(Test Bank) SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX THREE

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NURSING MED SURG 2-SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX THREE 1) The nurse performs an assessment on a client admitted with contact dermatitis. Which signs and symptoms should the nurse look for? ✓ Lesions with well-defined geometric margins 2) The nurse is providing home care instructions to the client who just had surgery for squamous cell carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which characteristics of this type of skin carcinoma? ✓ Firm, nodular lesion topped with a crust or with a central area of ulceration 3) The nurse is teaching the client about risk factors for skin cancer. Which statements by the client indicate that teaching was successful? Select all that apply. ✓ "I have to avoid excessive exposure to sunlight." ✓ "I am at higher risk for skin cancer because my mother had one." 4) The nurse is assessing a dark-skinned client for signs of anemia. The nurse should focus the assessment on which structures? Select all that apply. ✓ Lips ✓ Conjunctiva ✓ Mucous membranes 5) The nurse is providing teaching to a client who will undergo chemotherapy for cancer, and alopecia is expected from the chemotherapeutic agent. Which statement made by the client indicates a need for further teaching? ✓ "I can't believe my hair loss will be permanent." 6) The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body. Which finding suggests that an escharotomy may be necessary? ✓ High pressure alarm keeps sounding on the ventilator 7) A client with chloasma is extremely stressed about the change in her facial appearance. Which integumentary change observed by the nurse is consistent with this problem? ✓ Blotchy brown macules across the cheeks and forehead 8) The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? ✓ Hypertrophy of collagen fibers 9) The nurse observes the client's sacrum and notes the following. How will the nurse document this in the client's medical record? Refer to figure. View Figure ✓ Stage IV pressure ulcer 10) A client recently diagnosed with chronic kidney disease requiring hemodialysis has an arteriovenous fistula for access. The client asks the nurse what complications can occur with the access site. What complications should the nurse inform the client about? Select all that apply. ✓ Hepatitis ✓ Infection 11) The nurse has completed discharge teaching for a client who was admitted for reticular skin lesions. Which statement by the client indicates understanding of the discharge instructions? ✓ "I need to assess my skin for lesions that appear net-like." 12) A client exhibits erythema of the skin. The nurse plans care, knowing that which factors are responsible for this finding? Select all that apply. ✓ Fever ✓ Vasodilation ✓ Inflammation ✓ Excessively high environmental temperature 13) An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions? ✓ Spider angioma 14) An older client is lying in a supine position. The nurse understands that the client is at least risk for skin breakdown in which body area? ✓ Greater trochanter 15) In planning care for the client with psoriasis, the nurse understands that which represents a priority client problem? ✓ Altered body image 16) The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse should plan to assess which part of the integumentary system first? ✓ Nails 17) A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? ✓ Ecchymosis 18) A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? ✓ Autograft 19) The nurse is providing instructions to a client with psoriasis who will be receiving ultraviolet (UV) light therapy. Which statement would be most appropriate for the nurse to include in the client's instructions? ✓ "You will need to wear dark eye goggles during the treatment." 20) The nurse in the surgical care center will be assisting the health care provider to perform a punch biopsy of a client's skin lesion. Which interventions should be included in the preprocedure plan of care? Select all that apply. ✓ Obtain an informed consent. ✓ Prepare to apply direct pressure to the biopsy site after the procedure. ✓ Tell the client that a small piece of tissue will be removed for examination. 21) The nurse is developing a teaching plan for a group of adolescents regarding the causes of acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply. ✓ The exact cause of acne is unknown. ✓ Acne requires active treatment for control until it resolves. ✓ Oily skin and a genetic predisposition may be contributing factors for acne. ✓ The types of lesions in acne include comedones (open and closed), pustules, papules, and nodules. 22) The nurse is reviewing the health care records of clients scheduled to be seen at a health care clinic. The nurse determines that which client is at the greatest risk for development of an integumentary disorder? ✓ An outdoor construction worker 23) A client scheduled for a skin biopsy is concerned and asks the nurse how painful the procedure is. Which statement is the appropriate response by the nurse? ✓ "The local anesthetic may cause a burning or stinging sensation." 24) The nurse is preparing a client for punch biopsy. What should the nurse do to prepare for this procedure? ✓ Ensure that the consent form has been signed. 25) The nurse prepares to assist a health care provider who is examining a client's skin with a Wood's light. Which step should the nurse include in the plan for this procedure? ✓ Darken the room for the examination. 