The leg bone's connected to the...
A nurse is collecting data on a patient with a left tibia fracture. Which of the following findings is a priority finding?
a. Increased RBC count
b. Decreased body temperature
c. Absent left pedal pulse
d. Patient is tachypnic, dyspnic and has a feeling of impending doom.
d. Patient is tachypnic, dyspnic and has a feeling of impending doom.
A nurse is caring for a child who sustained a fracture. Which of the following actions should the nurse take? (select all that apply).
a. Place a heat pack on the site of injury.
b. Elevate the affected limb.
c. Check neurovascular status frequently.
d. Encourage ROM of the affected limb.
e. Stabilize the injury.
b. Elevate the affected limb.
c. Check neurovascular status frequently.
e. Stabilize the injury.
A nurse is reinforcing discharge teaching with the parents of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include?
a. Provide extra time for completion of ADLs
b. Use cold compresses for joint pan
c. Take ibuprofen on an empty stomach
d. Remain home during periods f exacerbation
e. Perform ROM exercises
a. Provide extra time for completion of ADLs
e. Perform ROM exercises
A nurse is reinforcing teaching with a group of caregivers about fractures. Which of the following information should the nurse include?
a. "Children need a longer time to heal from a fracture than an adult."
b. "Epiphyseal plate injuries ca result in altered bone growth."
c. "A greenstick fracture is a complete break in the bone."
d. "Bones are unable to bend, so they break."
b. "Epiphyseal plate injuries ca result in altered bone growth."
A nurse is reinforcing teaching with a client who has gout and a new prescription for allopurinol. For which of the following adverse effects should the client be taught to monitor? (select all that apply).
a. Stomatitis
b. Insomnia
c. Nausea
d. Rash
e. Increased gout pain
c. Nausea
d. Rash
e. Increased gout pain
The nurse is caring for a patient who has undergone a right knee arthroscopy. Two hours after the procedure, the patient's right pedal pulse is diminished compared with the previous assessment. What action should the nurse take?
a. Take vital signs
b. Notify the surgeon
c. Perform neurovascular assessment in 30 min.
d. Change the dressing and rewrap the elastic wrap.
b. Notify the surgeon
A nurse is caring for a child who has an arm cast. Which of the following is an early sign of altered neurovascular function?
a. Increased capillary refill
b. Pain
c. Instability to detect a pulse distal to the cast
d. Instability to move distal extremity
b. Pain
A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure?
a. Age 78 years
b. History of cancer
c. Previous joint replacement
d. Bronchitis 2 weeks ago
d. Bronchitis 2 weeks ago
A nurse is educating a patient with gout to avoid foods high in purines. Which of the following foods would you instruct your patient to avoid to prevent gout?
a. Cherry juice
b. Salmon
c. Pinto beans
d. tomatoes
b. Salmon
A patient with RA is being treated with hydroxychloroquine. The patient complains to the nurse, "I am having visual disturbances." The nurse knows that what serious complication can occur with use of this medication?
Retinal Damage (Blindness)
Have baseline eye exam and follow-up eye exams every 6 months with an ophthalmologist.
The nurse is caring for a patient immediately after a BTK amputation. Which data collection should the nurse consider a priority?
a. Sacral Edema
b. Emotions
c. Stump dressings
d. Blood sugar level
c. Stump dressings
A nurse is contributing to the plan of care for a client who is postoperative following an arthroscopy of the knee. Which of the following should the nurse recommend for inclusion in the plan? (select all that apply).
a. Check color and temperature of the extremity.
b. Apply warm compresses to incision sites.
c. Place pillows under the extremity.
d. Administer analgesic medication.
e. Monitor pulse and sensation in the foot.
a. Check color and temperature of the extremity.
c. Place pillows under the extremity.
d. Administer analgesic medication.
e. Monitor pulse and sensation in the foot.
A nurse is collecting data from a client who is scheduled to undergo a right knee arthroscopy. The nurse should expect which of the following findings? (select all that apply).
a. Skin reddened over the joint.
b. Pain when bearing weight.
c. Joint crepitus
d. Swelling of the affected joint.
e. Limited joint motion.
b. Pain when bearing weight.
c. Joint crepitus
d. Swelling of the affected joint.
e. Limited joint motion.
The nurse is caring for a patient with osteoporosis and COPD. The nurse understands that osteoporosis can be associated with COPD because...
