-old male who uses ergonomic techniques
c. A 45-year-old male with osteoarthritis
d. A 53-year-old female who uses a walker
Osteoarthritis causes changes to support structures, increasing the clients risk for low back pain. The other clients are not at high risk.
6. A nurse assesses a client who is recovering from anterior cervical
diskectomy and fusion. Which complication should alert the nurse to
urgently communicate with the health care provider?
a. Auscultated stridor
b. Weak pedal pulses
c. Difficulty swallowing
d. Inability to shrug shoulders
Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an
inability to shrug the shoulders are not complications of this surgery.
7. A nurse assesses a client with a spinal cord injury at level T5.
The clients blood pressure is 184/95 mm Hg, and the client presents
with a flushed face and blurred vision. Which action should the nurse
a. Initiate oxygen via a nasal cannula.
b. Place the client in a supine position.
c. Palpate the bladder for distention.
d. Administer a prescribed beta blocker.
The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic
injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.
8. An emergency room nurse initiates care for a client with a
cervical spinal cord injury who arrives via emergency medical
services. Which action should the nurse take first?
a. Assess level of consciousness.
b. Obtain vital signs.
c. Administer oxygen therapy.
d. Evaluate respiratory status.
The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.
9. An emergency department nurse cares for a client who experienced a
spinal cord injury 1 hour ago. Which prescribed medication should the
nurse prepare to administer?
a. Intrathecal baclofen (Lioresal)
b. Methylprednisolone (Medrol)
c. Atropine sulfate
d. Epinephrine (Adrenalin)
Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this
11. A nurse is caring for a client with paraplegia who is scheduled
to participate in a rehabilitation program. The client states, I do
not understand the need for rehabilitation; the paralysis will not go
away and it will not
get better. How should the nurse respond?
a. If you dont want to participate in the rehabilitation program, Ill let the provider know.
b. Rehabilitation programs have helped many clients with your injury. You should give it a chance.
c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability.
d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.
Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this clients needs.
12. After teaching a client with a spinal cord injury, the nurse
assesses the clients understanding. Which client statement indicates a
correct understanding of how to prevent respiratory problems at
a. Ill use my incentive spirometer every 2 hours while Im awake.
b. Ill drink thinned fluids to prevent choking.
c. Ill take cough medicine to prevent excessive coughing.
d. Ill position myself on my right side so I dont aspirate.
Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowlers position to prevent aspiration.
13. A nurse assesses a client with early-onset multiple sclerosis
(MS). Which clinical manifestation should the nurse expect to
a. Hyperresponsive reflexes
b. Excessive somnolence
d. Heat intolerance
Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.
14. A nurse cares for a client who presents with an acute
exacerbation of multiple sclerosis (MS). Which prescribed medication
should the nurse prepare to administer?
a. Baclofen (Lioresal)
b. Interferon beta-1b (Betaseron)
c. Dantrolene sodium (Dantrium)
d. Methylprednisolone (Medrol)
Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.
15. A nurse assesses a client with multiple sclerosis after
administering prescribed fingolimod (Gilenya). For which adverse
effect should the nurse monitor?
a. Peripheral edema
b. Black tarry stools
d. Nausea and vomiting
Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.
16. A nurse is teaching a client with multiple sclerosis who is
prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol).
Which statement should the nurse include in this clients discharge
a. Take warm baths to promote muscle relaxation.
b. Avoid crowds and people with colds.
c. Relying on a walker will weaken your gait.
d. Take prescribed medications when symptoms occur.
The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the clients symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.
19. A nurse prepares a client for prescribed magnetic resonance
imaging (MRI). Which action should the nurse implement prior to the
a. Implement nothing by mouth (NPO) status for 8 hours.
b. Withhold all daily medications until after the examination.
c. Administer morphine sulfate to prevent claustrophobia during the test.
d. Place the client in a gown that has cloth ties instead of metal snaps.
Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The
client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.
20. A nurse cares for a client with a spinal cord injury. With which
interdisciplinary team member should the nurse consult to assist the
client with activities of daily living?
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager
The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing,
dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.