26) The nurse prepares to treat a client with frostbite of the toes. Which action should the nurse anticipate will be prescribed for this condition? ✓ Rapid and continuous rewarming of the toes in a warm water bath until flushing of the skin occurs 27) The presence of which finding leads the home health nurse to suspect infestation of a client with scabies? ✓ Multiple straight or wavy, threadlike lines beneath the skin 28) The nurse suspects herpes zoster (shingles) when which assessment finding is noted? ✓ Clustered skin vesicles 29) Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction? ✓ "The UV light treatments are given on consecutive days." 30) The nurse prepares to care for a client with acute cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for the client? Select all that apply. ✓ Antibiotic therapy ✓ Warm compresses to the affected area 31) Which individuals are most likely to be at risk for development of psoriasis? Select all that apply. ✓ A woman experiencing menopause ✓ A client with a family history of the disorder ✓ An individual who has experienced a significant amount of emotional distress 32) A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? ✓ 9600 mL of lactated Ringer's solution 33) The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? ✓ Heart rate of 95 beats/minute 34) The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? ✓ Oral mucosa 35) The nurse is caring for a client who has vesicles filled with purulent fluid on the face and upper extremities. On the basis of these findings, the nurse should tell the client that the vesicles are consistent with which condition? ✓ Acne 36) The nurse is performing assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity? ✓ Erythema 37) A client complains of chronic pruritus. Which diagnosis should the nurse expect to note documented in the client's medical record that would support this client's complaint? ✓ Chronic kidney disease 38) A client being seen in an ambulatory clinic for an unrelated complaint has a butterfly rash noted across the nose. The nurse interprets that this finding is consistent with early manifestations of which disorder? ✓ Systemic lupus erythematosus (SLE) 39) The nurse notes that an older adult has a number of bright, ruby-colored, round lesions scattered on the trunk and thighs. How should the nurse document these lesions in the medical record? ✓ Appears to have cherry angiomas on trunk and thighs 40) The nurse is teaching a client about changes in body image related to chronic obstructive pulmonary disease (COPD). Which statement by the client would indicate that teaching was successful? ✓ "My nails may become clubbed." 41) The nurse is teaching a client who is preparing for discharge from the hospital after having a stroke about prevention of pressure ulcers while the client has limited mobility. Which statement by the client indicates the need for further teaching? ✓ "I can sit in my favorite chair all day." 42) The nurse is caring for a client with a diabetic ulcer. What discharge instructions should the nurse provide to the client? Select all that apply. ✓ Use a mild soap when washing the feet. ✓ Use lanolin on the feet to prevent dryness. ✓ Exercise the feet daily by walking and flexing at the ankle. 43) An older client has been lying in a supine position for the past 3 hours. The nurse who is repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply. ✓ Heels ✓ Elbows ✓ Sacrum ✓ Back of the head 44) An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank. ✓ Correct Answer: 22.5 % 45) A hospitalized client is diagnosed with scabies. The health care provider (HCP) recommended that the client and the client's roommate be treated with lindane. Which finding, if noted on this client's chart, would alert the nurse to notify the HCP before the treatment with lindane? ✓ Client history of seizure disorders 46) Isotretinoin has been prescribed for an adolescent with a diagnosis of severe cystic acne. The nurse provides instructions to the adolescent regarding the use of the medication. Which statement, if made by the adolescent, indicates a need for further instruction? ✓ "I need to be sure to take my vitamin A supplement so that the treatment will work." 47) The clinic nurse is caring for a client with a diagnosis of scabies who has just been prescribed crotamiton. The nurse instructs the client to perform which action when applying this medication? ✓ Massage the medication into the skin from the chin downward. Apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application. 48) A client has been given diphenhydramine as a topical agent for allergic dermatitis. The nurse should instruct the client to observe for which intended medication effect? ✓ A decrease in urticaria 49) A home health nurse is visiting a client who has been started on therapy with clotrimazole. The nurse determines the effectiveness of the medication by noting a decrease in which problem? ✓ Rash 50) An outbreak of head lice infestation has occurred at a local school. The school nurse is providing instructions to the mothers of the children attending the school regarding the application of malathion. The nurse should tell the mothers to take which action? ✓ Leave the lotion on for 8 to 12 hours, and then wash the hair with nonmedicated shampoo. 51) A client is seen in the clinic for a complaint of scalp itching that has been persistent over the past several weeks. After an assessment, it is determined that the client has head lice. Permethrin shampoo is prescribed, and the nurse provides instructions to the client regarding the use of the medication. The nurse should tell the client to take which measure? ✓ Wash, rinse, and towel-dry the hair before applying. 