1. Limited activity related to dyspnea
2. prolonged corticosteriod therapy
A nurse is educating a patient on medication for gout. The patient is prescribed colchicine. What patient education should the nurse give this patient to reduce GI upset?
Take medication with food; take antidiarrheal agent as prescribed; If severe GI distress occurs, stop colchicine and notify provider.
GI toxicity
Thrombocytopenia/suppressed bone marrow
Rhabdomyolysis
The nurse is caring for a patient with an open fracture. Which of the following actions are essential for the nurse to perform to help prevent osteomyelitis? (select all that apply).
1. Perform hand hygiene before dressing change.
2. Wear a protective gown.
3. Use aseptic technique.
4. Wear goggles.
5. Wear sterile gloves to apply new dressing.
6. Wear mask.
1. Perform hand hygiene before dressing change.
3. Use aseptic technique.
5. Wear sterile gloves to apply new dressing.
A nurse is caring for a child who is in skeletal traction. Which of the following actions should the nurse take? (select all that apply).
a. Remove the weights to reposition the client
b. Check the child's position frequently
c. Monitor pin sites frequently
d. Ensure the weights are hanging freely
e. Ensure the rope's knot is in contact with the pulley.
b. Check the child's position frequently
c. Monitor pin sites frequently
d. Ensure the weights are hanging freely
A nurse is reinforcing preoperative teaching for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse review with the client? (select all that apply).
a. Encourage complete autologous blood donation
b. Sit in a low reclining chair.
c. Instruct the client to roll onto the operative hip.
d. Use an abductor pillow when turning the client.
e. Instruct the client on the use of incentive spirometry.
a. Encourage complete autologous blood donation
d. Use an abductor pillow when turning the client.
e. Instruct the client on the use of incentive spirometry.
Mr. Smith has a cast on his right leg due to fractured tibia. He had 10 mg Morphine IV one hour ago, and is now complaining of pain 8/10. The nurse is concerned that it may be compartment syndrome. The nurse knows in severe acute compartment syndrome, the patient may have the six P's if treatment does not prevent late symptoms. What are the six P's?
1. Pain (severe, unrelenting and increased with passive stretching).
2. Paresthesia (painful tingling or burning)
3. Pallor (but there may be warmth/redness over the area).
4. Paralysis (late symptom)
5. Pulselessness (late and ominous sign)
6. Poikilothermia (temperature matches environment).
A patient has been prescribed glucocorticoid (Prednisone) for treatment of RA. The nurse informs the patient that she is at risk for ___________ with long-term use.
Osteoporosis
A nurse is caring for a patient being transferred into bed who has just had a plaster long-leg cast applied. The patient reports pain of 6 on a scale of 0 to 10. Place the nursing interventions in order of priority.
1. Expose cast to air dry.
2. Administer ordered analgesic.
3. Check circulation, sensory, and mobility status.
4. Palm cast as positioned upon pillow.
5. Obtain vital signs.
4, 1, 3, 5, 2.
A patient is scheduled for an MRI of the pelvis. Which of the following actions would the nurse take if during data collection it was revealed that the patient had had a previous surgery for heart problems?
a. Ask if there is any metal in the patient's body.
b. Obtain an order for a chest x-ray.
c. Cancel the MRI
d. Inform the physician.
a. Ask if there is any metal in the patient's body.
A patient is scheduled for a right total hip replacement. The nurse should teach which of the following post-operative leg positions?
a. Maintain legs in adduction
b. Maintain legs in abduction
c. Maintain internal leg rotation
d. Maintain more than 90 degree hip flexion.
b. Maintain legs in abduction
The nurse is caring for a patient with an external fixation device. Which of the following actions should the nurse implement? (Select all that apply)
a. Avoid touching the pins.
b. Follow agency protocol for pin care.
c. Cleanse pins with hydrogen peroxide four times daily.
d. Loosen screws holding the pins during cleaning.
e. Monitor pin sites at least daily.
f. Use strict aseptic technique for pin care.
b. Follow agency protocol for pin care.
e. Monitor pin sites at least daily.
f. Use strict aseptic technique for pin care.
What food/drink would you advise a client not to partake of if they were taking colchicine?
a. Cranberry/cranberry juice
b. Apples/apple juice
c. Cheese/milk
d. Grapefruit/grapefruit juice
d. Grapefruit/grapefruit juice
Grapefruit/juice can increase adverse effects.