22. A nurse assesses the health history of a client who is prescribed
ziconotide (Prialt) for chronic back pain. Which assessment question
should the nurse ask?
a. Are you taking a nonsteroidal anti-inflammatory drug?
b. Do you have a mental health disorder?
c. Are you able to swallow medications?
d. Do you smoke cigarettes or any illegal drugs?
Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.
1. A nurse assesses a client who recently experienced a traumatic
spinal cord injury. Which assessment data should the nurse obtain to
assess the clients coping strategies? (Select all that apply.)
a. Spiritual beliefs
b. Level of pain
c. Family support
d. Level of independence
e. Annual income
f. Previous coping strategies
ANS: A, C, D, F
Information about the clients preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the clients level of independence or dependence
and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security
often adapt to their injury. Information about the clients spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.
2. After teaching a client with a spinal cord tumor, the nurse
assesses the clients understanding. Which statements by the client
indicate a correct understanding of the teaching? (Select all that
a. Even though turning hurts, I will remind you to turn me every 2 hours.
b. Radiation therapy can shrink the tumor but also can cause more problems.
c. Surgery will be scheduled to remove the tumor and reverse my symptoms.
d. I put my affairs in order because this type of cancer is almost always fatal.
e. My family is moving my bedroom downstairs for when I am discharged home.
ANS: A, B, E
Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.
3. After teaching a male client with a spinal cord injury at the T4
level, the nurse assesses the clients understanding. Which client
statements indicate a correct understanding of the teaching related to
sexual effects of this injury? (Select all that apply.)
a. I will explore other ways besides intercourse to please my partner.
b. I will not be able to have an erection because of my injury.
c. Ejaculation may not be as predictable as before.
d. I may urinate with ejaculation but this will not cause infection.
e. I should be able to have an erection with stimulation.
ANS: C, D, E
Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the clients partner will not get an infection.
6. A nurse assesses a client with paraplegia from a spinal cord
injury and notes reddened areas over the clients hips and sacrum.
Which actions should the nurse take? (Select all that apply.)
a. Apply a barrier cream to protect the skin from excoriation.
b. Perform range-of-motion (ROM) exercises for the hip joint.
c. Re-position the client off of the reddened areas.
d. Get the client out of bed and into a chair once a day.
e. Obtain a low-air-loss mattress to minimize pressure.
ANS: C, E
Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the
already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the clients risk of
respiratory complications but will not decrease pressure on the clients hips and sacrum.
7. A nurse assesses a client who experienced a spinal cord injury at
the T5 level 12 hours ago. Which manifestations should the nurse
correlate with neurogenic shock? (Select all that apply.)
a. Heart rate of 34 beats/min
b. Blood pressure of 185/65 mm Hg
c. Urine output less than 30 mL/hr
d. Decreased level of consciousness
e. Increased oxygen saturation
ANS: A, C, D
Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.
8. A nurse plans care for a client with a halo fixator. Which
interventions should the nurse include in this clients plan of care?
(Select all that apply.)
a. Tape a halo wrench to the clients vest.
b. Assess the pin sites for signs of infection.
c. Loosen the pins when sleeping.
d. Decrease the clients oral fluid intake.
e. Assess the chest and back for skin breakdown.
ANS: A, B, E
A special halo wrench should be taped to the clients vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the clients chest and back for skin breakdown from the halo vest.
5. A client is taking long-term corticosteroids for myasthenia
gravis. What teaching is most important?
a. Avoid large crowds and people who are ill.
b. Check blood sugars four times a day.
c. Use two forms of contraception.
d. Wear properly fitting socks and shoes.
Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood
glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. Wearing well-fitting shoes would be important to avoid injury, but not just because the client takes corticosteroids.
6. A client with myasthenia gravis has the priority client problem of
inadequate nutrition. What assessment finding indicates that the
priority goal for this client problem has been met?
a. Ability to chew and swallow without aspiration
b. Eating 75% of meals and between-meal snacks
c. Intake greater than output 3 days in a row
d. Weight gain of 3 pounds in 1 month
Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty indicates an intact airway. Since the question does not indicate what the clients meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.
7. A client had a nerve laceration repair to the forearm and is being
discharged in a cast. What statement by the client indicates a poor
understanding of discharge instructions relating to cast care?
a. I can scratch with a coat hanger.
b. I should feel my fingers for warmth.
c. I will keep the cast clean and dry.
d. I will return to have the cast removed.
