Code Brown!
A patient arrives in the emergency department with a swollen ankle after a soccer injury. Which action by the nurse is appropriate?
A. Elevate the ankle above heart level.
B. Apply a warm moist pack to the ankle.
C. Ask the patient to try bearing weight on the ankle.
D. Assess the ankle’s passive range of motion (ROM).
A.
Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase swelling and risk further injury. Cold packs should be applied the first 24 hours to reduce swelling. The nurse should not ask the patient to move or bear weight on the swollen ankle because immobilization of the inflamed or injured area promotes healing by decreasing metabolic needs of the tissues.
Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?
A. Use a sunscreen with an SPF of at least 10 for adequate protection.
B. Water-resistant sunscreens provide good protection when swimming.
C. ry to stay out of the direct sun between the hours of 10 AM and 2 PM.
D. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
C.
The risk for skin damage from the sun is highest with exposure between 10 AM and 2 PM. No sunscreen is completely water resistant. Sunscreens classified as water resistant still need to be reapplied after swimming. Sunscreen with an SPF of at least 15 is recommended for people at normal risk for skin cancer. Although gradually increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not decreased.
Which abnormality on the skin of an older patient is the priority for the nurse to discuss with the health care provider?
A. Dry, scaly patches on the face
B. Numerous varicosities on both legs
C. Petechiae on the chest and abdomen
D. Small dilated blood vessels on the face
C.
Petechiae are caused by pinpoint hemorrhages and are associated with a variety of serious disorders such as meningitis and coagulopathies. The nurse should contact the patient’s health care provider about this finding for further diagnostic follow-up. The other skin changes are associated with aging. Although the other changes will also require ongoing monitoring or intervention by the nurse, they do not indicate a need for urgent action.
A patient is admitted to the emergency department with a left femur fracture. Which assessment finding by the nurse is most important to report to the health care provider?
A. Bruising of the left thigh
B. Reports of severe thigh pain
C. Slow capillary refill of the left foot
D. Outward pointing toes on the left foot
C.
Prolonged capillary refill may indicate complications such as compartment syndrome. The other findings are typical with a left femur fracture.
A patient with gout has a new prescription for losartan (Cozaar). What should the nurse plan to monitor?
A. Blood glucose
B. Blood pressure
C. Erythrocyte count
D. Lymphocyte count
B.
Losartan may be effective for treating older patients with gout and hypertension. Losartan promotes urate excretion and may normalize serum urate. Losartan, an angiotensin II receptor antagonist, should lower blood pressure. It does not affect blood glucose, red blood cells, or lymphocytes.
Which patient should the nurse assess first?
A. A patient with burns who reports a level 8 (0 to 10 scale) pain.
B. A patient with smoke inhalation who has wheezes and altered mental status.
C. A patient with full-thickness leg burns who is scheduled for a dressing change.
D. A patient with partial thickness burns who is receiving IV fluids at 500 mL/hr.
B.
This patient has evidence of lower airway injury and hypoxemia and should be assessed at once to determine the need for O2 or intubation (or both). The other patients should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?
A. Blood glucose 136mg/dL
B. Separation of proximal wound edges
C. Oral temperature of 101° F (38.3° C)
D. Patient reports increased incisional pain
B.
Wound separation 3 days postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider. The other findings will also be reported but do not require intervention by the HCP as rapidly.
A patient with muscular dystrophy is hospitalized with pneumonia. Which nursing action should the nurse include in the plan of care?
A. Logroll the patient every 2 hours
B. Assist the patient with ambulation.
C. Discuss the need for genetic testing with the patient.
D. Teach the patient about the muscle biopsy procedure.
B.
Because the goal for the patient with muscular dystrophy is to keep the patient active for as long as possible, assisting the patient to ambulate will be part of the care plan. The patient will not require logrolling. Muscle biopsies are necessary to confirm the diagnosis but are not necessary for a patient who already has a diagnosis. There is no need for genetic testing because the patient already knows the diagnosis.
