Bones
A nurse is caring for four patients. After the hand-off report, which patient does the nurse see first?
a. Patient with osteoporosis and a white blood cell count of 27,000/mm3 (27 109/L)
b. Patient with osteoporosis and a bone fracture who requests pain medication
c. Post-microvascular bone transfer patient whose distal leg is cool and pale
d. Patient with suspected bone tumor who just returned from having a spinal CT
ANS: C
This patient 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 patient with osteoporosis. The patient requesting pain medication should be seen second. The patient who just returned from a CT scan is stable and needs no specific postprocedure care.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Musculoskeletal disorders | nursing assessment | perfusion
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
What information does the nurse teach a women’s group about osteoporosis?
a. “Primary osteoporosis occurs in postmenopausal women due to lack of estrogen.”
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.”
ANS: A
Women are more at risk of developing primary osteoporosis after menopause due to the lack of estrogen. Men have a slower loss of bone after the age of 75. Many treatments are now available for women to slow osteoporosis after menopause.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Musculoskeletal disorders | osteoporosis | older adult | gender differences
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance
A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this patient’s teaching to prevent bloodborne infections?
a. “Wash your hands after completing each test.”
b. “Do not share your monitoring equipment.”
c. “Blot excess blood from the strip with a cotton ball.”
d. “Use gloves when monitoring your blood glucose.”
ANS: B
Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The patient would be taught to avoid sharing any equipment, including the lancet holder. The patient would be taught to wash his or her hands before testing. The patient would not need to blot excess blood away from the strip or wear gloves.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Diabetes mellitus | insulin | medication safety
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse assesses a patient after administering a prescribed beta-blocker. Which assessment would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg
b. Respiratory rate decreased from 25 to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 to 80 beats/min
ANS: D
Beta-blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta-blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.
PTS: 1 DIF: Cognitive Level: Applying KEY: Beta blocker | medication
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse reviews the laboratory results of a patient who is receiving intravenous insulin. Which would alert the nurse to intervene immediately?
a. Serum chloride level of 98 mEq/L (98 mmol/L)
b. Serum calcium level of 8.8 mg/dL (2.2 mmol/L)
c. Serum sodium level of 132 mEq (132 mmol/L)
d. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)
ANS: D
Insulin activates the sodium–potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Diabetes mellitus | insulin | medication safety
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
An emergency department nurse cares for a patient who sustained a crush injury to the right lower leg. The patient reports numbness and tingling in the affected leg. Which action would the nurse take first?
a. Assess the pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Loosen the traction.
ANS: A
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 would be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, would never be loosened without a provider’s prescription.
PTS: 1 DIF: Cognitive Level: Applying KEY: Fracture | compartment syndrome
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A trauma nurse cares for several patients with fractures. Which patient would 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
ANS: D
Deep vein thrombosis (DVT) as a complication with bone fractures occurs more often when fractures are sustained in the lower extremities and the patient 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 patients do not have risk factors for DVT.
PTS: 1 DIF: Cognitive Level: Applying KEY: Fracture | health screening
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
After teaching a patient with diabetes mellitus to inject insulin, the nurse assesses the patient’s understanding. Which statement made by the patient indicates a need for additional teaching?
a. “The lower abdomen is the best location because it is closest to the pancreas.”
b. “I can reach my thigh the best, so I will use the different areas of my thighs.”
c. “By rotating the sites in one area, my chance of having a reaction is decreased.”
d. “Changing injection sites from the thigh to the arm will change absorption rates.”
ANS: A
The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.
PTS: 1 DIF: Cognitive Level: Evaluating
KEY: Diabetes mellitus | insulin | medication safety
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse is caring for a patient with a nonhealing arterial lower leg ulcer. What action by the nurse is best?
a. Consult with the wound care nurse.
b. Give pain medication prior to dressing changes.
c. Maintain sterile technique for dressing changes.
d. Prepare the patient for eventual amputation.
ANS: A
A nonhealing wound needs the expertise of the wound care nurse. Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The patient may need an amputation, but other options need to be tried first.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Peripheral vascular disease | consultation | wound care
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse cares for a patient who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 07:00. At which time would the nurse assess the patient for potential problems related to the NPH insulin?
a. 08:00
b. 16:00
c. 20:00
d. 23:00
ANS: B
Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the patient at 08:00 would be too soon. Checking the patient at 20:00 and 23:00 would be too late. The nurse would check the patient at 16:00.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Diabetes mellitus | insulin | medication safety
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse assesses an older adult patient who was admitted 2 days ago with a fractured hip. The nurse notes that the patient is confused and restless. The patient’s vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action would the nurse take first?
a. Administer oxygen via nasal cannula.
b. Re-position to a high-Fowler’s position.
c. Increase the intravenous flow rate.
d. Assess response to pain medications.