Nothing should be placed under the cast to use for scratching. The other statements show good indication that the client has understood the discharge instructions.
10. A client has trigeminal neuralgia and has begun skipping meals
and not brushing his teeth, and his family believes he has become
depressed. What action by the nurse is best?
a. Ask the client to explain his feelings related to this disorder.
b. Explain how dental hygiene is related to overall health.
c. Refer the client to a medical social worker for assessment.
d. Tell the client that he will become malnourished in time.
Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.
11. A client is receiving plasmapheresis. What action by the nurse
best prevents infection in this client?
a. Giving antibiotics prior to treatments
b. Monitoring the clients vital signs
c. Performing appropriate hand hygiene
d. Placing the client in protective isolation
Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could
alert the nurse to its possibility. The client does not need isolation.
13. A client with myasthenia gravis (MG) asks the nurse to explain
the disease. What response by the nurse is best?
a. MG is an autoimmune problem in which nerves do not cause muscles to contract.
b. MG is an inherited destruction of peripheral nerve endings and junctions.
c. MG consists of trauma-induced paralysis of specific cranial nerves.
d. MG is a viral infection of the dorsal root of sensory nerve fibers.
MG is an autoimmune disorder in which nerve fibers are damaged and their impulses do not lead to muscle contraction. MG is not an inherited or viral disorder and does not paralyze specific cranial nerves.
1. A client with myasthenia gravis is prescribed pyridostigmine
(Mestinon). What teaching should the nurse plan regarding this
medication? (Select all that apply.)
a. Do not eat a full meal for 45 minutes after taking the drug.
b. Seek immediate care if you develop trouble swallowing.
c. Take this drug on an empty stomach for best absorption.
d. The dose may change frequently depending on symptoms.
e. Your urine may turn a reddish-orange color while on this drug.
ANS: A, B, D
Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the clients manifestations. Taking the drug on an empty stomach is not related although the client needs to eat within 45 to 60 minutes afterwards. The clients urine will not turn reddish-orange while on this drug.
3. A client with myasthenia gravis is malnourished. What actions to
improve nutrition may the nurse delegate to the unlicensed assistive
personnel (UAP)? (Select all that apply.)
a. Assessing the clients gag reflex
b. Cutting foods up into small bites
c. Monitoring prealbumin levels
d. Thickening liquids prior to drinking
e. Weighing the client daily
ANS: B, D
Cutting food up into smaller bites makes it easier for the client to chew and swallow. Thickened liquids help prevent aspiration. The UAP can weigh the client, but this does not help improve nutrition. The nurse assesses
the gag reflex and monitors laboratory values.
1. A nurse assesses a client with a fracture who is being treated
with skeletal traction. Which assessment should alert the nurse to
urgently contact the health provider?
a. Blood pressure increases to 130/86 mm Hg
b. Traction weights are resting on the floor
c. Oozing of clear fluid is noted at the pin site
d. Capillary refill is less than 3 seconds
The immediate action of the nurse should be to reapply the weights to give traction to the fracture. The health care provider must be notified that the weights were lying on the floor, and the client should be realigned in
bed. The clients blood pressure is slightly elevated; this could be related to pain and muscle spasms resulting from lack of pressure to reduce the fracture. Oozing of clear fluid is normal, as is the capillary refill time.
2. A nurse coordinates care for a client with a wet plaster cast.
Which statement should the nurse include when delegating care for this
client to an unlicensed assistive personnel (UAP)?
a. Assess distal pulses for potential compartment syndrome.
b. Turn the client every 3 to 4 hours to promote cast drying.
c. Use a cloth-covered pillow to elevate the clients leg.
d. Handle the cast with your fingertips to prevent indentations.
When delegating care to a UAP for a client with a wet plaster cast, the UAP should be directed to ensure that the extremity is elevated on a cloth pillow instead of a plastic pillow to promote drying. The client should be
assessed for impaired arterial circulation, a complication of compartment syndrome; however, the nurse should not delegate assessments to a UAP. The client should be turned every 1 to 2 hours to allow air to circulate and
dry all parts of the cast. Providers should handle the cast with the palms of the hands to prevent indentations.