52) Lindane is prescribed. The nurse reviews the client's record, knowing that this medication therapy would be contraindicated in which client? ✓ A child 53) The nurse is applying a topical glucocorticoid as prescribed for a client with psoriasis. The nurse would be concerned about the potential for systemic absorption of the medication if it were being applied in which situation? ✓ Applied to a reddened, itchy area underneath an occlusive dressing 54) A topical corticosteroid is prescribed for an infant with dermatitis in the gluteal area. The nurse provides instructions to the mother regarding the use of the medication. Which statement by the mother indicates an understanding of the use of the medication? ✓ "The medication will help relieve the inflammation." 55) A child with severe seborrheic dermatitis is receiving treatments of topical corticosteroid applied over an extensive area of the body, followed by the application of an occlusive dressing. The nurse should monitor the child closely, knowing that which systemic effect can occur as a result of this treatment? ✓ Growth retardation 56) A client with acute seborrheic dermatitis of the back, chest, and legs is receiving treatments with salicylic acid. The nurse should monitor the client for which symptom that indicates the presence of systemic toxicity from this medication? ✓ Increased respirations 57) Topical azelaic acid is prescribed for a client, and the clinic nurse provides instructions regarding the use of this medication. Which statement by the client indicates a need for further instruction? ✓ "The medication is used to treat my eczema." 58) Minoxidil is prescribed for a client to treat hair loss. The nurse provides instructions to the client regarding the application of the medication. Which statement by the client indicates that teaching is effective? ✓ "I will apply the prescribed amount of solution twice a day." 59) Minoxidil is prescribed for a client to treat hair loss. The client asks the nurse if the hair will continue to grow when the medication is stopped. What is the appropriate nursing response? ✓ "Newly gained hair is lost in 3 to 4 months." 60) The school nurse has provided instructions regarding the use of permethrin rinse to the parents of children diagnosed with pediculosis capitis (head lice). Which statement by one of the parents indicates a need for further instruction? ✓ "It is applied to the hair and then shampooed out." 61) A child is diagnosed with impetigo. The health care provider prescribes a topical medication for treatment. The nurse anticipates that which medication will be prescribed? ✓ Mupirocin 62) Coal tar has been prescribed for the client with psoriasis, and the nurse provides instructions to the client regarding this treatment. Which statement by the client indicates a need for further instruction? ✓ "The medication can cause diarrhea." 63) Mafenide acetate is prescribed for a client with a burn injury to the hand. Which should the nurse include in the instructions to the client regarding the use of this medication? ✓ It is normal to experience local discomfort and stinging and burning after the medication is applied. 64) A burn-injured client is receiving treatments of topical mafenide acetate to the site of injury. The nurse should monitor the client for which systemic effect that can occur from the use of this medication? ✓ Acidosis 65) The nurse is planning care for a client returning from the operating room after having an autograft applied to the right lower extremity. Which nursing intervention is focused on promoting graft "take"? ✓ Leave the dressing intact for 3 to 5 days. 66) Sodium hypochlorite solution is prescribed for a client with a wound on the left foot that is draining purulent material. Which action should the nurse plan to take? ✓ Irrigate the wound with the solution. 67) Tretinoin is prescribed for a client with acne, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction? ✓ "If my skin begins to peel, I will notify the health care provider (HCP)." 68) The nurse provides instructions to a client regarding the use of topical tretinoin. Which statement by the client indicates a need for further instruction? ✓ "I cannot use any cosmetics while I am using this medication." 69) Isotretinoin is prescribed for a client to treat severe cystic acne, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates a need for further instruction? ✓ "I cannot crush or chew the tablets if I have difficulty swallowing them whole." 70) Tetracycline is prescribed for a client with severe acne. The nurse instructs the client regarding the importance of reporting which finding if it occurs? ✓ Persistent diarrhea 71) A health care provider (HCP) prescribes isotretinoin for a client with severe acne. The nurse reviews the client's record 72) and notifies the HCP if which prescribed medication is noted on the medication record? ✓ Doxycycline 73) The health care provider has prescribed a topical antiinflammatory cream for a client with a muscular sprain. The nurse provides instructions to the client regarding the medication. Which statement by the client indicates an understanding of this prescribed treatment? ✓ "The medication will act as a local anesthetic." 74) Collagenase is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication? ✓ "I will apply the ointment once a day and cover it with a sterile dressing." 