ANS: A
The patient 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 would 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 patient who is confused without further assessment and orders. Sitting the patient in a high-Fowler’s position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the patient to be restless.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Fracture | pulmonary embolism | respiratory distress/failure | older adult
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse notes crepitation when performing range-of-motion exercises on a patient with a fractured left humerus. Which action would the nurse take next?
a. Immobilize the left arm.
b. Assess the patient’s distal pulse.
c. Monitor for signs of infection.
d. Administer prescribed steroids.
ANS: A
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 would immobilize the patient’s arm and tell the patient not to move the arm. The grating sound does not indicate circulation impairment or infection. Steroids would not be indicated.
PTS: 1 DIF: Cognitive Level: Applying KEY: Fracture | range of motion
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse assesses a patient who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this patient?
a. pH 7.38, HCO 22 mEq/L (22 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg
b. pH 7.28, HCO 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg
c. pH 7.48, HCO 28 mEq/L (28 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg
d. pH 7.32, HCO 22 mEq/L (22 mmol/L), PCO2 58 mm Hg, PO2 88 mm Hg
ANS: B
When the lungs can no longer offset acidosis, the pH decreases to below normal. A patient who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.
PTS: 1 DIF: Cognitive Level: Analyzing KEY: Diabetes mellitus | hyperglycemia
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse is assessing an obese patient in the clinic for follow-up after an episode of deep-vein thrombosis. The patient has lost 20 lbs since the last visit. What action by the nurse is best?
a. Ask if the weight loss was intended.
b. Encourage a high-protein, high-fiber diet.
c. Measure for new compression stockings.
d. Review a 3-day food recall diary.
ANS: C
Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the patient would be remeasured and new stockings ordered if needed. The other options are appropriate, but not the most important.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Thromboembolic event | deep vein thrombosis | nursing assessment
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse teaches a patient with diabetes mellitus about sick-day management. Which statement would the nurse include in this patient’s teaching?
a. “When ill, avoid eating or drinking to reduce vomiting and diarrhea.”
b. “Monitor your blood glucose levels at least every 4 hours while sick.”
c. “If vomiting, do not use insulin or take your oral antidiabetic agent.”
d. “Try to continue your prescribed exercise regimen even if you are sick.”
ANS: B
When ill, the patient should monitor his or her blood glucose at least every 4 hours. The patient should continue taking the medication regimen while ill. The patient should continue to eat and drink as tolerated but should not exercise while sick.
PTS: 1 DIF: Cognitive Level: Understanding KEY: Diabetes mellitus | hyperglycemia
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
An emergency department nurse triages a patient with diabetes mellitus who has fractured her arm. Which action would the nurse take first?
a. Remove the medical alert bracelet from the fractured arm.
b. Immobilize the arm by splinting the fractured site.
c. Place the patient in a supine position with a warm blanket.
d. Cover any open areas with a sterile dressing.
ANS: A
A patient’s medical alert bracelet would be removed from the fractured arm before the affected extremity swells. Immobilization, positioning, and dressing should occur after the bracelet is removed.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Fracture | diabetes mellitus | patient safety
MSC: Integrated Process: Nursing Process/Planning
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
The nurse sees several patients with osteoporosis. For which patient would bisphosphonates not be a good option?
a. Patient with diabetes who has a serum creatinine of 0.8 mg/dL (61 mcmol/L)
b. Patient who recently fell and has vertebral compression fractures
c. Hypertensive patient who takes calcium channel blockers
d. Patient with a spinal cord injury who cannot tolerate sitting up
ANS: D
Patients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them. The patient who cannot tolerate sitting up is not a good candidate for this class of drug. Poor renal function also makes patients bad candidates for this drug, but the patient with a creatinine of 0.8 mg/dL (61 mcmol/L) is within normal range. Diabetes and hypertension are not related unless the patient also has renal disease. The patient who recently fell and sustained fractures is a good candidate for this drug if the fractures are related to osteoporosis.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Musculoskeletal disorders | osteoporosis | bisphosphonates | adverse effects
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
A nurse teaches a patient with type 1 diabetes mellitus. Which statement would the nurse include in this patient’s teaching to decrease the patient’s insulin needs?
a. “Limit your fluid intake to 2 L a day.”
b. “Animal organ meat is high in insulin.”
c. “Limit your carbohydrate intake to 80 g a day.”
d. “Walk at a moderate pace for 1 mile daily.”
ANS: D
Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for patients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 g of carbohydrates each day.