3. A nurse obtains the health history of a client with a fractured
femur. Which factor identified in the clients history should the nurse
recognize as an aspect that may impede healing of the
a. Sedentary lifestyle
b. A 30pack-year smoking history
c. Prescribed oral contraceptives
d. Pagets disease
Pagets disease and bone cancer can cause pathologic fractures such as a fractured femur that do not achieve total healing. The other factors do not impede healing but may cause other health risks.
4. An emergency department nurse cares for a client who sustained a
crush injury to the right lower leg. The client reports numbness and
tingling in the affected leg. Which action should the nurse take
a. Assess the pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Loosen the traction.
These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a providers prescription.
5. A nurse assesses an older adult client who was admitted 2 days ago
with a fractured hip. The nurse notes that the client is confused and
restless. The clients vital signs are heart rate 98 beats/min,
respiratory rate 32
breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first?
a. Administer oxygen via nasal cannula.
b. Re-position to a high-Fowlers position.
c. Increase the intravenous flow rate.
d. Assess response to pain medications.
The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer
oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and
orders. Sitting the client in a high-Fowlers position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless.
6. A trauma nurse cares for several clients with fractures. Which
client should the nurse identify as at highest risk for developing
deep vein thrombosis?
a. An 18-year-old male athlete with a fractured clavicle
b. A 36-year old female with type 2 diabetes and fractured ribs
c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis
d. A 74-year-old man who smokes and has a fractured pelvis
Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the client has additional risk factors for thrombus formation. Other risk factors include obesity, smoking, oral contraceptives, previous thrombus events, advanced age, venous stasis, and heart disease. The other clients do not have risk factors for DVT.
7. A nurse delegates care of a client in traction to an unlicensed
assistive personnel (UAP). Which statement should the nurse include
when delegating hygiene care for this client?
a. Remove the traction when re-positioning the client.
b. Inspect the clients skin when performing a bed bath.
c. Provide pin care by using alcohol wipes to clean the
d. Ensure that the weights remain freely hanging at all times.
Traction weights should be freely hanging at all times. They should not be lifted manually or allowed to rest on the floor. The client should remain in traction during hygiene activities. The nurse should assess the clients
skin and provide pin and wound care for a client who is in traction; this should not be delegated to the UAP.
8. A nurse notes crepitation when performing range-of-motion
exercises on a client with a fractured left humerus. Which action
should the nurse take next?
a. Immobilize the left arm.
b. Assess the clients distal pulse.
c. Monitor for signs of infection.
d. Administer prescribed steroids.
A grating sound heard when the affected part is moved is known as crepitation. This sound is created by bone fragments. Because bone fragments may be present, the nurse should immobilize the clients arm and tell the client not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.
9. A nurse reviews prescriptions for an 82-year-old client with a
fractured left hip. Which prescription should alert the nurse to
contact the provider and express concerns for client safety?
a. Meperidine (Demerol) 50 mg IV every 4 hours
b. Patient-controlled analgesia (PCA) with morphine sulfate
c. Percocet 2 tablets orally every 6 hours PRN for pain
d. Ibuprofen elixir every 8 hours for first 2 days
Meperidine (Demerol) should not be used for older adults because it has toxic metabolites that can cause seizures. The nurse should question this prescription. The other prescriptions are appropriate for this clients
10. A nurse is caring for a client who is recovering from an
above-the-knee amputation. The client reports pain in the limb that
was removed. How should the nurse respond?
a. The pain you are feeling does not actually exist.
b. This type of pain is common and will eventually go away.
c. Would you like to learn how to use imagery to minimize your pain?
d. How would you describe the pain that you are feeling?
The nurse should ask the client to rate the pain on a scale of 0 to 10 and describe how the pain feels. Although phantom limb pain is common, the nurse should not minimize the pain that the client is experiencing by stating that it does not exist or will eventually go away. Antiepileptic drugs and antispasmodics are used to treat neurologic pain and muscle spasms after amputation. Although imagery may assist the client, the nurse must
assess the clients pain before determining the best action.