75) Which clients can safely receive lindane? Select all that apply. ✓ An 89-year-old client with dementia ✓ A 32-year-old client with renal stones ✓ A 42-year-old woman with osteoporosis ✓ A 52-year-old man with hypertension and high cholesterol 76) A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and should appropriately document which intervention? ✓ Change the hydrocolloid dressing every 3 to 5 days. 77) A client is prescribed mupirocin intranasally twice daily. The nurse correlates this prescription with the client's medical record and expects to note which result specifically related to the indication for this medication? ✓ Positive methicillin-resistant Staphylococcus aureas (MRSA) by polymerase chain reaction (PCR) 78) The health care provider has prescribed coal tar treatments for a client with psoriasis, and the nurse provides information to the client about the treatments. Which statement made by the client indicates a need for further education about the treatments? ✓ "The medication always causes systemic toxicity." 79) Sodium hypochlorite is prescribed for a client with a leg wound that is draining purulent material. The home health nurse 80) teaches a family member how to perform wound treatments. Which statement, if made by the family member, indicates a need for further teaching? ✓ "I will soak a sterile dressing with solution and pack it into the wound." 81) The nurse has provided instructions to a client regarding the use of tretinoin. Which statement made by the client indicates the need for further instruction? ✓ "I must apply it to wet to damp skin." 82) A client is seen in the clinic for complaints of skin itchiness that has persisted for several weeks. After an assessment, the client is determined to have scabies. Lindane is prescribed, and the nurse provides instructions to the client regarding the use of the medication. Which action should the nurse tell the client to take? ✓ Leave the cream on for 8 to 12 hours, and then remove it by washing. 83) A topical corticosteroid is prescribed for a client with dermatitis. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client would indicate a need for further instruction? ✓ "I should place a bandage over the site after applying the medication." 84) A client has a wound with a moderate amount of drainage and is scheduled for a dressing change. Which dressing, if selected by the student nurse, requires further intervention by the nursing instructor? ✓ Semipermeable transparent film 85) The home health care nurse makes a home visit to a client who has an ulcer on the medial aspect of the left ankle. The wound is being treated with a hydrocolloid dressing. The nurse removes the hydrocolloid dressing, cleanses the wound as prescribed, and reapplies the hydrocolloid dressing. The nurse schedules the next visit for wound care and changing the hydrocolloid dressing in how many days, which is the maximum number of days? Fill in the blank. ✓ Correct Answer: 7 days 86) Isotretinoin is prescribed for a client with severe cystic acne. The nurse provides instructions to the client regarding administration of the medication. Which phrase stated by the client indicates a need for further teaching regarding this medication? ✓ "I need to continue to take my vitamin A supplements." 87) A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the past 3 days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication? ✓ White blood cell count of 3000 mm3 (3 × 109/L) 88) The nurse is providing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which statement made by the mother indicates an understanding of the use of this medication? ✓ "I need to wash the sites gently before I apply the medication." 89) A client with psoriasis is being treated with calcipotriene cream. Administration of high doses of this medication can cause which side or adverse effect? ✓ Hypercalcemia 90) Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions? ✓ Apply once a day and cover it with a sterile dressing. 91) The nurse is caring for a client at home with a diagnosis of actinic keratosis. The client tells the nurse that her skin is very dry and irritated. The treatment includes diclofenac sodium. The nurse teaches the client that this medication is from which class of medications? ✓ Nonsteroidal antiinflammatory drugs (NSAIDs) 92) A client with muscle aches and a diagnosis of rheumatism has been given a prescription for capsaicin topical cream. The nurse determines that the client understands the use of the medication if the client makes which statement? ✓ "The medication will act as a local analgesic." 93) A client with a burn injury is applying mafenide acetate cream to the wound. The client calls the health care provider's (HCP's) office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action? ✓ Continue with the treatment, as this is expected. 94) A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse should implement which action while using this solution? ✓ Rinse off immediately following irrigation. 95) An adolescent with severe cystic acne has been prescribed isotretinoin. Which statement by the client would suggest the need for further teaching? ✓ "I need to take my vitamin A supplement so that the treatment will work." 96) An ambulatory care client with allergic dermatitis has been given a prescription for a tube of diphenhydramine 1% to use as a topical agent. The nurse determines that the medication was effective if which finding was noted? ✓ Decrease in urticaria 97) The nurse has completed giving discharge instructions to a client who has had a total joint replacement (TJR) of the knee with a metal prosthetic system. The nurse determines that the client understands the instructions if the client makes which statement? ✓ "All caregivers should be told about the metal implant." 