In the immediate period after a total knee replacement, it would be a priority for the nurse to assess the client's:
B - Pedal pulses
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are know as:
D - ligaments
Which serum potassium result best supports the rationale for administering a stat dose of IV potassium chloride 20 mEq in 200 mL of normal saline over 2 hours?
A - 3.1 mEq/L
The medical record indicates that a person has an injury to Broca's area. When meeting this person, you expect:
A - difficulty speaking
The control of body temperature is located in:
D - the hypothalamus
Which nursing diagnosis would it be most important to identify when preparing to discharge a client who has undergone a total hip replacement?
A - Risk for injury.
Heberden and Bouchard nodes are hard and nontender and are associated with:
A - osteoarthritis
A patient is admitted with anorexia nervosa and a serum potassium level of 2.4 mEq/L. What complication is most important for the nurse to observe for in this patient?
B - Cardiac dysrhythmias
The nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which client task should the nurse delegate to the UAP?
C - A client with mild dementia who needs assistance with her food tray
The nurse teaches a group of fire fighters about the spread of tuberculosis (TB). Which statement by a fire fighter indicates the teaching has been effective?
C - "I could get TB if I inhale infected droplets when an infected individual coughs."
A client who has fractured the left foot will be using crutches until a walking cast is applied. When teaching the client the correct technique for the three-point gait, the instructions would include:
D - Moving both crutches and the injured leg forward, then moving the other leg.
To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform
D - isometric contractions.
A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. The nurse will monitor for
C - elevated serum potassium.
An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first?
A - the client complaining of chest pain and nausea who is diaphoretic
A common clinical manifestation in a patient with chronic obstructive pulmonary disease (COPD) is:
B - pursed-lip breathing.
The nurse applies downward pressure towards the foot with one hand, while pushing the patella backwards against the femur with one finger of the opposite hand. The test was positive for increased fluid in the suprapatellar pouch over the patella at the knee joint. Which of the following best describes this test?
D - Ballotement
Crepitation is an audible sound that is produced by:
A - roughened articular surfaces moving over each other.
The nurse is caring for a client receiving TPN. During the assessment, the nurse notes absence of breath sounds on the right side, where the central catheter is placed. Which of the following does the nurse suspect is responsible for this abnormal assessment finding?
C - pneumothorax
The nurse is caring for a 63-yr-old with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. Which information about the patient is important to discuss with the health care provider before the test?
A - History of renal insufficiency
Which of the following is an appropriate position to have the patient assume when auscultating for extra heart sounds or murmurs?
A - left-side lying
While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of (select all that apply).
A - flexion and extension.
A patient with tendonitis asks what the tendon does. The nurse's response is based on the knowledge that tendons
A - connect bone to muscle.
The nurse knows that gentamycin, an aminoglycoside, may cause eighth cranial nerve damage. Which assessment finding would alert the nurse to this adverse effect?
C - Tinnitus
The nurse is caring for a client with documented severe allergies to latex. Which item on the client's meal tray should the nurse remove?
A - a banana
The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr-old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene?
B - Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second.