13. A nurse assesses a client with a pelvic fracture. Which
assessment finding should the nurse identify as a complication of this
The pelvis is very vascular and close to major organs. Injury to the pelvis can cause integral damage that may manifest as blood in the urine (hematuria) or stool. The nurse should also assess for signs of hemorrhage and
hypovolemic shock, which include hypotension and tachycardia. Constipation and infection are not complications of a pelvic fracture.
14. A nurse cares for a client placed in skeletal traction. The
client asks, What is the primary purpose of this type of traction? How
should the nurse respond?
a. Skeletal traction will assist in realigning your fractured bone.
b. This treatment will prevent future complications and back pain.
c. Traction decreases muscle spasms that occur with a fracture.
d. This type of traction minimizes damage as a result of fracture treatment.
Skeletal traction pins or screws are surgically inserted into the bone to aid in bone alignment. As a last resort, traction can be used to relieve pain, decrease muscle spasm, and prevent or correct deformity and tissue damage. These are not primary purposes of skeletal traction.
15. A nurse cares for a client in skeletal traction. The nurse notes
that the skin around the clients pin sites is swollen, red, and crusty
with dried drainage. Which action should the nurse take next?
a. Request a prescription to decrease the traction weight.
b. Apply an antibiotic ointment and a clean dressing.
c. Cleanse the area, scrubbing off the crusty areas.
d. Obtain a prescription to culture the drainage.
These clinical manifestations indicate inflammation and possible infection. Infected pin sites can lead to osteomyelitis and should be treated immediately. The nurse should obtain a culture and assess vital signs. The provider should be notified. By decreasing the traction weight, applying a new dressing, or cleansing the area, the infection cannot be significantly treated.
16. A nurse cares for a client recovering from an above-the-knee
amputation of the right leg. The client reports pain in the right
foot. Which prescribed medication should the nurse administer
a. Intravenous morphine
b. Oral acetaminophen
c. Intravenous calcitonin
d. Oral ibuprofen
The client is experiencing phantom limb pain, which usually manifests as intense burning, crushing, or cramping. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Opioid
analgesics such as morphine are not as effective for phantom limb pain as they are for residual limb pain. Oral acetaminophen and ibuprofen are not used in treating phantom limb pain.
17. A nurse plans care for a client who is recovering from a
below-the-knee amputation of the left leg. Which intervention should
the nurse include in this clients plan of care?
a. Place pillows between the clients knees.
b. Encourage range-of-motion exercises.
c. Administer prophylactic antibiotics.
d. Implement strict bedrest in a supine position.
Clients with a below-the-knee amputation should complete range-of-motion exercises to prevent flexion contractions and prepare for a prosthesis. A pillow may be used under the limb as support. Clients recovering from this type of amputation are at low risk for infection and should not be prescribed prophylactic antibiotics. The client should be encouraged to re-position, move, and exercise frequently, and therefore should not be restricted to bedrest.
18. An emergency department nurse triages a client with diabetes
mellitus who has fractured her arm. Which action should the nurse take
a. Remove the medical alert bracelet from the fractured arm.
b. Immobilize the arm by splinting the fractured site.
c. Place the client in a supine position with a warm blanket.
d. Cover any open areas with a sterile dressing.
A clients medical alert bracelet should be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.
20. A nurse cares for a client with a fractured fibula. Which
assessment should alert the nurse to take immediate action?
a. Pain of 4 on a scale of 0 to 10
b. Numbness in the extremity
c. Swollen extremity at the injury site
d. Feeling cold while lying in bed
The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.
21. After teaching a client with a fractured humerus, the nurse
assesses the clients understanding. Which dietary choice demonstrates
that the client correctly understands the nutrition needed to assist
in healing the
a. Baked fish with orange juice and a vitamin D supplement
b. Bacon, lettuce, and tomato sandwich with a vitamin B supplement
c. Vegetable lasagna with a green salad and a vitamin A supplement
d. Roast beef with low-fat milk and a vitamin C supplement
The client with a healing fracture needs supplements of vitamins B and C and a high-protein, high-calorie diet. Milk for calcium supplementation and vitamin C supplementation are appropriate. Meat would increase protein in the diet that is necessary for bone healing. Fish, a sandwich, and vegetable lasagna would provide less protein.
