Musculoskelatal issues
The nurse is caring for a patient with osteoporosis who is at increased risk for falls. Which
intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?
A. Identifying environmental factors that increase risk for falls.
B. Monitoring gait, balance, and fatigue level with ambulation and reporting findings to the provider.
C. Collaborating with the physical therapist to provide the patient with a walker.
D. Assisting the patient with ambulation to the bath- room and in the hall.
D. Assisting the patient with ambulation to the bath- room and in the hall.
What is a late sign of compartment syndrome?*
A. Paralysis
B. Pain
C. Parethesia
D. Pulselessness
D. Pulselessness
Paralysis is not a sign of compartment syndrome
The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention?
A. BP 110/80
B. 24-hour urine output of 300 ml
C. Pain rating of 4 on 1-10 scale
D. Temperature of 99.3 F
B. 24-hour urine output of 300 ml.
The normal urine output is >30ml/hr. =720ml/24 h.
300 ml/24 h. = 12.5ml. Oliguria
the RN is providing D/C instructions to a patient who underwent a THR. The instructions should include what following information:
A. Don't cross your legs or flex your hips more than 60 degrees.
B. Don't cross your legs or flex your hips more than 30 degrees.
C. Don't cross your legs or flex your hips more than 90 degrees.
D. Don't cross your legs or flex your hips more than 120 degrees.
"Don't flex your hip more than 90 degrees, don't cross your legs, and have someone help you put your shoes on.
A patient has a fractured femur. Which finding would the nurse instruct the unlicensed assistive personnel (UAP) to report immediately?
A. The patient reports pain.
B. The patient appears confused.
C. The patient’s blood pressure is 136/88 mm Hg.
D. the patient had a hard time positioning on the bedpan.
B. The patient appears confused. Think blood clot/stroke.
A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention?
A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated.
B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awake.
C. Encourage early ambulation and patient to eat meals in beside chair.
D.Repositioning every 3-4 hours.
D. All options are correct expect for repositioning every 3-4 hours. If the patient is unable to reposition themselves or ambulate, they must be repositioned every 1 to 2 hours minimally.
During a routine examination a 75 year old's height was measured at 5-foot 3-1/2. The patient states "how is that possible, I was always 5 foot 4 inches tall. The RN states:
A. After age 40 the spine compresses resulting in a loss of height.
B. After menopause bone minerals decrease resulting in a loss of height.
C. After age 65 stooping occurs giving the impression of a loss of height.
D. Occasionally, there is a deviation of height dependent upon the tool used.
B. After menopause, the body's bone density declines, resulting in a gradual loss of height." The nurse should tell the client that after menopause, the loss of estrogen leads to a loss in bone density, resulting in a loss of height.
After the nurse receives change-of-shift report, which patient should be assessed first?
A. A 42-year-old patient with carpal tunnel syndrome who reports pain.
B. A 64-year-old patient with osteoporosis awaiting discharge.
C. A 28-year-old patient with a fracture who reports that the cast is tight.
D. A 56-year-old patient with a left leg amputation who reports phantom pain.
C. A 28-year-old patient with a fracture who reports that the cast is tight.
Possible compartment syndrome.
The RN is educating a patient to use the incentive spirometry. What demonstration by the patient lets you know the patient understands how to use the device properly?
A. The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level.
B. The patient blows on the mouthpiece rapidly.
C. The patient uses the incentive spirometry once a shift.
D. The patient rapidly inhales on the devices and exhales and maintains the flow indicator between 600 to 900 level.
A. All of the options are wrong except for "The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level".
What is the most important assessment for the nurse to perform when assessing peripheral pulses on a patient with a post fall injury?
A. Local temperature and visible pulses.
B. Color of the skin and rhythm above the fracture site.
C. Amplitude and symmetry of both extremities.
D. Strong contractility and rate of the unaffected limb.
C. Amplitude and symmetry of both extremities Assessment of any peripheral pulse should include the characteristics of the pulse (e.g., amplitude, rhythm, and rate).
The charge nurse is making assignments for the day shift. Which patient should be assigned to the nurse who was floated from the post-anesthesia care unit (PACU) for the day?
A. A 35-year-old patient with osteomyelitis who needs teaching before hyperbaric oxygen therapy.
B. A 62-year-old patient with osteomalacia who is being discharged to a long-term care facility.
C. A 68-year-old patient with osteoporosis given a new orthotic device whose knowledge of its use must be assessed.
D. A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement.
D. A 72-year-old patient with Paget disease who has just returned from surgery for total knee replacement.
A patient is 3 days post-opt from abdominal surgery. The patient uses the call light and asks you to come to his room immediately. On arrival, you see that approximately 2 inches of internal organs are protruding through the incision. What intervention would you NOT do?
A. Position the patient in prone position with knees extended to put pressure on the site.
B. Cover the wound with sterile normal saline dressing.
C. Monitor for signs of shock.
D. Notify the MD and administer as prescribed antiemetic to prevent vomiting.
A. You would NOT position the patient in prone position with knees extended to put pressure on the site. this would cause wound pressure. The patient is experiencing wound evisceration.
The nurse should know to use an abduction pillow after a THR to ensure which of the following:
A. prevent hip flexion.
B. Prevent a wound of the affected limb.
C. Increase circulation.
D. Prevent dislocation of the prosthesis.
D. Prevent dislocation of the prosthesis. After a total hip replacement, it is important to maintain the hip in a state of abduction to prevent dislocation of the prosthesis.
BONUS QUESTION!
Osteomalacia is softening of the bones. It most often occurs because of a problem with vitamin D, which helps your body absorb calcium. In children, what is this condition called?
Rickets!
A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would?
A. Continue to monitor the patient, increase head of bed 30 degrees and check another set of vitals.
B. Notify the MD of your findings.
C. Contact the blood bank and order 2 units of O- blood.
D. Check the patient's blood glucose. If lower than 70mg/dl. Provide juice or another carbohydrate.
B. This is an emergency situation. The patient is more than likely experiencing a hemorrhage. Notifying the MD would be the first line of action.