98) The nurse develops a plan of care for a client with a spica cast that covers a lower extremity and documents that the client is at risk for constipation. When planning for bowel elimination needs, the nurse should include which in the plan of care? ✓ Use a fracture pan for bowel elimination. 99) The nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching, the nurse performs an assessment on the client. The priority nursing assessment should include which information? ✓ The client's vital signs, muscle strength, and previous activity level 100) The nurse is providing instructions to a client regarding ambulation after the application of a fiberglass cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin at which time period? ✓ Within 20 to 30 minutes of application 101) The nurse is caring for a client in skeletal leg traction with an overbed frame. Which nursing intervention will best assist the client with self- positioning in bed? ✓ Place a trapeze on the bed frame to provide a means for the client to lift the hips off the bed. 102) The nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which is the priority nursing action? ✓ Call the health care provider. 103) The home care nurse visits a client who has a cast applied to the left lower leg. On assessment of the client, the nurse notes the presence of skin irritation from the edges of the cast. Which nursing intervention is most appropriate? ✓ Petal the cast edges with appropriate material. 104) A client who has been taking high doses of acetylsalicylic acid to relieve pain from osteoarthritis now has more generalized joint pain and an elevated temperature. The nurse should assess for which complication to determine whether the client has other signs of aspirin toxicity? ✓ Ringing in the ears 105) The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? ✓ Weak pedal pulses 106) The nurse is caring for a client in skeletal traction. On assessing the pin sites, the nurse notes the presence of purulent drainage. Which nursing action is most appropriate? ✓ Notify the health care provider. 107) The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education? ✓ Comminuted fracture 108) The home care nurse is providing instructions to a client regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How should the nurse accurately demonstrate this technique? ✓ Crutches and the affected leg down, followed by the unaffected leg 109) The home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? ✓ The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. 110) A male client arrives in the hospital emergency department and tells the nurse that he twisted his ankle while jogging. The client is seen by the health care provider and is diagnosed with a sprained ankle. The nurse provides instructions to the client regarding home care for the injury. Which statement, if made by the client, would indicate an understanding of appropriate care measures for the next 24 hours? ✓ "I should elevate my foot above the level of the heart." 111) The community health nurse is providing an educational session for community members regarding dietary measures that will assist in reducing the risk of osteoporosis. The nurse should instruct the community members to increase dietary intake of which food known to be helpful in minimizing this risk? ✓ Yogurt 112) The nurse is teaching a client with a right arm cast how to prevent stiff or frozen shoulder. What should the nurse instruct the client to do? ✓ Lift the shoulder of the casted arm over the head periodically throughout the day. 113) The nurse is preparing to perform pin site care for a client in skeletal traction. On assessment of the pin site, the nurse notes the presence of serous drainage. Which nursing action would be appropriate? ✓ Document the findings. 114) The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse should make which interpretation about this finding? ✓ Impaired venous return 115) The nurse is caring for a client with a long bone fracture at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by performing an assessment of which item(s)? ✓ The neurological and respiratory systems 116) The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings should be listed in the care plan as a sign/symptom of fat embolism? ✓ Dyspnea and chest pain 117) The nurse is caring for a client at risk for fat embolism because of a fracture of the left femur and pelvis sustained in a fall. The client also sustained a head injury, is comatose, and is unable to communicate verbally. Which assessment findings should the nurse identify as early signs of possible fat embolism? ✓ Increased heart rate and adventitious breath sounds 118) The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? ✓ Check the neurovascular status of the toes on the casted leg. 119) The nurse is caring for a client after the application of a plaster cast for a fractured left radius. The nurse should suspect impairment with the neurovascular status of the client's casted extremity if which findings are noted? Select all that apply. ✓ Client report of severe, deep, unrelenting pain ✓ Client report of pain as nurse assesses finger movement ✓ Client report of numbness and tingling sensation in the fingers 120) The nurse has delegated the ambulation of a client to the unlicensed assistive personnel (UAP). Which actions by the UAP support a clear understanding of the appropriate steps to carry out this task safely? Select all that apply. ✓ Remove clutter that may interfere with ambulation. ✓ Assist client in applying nonskid shoes before ambulation. ✓ Instruct client to sit up on the bedside and dangle before ambulation. ✓ Observe the client for dizziness during ambulation and report immediately. 