22. A nurse cares for an older adult client with multiple fractures.
Which action should the nurse take to manage this clients
a. Meperidine (Demerol) injections every 4 hours around the clock
b. Patient-controlled analgesia (PCA) pump with morphine
c. Ibuprofen (Motrin) 600 mg orally every 4 hours PRN for pain
d. Morphine 4 mg intravenous push every 2 hours PRN for pain
The older adult client should never be treated with meperidine because toxic metabolites can cause seizures. The client should be managed with a PCA pump to control pain best. Motrin most likely would not provide
complete pain relief with multiple fractures. IV morphine PRN would not control pain as well as a pump that the client can control.
25. A nurse cares for an older adult client who is recovering from a
leg amputation surgery. The client states, I dont want to live with
only one leg. I should have died during the surgery. How should the
a. Your vital signs are good, and you are doing just fine right now.
b. Your children are waiting outside. Do you want them to grow up without a father?
c. This is a big change for you. What support system do you have to help you cope?
d. You will be able to do some of the same things as before you became disabled.
The client feels like less of a person following the amputation. The nurse should help the client to identify coping mechanisms that have worked in the past and current support systems to assist the client with coping.
The nurse should not ignore the clients feelings by focusing on vital signs. The nurse should not try to make the client feel guilty by alluding to family members. The nurse should not refer to the client as being disabled
as this labels the client and may fuel the clients poor body image.
27. A nurse plans care for a client who is prescribed skeletal
traction. Which intervention should the nurse include in this plan of
care to decrease the clients risk for infection?
a. Wash the traction lines and sockets once a day.
b. Release traction tension for 30 minutes twice a day.
c. Do not place the traction weights on the floor.
d. Schedule for pin care to be provided every shift.
To decrease the risk for infection in a client with skeletal traction of external fixation, the nurse should provide routine pin care and assess manifestations of infection at the pin sites every shift. The traction lines and sockets are external and do not come in contact with the clients skin; these do not need to be washed. Although traction weights should not be removed or released for any period of time without a prescription, or placed on the floor, this does not decrease the risk for infection.
1. A nurse teaches a client with a fractured tibia about external
fixation. Which advantages of external fixation for the immobilization
of fractures should the nurse share with the client? (Select all that
a. It leads to minimal blood loss.
b. It allows for early ambulation.
c. It decreases the risk of infection.
d. It increases blood supply to tissues.
e. It promotes healing.
ANS: A, B, E
External fixation is a system in which pins or wires are inserted through the skin and bone and then connected to a ridged external frame. With external fixation, blood loss is less than with internal fixation, but the risk for infection is much higher. The device allows early ambulation and exercise, maintains alignment, stabilizes the fracture site, and promotes healing. The device does not increase blood supply to the tissues. The nurse should assess for distal circulation, movement, and sensation, which can be disturbed by fracture injuries and treatments.
2. An emergency nurse assesses a client who is admitted with a pelvic
fracture. Which assessments should the nurse monitor to prevent a
complication of this injury? (Select all that apply.)
b. Urinary output
c. Blood pressure
d. Pupil reaction
e. Skin color
ANS: B, C, E
With a pelvic fracture, internal organ damage may result in bleeding and hypovolemic shock. The nurse monitors the clients heart rate, blood pressure, urine output, skin color, and level of consciousness frequently to determine whether shock is manifesting. It is important to monitor the urine for blood to assess whether the urinary system has been damaged with the pelvic fracture. Changes in temperature and pupil reactions are not directly associated with hypovolemic shock. Temperature changes are usually associated with hypo- or hyperthermia or infectious processes. Pupillary changes occur with brain injuries, bleeds, or neurovascular accidents.
3. A nurse cares for a client with a fracture injury. Twenty minutes
after an opioid pain medication is administered, the client reports
pain in the site of the fracture. Which actions should the nurse take?
(Select all that apply.)
a. Administer additional opioids as prescribed.
b. Elevate the extremity on pillows.
c. Apply ice to the fracture site.
d. Place a heating pad at the site of the injury.
e. Keep the extremity in a dependent position.
ANS: A, B, C
The client with a new fracture likely has edema; elevating the extremity and applying ice probably will help in decreasing pain. Administration of an additional opioid within the dosage guidelines may be ordered. Heat will
increase edema and may increase pain. Dependent positioning will also increase edema.