Which information in a 67-yr-old woman’s health history should alert the nurse to the need for a focused assessment of the musculoskeletal system?
A. The patient sprained her ankle at age 13.
B. The patient’s father died of tuberculosis.
C. The patient’s mother became shorter with aging.
D. The patient takes ibuprofen for occasional headaches.
C.
A family history of height loss with aging may indicate osteoporosis, and the nurse should perform a more thorough assessment of the patient’s current height and other risk factors for osteoporosis. A sprained ankle during adolescence does not place the patient at increased current risk for musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.
A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy?
A. Shave biopsy
B. Punch biopsy
C. Incisional biopsy
D. Excisional biopsy
C.
An incisional biopsy would remove the entire mole and the tissue borders. The appearance of the mole indicates that it may be cancerous. A shave biopsy would not remove the entire mole. The mole is too large to be removed with punch biopsy. Excisional biopsies are done for smaller lesions and where a good cosmetic effect is desired, such as on the face
A patient with severe kyphosis is scheduled for dual-energy x-ray absorptiometry (DXA) testing. Which action should the nurse plan to take?
A. Explain the procedure to the patient.
B. Start an IV line for contrast injection.
C. Give an oral sedative 60 to 90 minutes before the procedure.
D. Screen the patient for allergies to shellfish or iodine products.
A.
DXA testing is painless and noninvasive. No IV access is necessary. Contrast medium is not used. Shellfish or iodine allergies are not a concern with DXA testing. Because the procedure is painless, antianxiety medications are not typically required.
Which finding for a 77-yr-old patient seen in the outpatient clinic is the highest priority for further nursing assessment and intervention?
A. Symmetric joint swelling of fingers
B. Decreased right knee range of motion
C. Report of left hip aching when jogging
D. History of recent loss of balance and fall
D.
A history of falls is a safety issue that requires further assessment and development of fall prevention strategies. The other changes may require additional attention but are less urgent.
Which laboratory result should the nurse monitor to determine if prednisone has been effective for a patient who has an acute exacerbation of rheumatoid arthritis?
A. Blood glucose
B. C-reactive protein
C. Serum electrolytes
D. Liver function tests
B.
C-reactive protein is a serum marker for inflammation, and a decrease would indicate the corticosteroid therapy was effective. Blood glucose and serum electrolytes will also be monitored to assess for side effects of prednisone. Liver function is not routinely monitored in patients receiving corticosteroids.
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative-pressure wound therapy?
A. Low serum albumin level
B. Serosanguineous drainage
C. Deep red and moist wound bed
D. Cobblestone wound appearance
A.
Serum protein levels may decrease with negative pressure therapy, which will adversely affect wound healing. The other findings are expected with wound healing.
Which action should the nurse take to evaluate the effectiveness of Buck’s traction for a patient who has an intracapsular fracture of the right femur?
A. Assess for pain
B. Check for contractures
C. Palpate peripheral pulses
D. Monitor for hip dislocation
A.
Buck’s traction is used to reduce painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck’s traction
Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain?
A. Provide information about therapeutic neck exercises.
B. Ask about numbness or tingling of the hands and arms.
C. Suggest the patient alternate the use of heat and cold to the neck.
D. Teach about the use of nonsteroidal antiinflammatory drugs (NSAIDs).
B.
The nurse’s initial action should be further assessment of related symptoms because cervical nerve root compression will require different treatment than musculoskeletal neck pain. The other actions may also be appropriate, depending on the assessment findings.
What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures?
A. Tack down scatter rugs on the floor in the home.
B. Expect most falls to happen outside the home in the yard.
C. Buy shoes that provide good support and are comfortable to wear.
D. Get instruction in range-of-motion exercises from a physical therapist.
C.
Comfortable shoes with good support will help decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Activities of daily living provide range-of-motion exercise; these do not need to be taught by a physical therapist. Falls inside the home are responsible for many injuries.
The home health nurse notices irregular patterns of bruising at different stages of healing on an older patient’s body. Which action should the nurse take first?