PTS: 1 DIF: Cognitive Level: Applying KEY: Diabetes mellitus | exercise
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance
An older patient with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the patient may indicate a barrier to proper foot care?
a. “I nearly always wear comfy sweatpants and house shoes.”
b. “I’m glad I get energy assistance so my house isn’t so cold.”
c. “My daughter makes sure I have plenty of lotion for my feet.”
d. “My hands shake when I try to do things requiring coordination.”
ANS: D
Patients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The patient whose hands shake may cause injury when trimming toenails. The nurse would refer this patient to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for patients with PVD. Keeping the house at a comfortable temperature makes it less likely the patient will use alternative heat sources, such as heating pads, to stay warm. The patient should keep the feet moist and soft with lotion.
PTS: 1 DIF: Cognitive Level: Analyzing
KEY: Peripheral vascular disease | self-care | home safety
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Health Promotion and Maintenance
A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
a. “Do you have trouble affording your medications?”
b. “Most people with hypertension do not have symptoms.”
c. “You are lucky; most people get severe morning headaches.”
d. “You need to take your medicine or you will get kidney failure.”
ANS: B
Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse would explain this to the patient. Asking about paying for medications is not related because the patient has already admitted nonadherence. Threatening the patient with possible complications will not increase compliance.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: Hypertension | antihypertensive medications | medication adherence
MSC: Integrated Process: Communication and Documentation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A patient is in the internal medicine clinic reporting bone pain in the lower leg. The patient’s alkaline phosphatase level is elevated. What action by the nurse is most appropriate?
a. Assess the patient for leg swelling.
b. Facilitate an oncology workup.
c. Instruct the patient on fluid restrictions.
d. Teach the patient about ibuprofen (Motrin).
ANS: A
This patient has manifestations of a bone tumor. The nurse should assess for other manifestations such as swelling at the site of pain. Other care measures can be instituted once the patient has a confirmed diagnosis.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Musculoskeletal disorders | musculoskeletal assessment | nursing assessment | laboratory values
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk PotentiaL
A patient in a nursing home refuses to take medications. The patient is at high risk for osteomalacia. What action by the nurse is best?
a. Ensure that the patient gets at least 5 minutes of sun exposure daily.
b. Give the patient daily vitamin D injections.
c. Hide vitamin D supplements in favorite foods.
d. Plan to serve foods naturally high in vitamin D
ANS: A
Sunlight is a good source of vitamin D, and the nursing staff can ensure some sun exposure each day. A minimum of 5 minutes is needed. Vitamin D is not given by injection. Hiding the supplement in food is unethical. Very few foods are naturally high in vitamin D, but some are supplemented.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Musculoskeletal disorders | ethics | nursing interventions
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse assesses a patient with diabetes mellitus 3 hours after a surgical procedure and notes that the patient’s breath has a “fruity” odor. What action would the nurse take?
a. Encourage the patient to use an incentive spirometer.
b. Increase the patient’s intravenous fluid flow rate.
c. Consult the provider to test for ketoacidosis.
d. Perform meticulous pulmonary hygiene care.
ANS: C
The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the patient to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a “fruity” odor to the breath. Documentation would occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this patient’s problem.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Diabetes mellitus | hyperglycemia | postoperative nursing
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse cares for an older adult patient with heart failure. The patient states, “I don’t know what to do. I don’t want to be a burden to my daughter, but I can’t do it alone. Maybe I should die.” What is the best response by the nurse?
a. “Would you like to talk more about this?”
b. “You are lucky to have such a devoted daughter.”
c. “It is normal to feel as though you are a burden.”
d. “Would you like to meet with the chaplain?”
ANS: A
Depression can occur in patients with heart failure, especially older adults. Having the patient talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the patient to respond safely and honestly. The other options minimize the patient’s concerns and do not allow the nurse to obtain more information to provide patient-centered care.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Heart failure | support | psychosocial response MSC: Integrated Process: Caring
NOT: Patient Needs Category: Psychosocial Integrity
A nurse cares for a patient who has a family history of diabetes mellitus. The patient states, “My father has type 1 diabetes mellitus. Will I develop this disease as well?” How would the nurse respond?
a. “Your risk of diabetes is higher than the general population, but it may not occur.”
b. “No genetic risk is associated with the development of type 1 diabetes mellitus.”
c. “The risk for becoming a diabetic is 50% because of how it is inherited.”
d. “Female children do not inherit diabetes mellitus, but male children will.”
ANS: A
Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Patients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.
PTS: 1 DIF: Cognitive Level: Understanding KEY: Diabetes mellitus | genetics
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care