4. A nurse plans care for a client who is recovering from open
reduction and internal fixation (ORIF) surgery for a right hip
fracture. Which interventions should the nurse include in this clients
plan of care? (Select all that apply.)
a. Elevate heels off the bed with a pillow.
b. Ambulate the client on the first postoperative day.
c. Push the clients patient-controlled analgesia button.
d. Re-position the client every 2 hours.
e. Use pillows to encourage subluxation of the hip.
ANS: A, B, D
Postoperative care for a client who has ORIF of the hip includes elevating the clients heels off the bed and re-positioning every 2 hours to prevent pressure and skin breakdown. It also includes ambulating the client on the first postoperative day, and using pillows or an abduction pillow to prevent subluxation of the hip. The nurse should teach the client to use the patient-controlled analgesia pump, but the nurse should never push the button for the client.
5. A nurse assesses a client with a cast for potential compartment
syndrome. Which clinical manifestations are correctly paired with the
physiologic changes of compartment syndrome? (Select all that
a. Edema Increased capillary permeability
b. Pallor Increased blood blow to the area
c. Unequal pulses Increased production of lactic acid
d. Cyanosis Anaerobic metabolism
e. Tingling A release of histamine
ANS: A, C, D
Clinical manifestations of compartment syndrome are caused by several physiologic changes. Edema is caused by increased capillary permeability, release of histamine, decreased tissue perfusion, and vasodilation. Unequal
pulses are caused by an increased production of lactic acid. Cyanosis is caused by anaerobic metabolism. Pallor is caused by decreased oxygen to tissues, and tingling is caused by increased tissue pressure.
7. A nurse teaches a client about prosthesis care after amputation.
Which statements should the nurse include in this clients teaching?
(Select all that apply.)
a. The device has been custom made specifically for you.
b. Your prosthetic is good for work but not for exercising.
c. A prosthetist will clean your inserts for you each month.
d. Make sure that you wear the correct liners with your prosthetic.
e. I have scheduled a follow-up appointment for you.
ANS: A, D, E
A client with a new prosthetic should be taught that the prosthetic device is custom made for the client, taking into account the clients level of amputation, lifestyle (including exercise preferences), and occupation. In
collaboration with a prosthetist, the client should be taught proper techniques for cleansing the sockets and inserts, wearing the correct liners, and assessing shoe wear. Follow-up care and appointments are important for
1. A client has a bone density score of 2.8. What action by the nurse
a. Asking the client to complete a food diary
b. Planning to teach about bisphosphonates
c. Scheduling another scan in 2 years
d. Scheduling another scan in 6 months
A T-score from a bone density scan at or lower than 2.5 indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease. One class of such medications is bisphosphonates. A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at this point, dietary changes will not prevent the disease. Simply scheduling another scan will not help treat the disease either.
2. A nurse is assessing an older client and discovers back pain with
tenderness along T2 and T3. What action by the nurse is best?
a. Consult with the provider about an x-ray.
b. Encourage the client to use ibuprofen (Motrin).
c. Have the client perform hip range of motion.
d. Place the client in a rigid cervical collar.
Back pain with tenderness is indicative of a spinal compression fracture, which is the most common type of osteoporotic fracture. The nurse should consult the provider about an x-ray. Motrin may be indicated but not until there is a diagnosis. Range of motion of the hips is not related, although limited spinal range of motion may be found with a vertebral compression fracture. Since the defect is in the thoracic spine, a cervical collar is not needed.
3. A client has been advised to perform weight-bearing exercises to
help minimize osteoporosis. The client admits to not doing the
prescribed exercises. What action by the nurse is best?
a. Ask the client about fear of falling.
b. Instruct the client to increase calcium.
c. Suggest other exercises the client can do.
d. Tell the client to try weight lifting.
Fear of falling can limit participation in activity. The nurse should first assess if the client has this fear and then offer suggestions for dealing with it. The client may or may not need extra calcium, other exercises, or weight lifting.