A. Ensure the patient wears shoes with nonslip soles.
B. Discourage using throw rugs throughout the house.
C. Talk with the patient alone and ask about the bruising.
C.
The nurse should note irregular patterns of bruising, especially in the shapes of hands or fingers, in different stages of resolution. These may be indications of other health problems or abuse and should be further investigated. It is important that the nurse interview the patient alone because, if mistreatment is occurring, the patient may not disclose it in the presence of the person who may be the abuser. Throw rugs and shoes with slippery surfaces may contribute to falls. Radiographs may be needed if the patient has fallen recently and reports pain or decreased mobility. However, the nurse’s first nursing action is to further assess the patient’s safety.
Which instructions should the nurse include in the teaching plan for a patient with impetigo?
A. Clean the crusted areas with soap and water.
B. Spread alcohol-based cleansers on the lesions.
C. Avoid use of antibiotic ointments on the lesions.
D. Use petroleum jelly (Vaseline) to soften crusty areas.
A.
The treatment for impetigo includes softening of the crusts with warm saline soaks and then soap-and-water removal. Alcohol-based cleansers and use of petroleum jelly are not recommended for impetigo. Antibiotic ointments, such as mupirocin (Bactroban), may be applied to the lesions.
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?
A. Administer vitamins and minerals intravenously.
B. nsert a feeding tube and initiate enteral nutrition.
C. Infuse total parenteral nutrition via a central catheter.
D. Encourage an oral intake of at least 5000 kcal per day.
B.
Enteral nutrition can usually be started during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be given during the emergent phase, but these will not assist in meeting the patient’s caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients unless the gastrointestinal tract is not available for use
The nurse working in the dermatology clinic assesses a young adult female patient who has severe cystic acne. Which assessment finding is of concern related to the patient’s prescribed isotretinoin?
A. The patient recently had an intrauterine device removed.
B. The patient already has some acne scarring on her forehead.
C. The patient has also used topical antibiotics to treat the acne.
D. The patient has a strong family history of rheumatoid arthritis.
A.
Because isotretinoin is teratogenic, contraception is required for women who are using this medication. The nurse will need to determine whether the patient is using other birth control methods. More information about the other patient data may also be needed, but the other data do not indicate contraindications to isotretinoin use.
A young male patient with paraplegia who has a stage 2 sacral pressure injury is being cared for at home by his family. To prevent further tissue damage, what instructions are most important for the nurse to teach the patient and family?
A. Change the patient’s bedding frequently.
B. Apply a hydrocolloid dressing over the injury.
C. Change the patient’s position every 1 to 2 hours.
D. Record the size and appearance of the injury weekly.
C.
The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning. The other interventions may also be included in family teaching.
Which menu choice by a patient with osteoporosis indicates the nurse’s teaching about appropriate diet has been effective?
A. Pancakes with syrup and bacon
B. Whole wheat toast and fresh fruit
C. Egg-white omelet and a half grapefruit
D. Oatmeal with skim milk and fruit yogurt
D.
Skim milk and yogurt are high in calcium. The other choices do not contain any high-calcium foods.
The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient’s total body surface area (TBSA) has been injured?
27%
When using the rule of nines, the anterior trunk is considered to cover 18% of the patient’s body and the anterior (4.5%) and posterior (4.5%) left arm equals 9%.
Which assessment information should indicate to the nurse that a patient with an exacerbation of rheumatoid arthritis (RA) is experiencing a side effect of prednisone?
A. The patient has joint pain and stiffness.
B. The patient’s blood glucose is 165 mg/dL.
C. The patient has experienced a recent 5-pound weight loss.
D. The patient’s erythrocyte sedimentation rate (ESR) has increased.
B.
Corticosteroids have the potential to cause diabetes. The finding of elevated blood glucose reflects this side effect of prednisone. Corticosteroids increase appetite and lead to weight gain. An elevated ESR with no improvement in symptoms would indicate the prednisone was not effective but would not be side effects of the medication.