4. The nurse sees several clients with osteoporosis. For which client would bisphosphonates not be a good option?
a. Client with diabetes who has a serum creatinine of 0.8
b. Client who recently fell and has vertebral compression fractures
c. Hypertensive client who takes calcium channel blockers
d. Client with a spinal cord injury who cannot tolerate sitting up
Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes clients
bad candidates for this drug, but the client with a creatinine of 0.8 mg/dL is within normal range. Diabetes and hypertension are not related unless the client also has renal disease. The client who recently fell and sustained
fractures is a good candidate for this drug if the fractures are related to osteoporosis.
9. A nurse is caring for four clients. After the hand-off report,
which client does the nurse see first?
a. Client with osteoporosis and a white blood cell count of 27,000/mm3
b. Client with osteoporosis and a bone fracture who requests pain medication
c. Post-microvascular bone transfer client whose distal leg is cool and pale
d. Client with suspected bone tumor who just returned from having a spinal CT
This client is the priority because the assessment findings indicate a critical lack of perfusion. A high white blood cell count is an expected finding for the client with osteoporosis. The client requesting pain medication should be seen second. The client who just returned from a CT scan is stable and needs no specific postprocedure care.
15. A nurse sees clients in an osteoporosis clinic. Which client
should the nurse see first?
a. Client taking calcium with vitamin D (Os-Cal) who reports flank pain 2 weeks ago
b. Client taking ibandronate (Boniva) who cannot remember when the last dose was
c. Client taking raloxifene (Evista) who reports unilateral calf swelling
d. Client taking risedronate (Actonel) who reports occasional dyspepsia
The client on raloxifene needs to be seen first because of the manifestations of deep vein thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had a kidney stone but is not acutely ill
now. The client who cannot remember taking the last dose of ibandronate can be seen last. The client on risedronate may need to change medications.
16. What information does the nurse teach a womens group about
a. For 5 years after menopause you lose 2% of bone mass yearly.
b. Men actually have higher rates of the disease but are underdiagnosed.
c. There is no way to prevent or slow osteoporosis after menopause.
d. Women and men have an equal chance of getting osteoporosis.
For the first 5 years after menopause, women lose about 2% of their bone mass each year. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after
17. A client with osteoporosis is going home, where the client lives
alone. What action by the nurse is best?
a. Arrange a home safety evaluation.
b. Ensure the client has a walker at home.
c. Help the client look into assisted living.
d. Refer the client to Meals on Wheels.
This client has several risk factors that place him or her at a high risk for falling. The nurse should consult social work or home health care to conduct a home safety evaluation. The other options may or may not be needed based upon the clients condition at discharge.
1. A nurse is assessing a community group for dietary factors that
contribute to osteoporosis. In addition to inquiring about calcium,
the nurse also assesses for which other dietary components? (Select
all that apply.)
d. Carbonated beverages
e. Vitamin D
ANS: A, B, D, E
Dietary components that affect the development of osteoporosis include alcohol, caffeine, high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing lifestyle factor. Fat intake does not contribute to osteoporosis.
2. A nurse is providing education to a community womens group about
lifestyle changes helpful in preventing osteoporosis. What topics does
the nurse cover? (Select all that apply.)
a. Cut down on tobacco product use.
b. Limit alcohol to two drinks a day.
c. Strengthening exercises are important.
d. Take recommended calcium and vitamin D.
e. Walk 30 minutes at least 3 times a week.
ANS: C, D, E
Lifestyle changes can be made to decrease the occurrence of osteoporosis and include strengthening and weight-bearing exercises and getting the recommended amounts of both calcium and vitamin D. Tobacco
should be totally avoided. Women should not have more than one drink per day.
4. A client with chronic osteomyelitis is being discharged from the
hospital. What information is important for the nurse to teach this
client and family? (Select all that apply.)
a. Adherence to the antibiotic regimen
b. Correct intramuscular injection technique
c. Eating high-protein and high-carbohydrate foods
d. Keeping daily follow-up appointments
e. Proper use of the intravenous equipment
ANS: A, C, E
The client going home with chronic osteomyelitis will need long-term antibiotic therapyfirst intravenous, then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the
regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.
7. The nurse studying osteoporosis learns that which drugs can cause
this disorder? (Select all that apply.)
a. Antianxiety agents
e. Loop diuretics
ANS: C, D, E
Several classes of drugs can cause secondary osteoporosis, including barbiturates, corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with the formation of osteoporosis.