121) A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? ✓ Abductor splint 122) A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. ✓ Heat ✓ Analgesics ✓ Muscle relaxers ✓ Intermittent traction 123) The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented? ✓ Use a raised toilet seat. 124) The nurse is talking to a client who had a below-the- knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? ✓ Altered body image 125) The home health nurse is planning to teach a client with osteoporosis about home modifications to reduce the risk of falls. Which recommendations would be necessary to include in the teaching plan? Select all that apply. ✓ Use night lights. ✓ Remove scatter rugs. ✓ Use staircase railings. ✓ Place hand rails in the bathroom. 126) A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? ✓ Inability to entertain self 127) A client with a fractured femur experiences sudden dyspnea, tachypnea, and tachycardia. A set of arterial blood gas tests reveals the following: pH, 7.35 (7.35); Paco2, 43 mm Hg (43 mm Hg); Pao2, 58 mm Hg (58 mm Hg); HCO3, 23 mEq/L (23 mmol/L). The nurse interprets that the client probably has experienced fat embolus because of the result of which parameter? o Pao2 128) The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? o "Bleeding and swelling caused increased pressure in an area that couldn't expand." 129) The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse should use which method to reposition the client? o A pillow to keep the right leg abducted during turning 130) The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information should the nurse include? o "You will use full weight bearing by discharge." 131) The nurse is planning to teach the client with below- the-knee amputation about care to prevent skin breakdown. Which point should the nurse include in developing the teaching plan? o The socket of the prosthesis must be dried carefully before it is used. 132) A client has just undergone spinal fusion after experiencing herniation of a lumbar disk. The nurse should include which interventions to maintain client safety after this procedure? Select all that apply. o Keep the head of the bed flat. o Place pillows under the length of the legs. o Use logrolling technique for repositioning. o Assist the client with eating meals and drinking fluids. 133) A client has several fractures of the lower leg, which has been placed in an external fixation device. The client is upset about the appearance of the leg, which is edematous. The nurse documents which client problem in the plan of care? o Body image alteration 134) A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action? o Slightly elevating the foot of the bed 135) The nurse is reviewing the postprocedure plan of care formulated by a nursing student for a client scheduled for a bone biopsy. The nurse determines that the student needs additional information about postprocedure care if which inaccurate intervention is documented? o Administering opioid analgesics intramuscularly 136) A client has had a bone scan done. The nurse determines that the client demonstrates understanding of postprocedure care when the client makes which statement? ✓ "I need to drink plenty of water for 1 to 2 days after the procedure." 137) A client seeks treatment in the hospital emergency department for a lower leg injury. Deformity of the lower portion of the leg is evident, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced which injury? ✓ Fracture 138) The nurse is caring for a client who is an athlete and has sustained an injury to the anterior cruciate ligament. The nurse is providing education to the client regarding the potential treatment measures for this injury. What should the nurse include in the teaching? Select all that apply. ✓ Physical therapy ✓ Knee immobilizer ✓ Aspiration of joint fluid ✓ Antiinflammatory medications 139) The nurse is evaluating a client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performs which action? ✓ Moves the cane when the right leg is moved 140) The nurse is planning to teach a client how to stand on crutches. The nurse will incorporate into written instructions that the client should be told to place the crutches in what manner? ✓ 6 inches (15 cm) to the front and side of the toes 141) A client is admitted to the nursing unit after a left below-the-knee amputation after a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." How should the nurse interpret this client statement? ✓ A normal response that indicates the presence of phantom limb sensation 142) The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction? ✓ "Pain or fatigue is expected, and I should try to continue with the activity if this occurs." 143) The nurse has provided discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further instruction? ✓ "I should sit in my recliner when I get home." 144) The community health nurse is providing a teaching session on osteoporosis to women living in the community. The nurse informs these community residents that which is a risk factor for this disorder? ✓ A diet low in vitamin D 145) The nurse is performing an assessment on a client with suspected Paget's disease. On assessment the nurse would expect the client to report which as the most common symptom of this disease? ✓ Bone pain 146) Diagnostic studies are prescribed for a client with suspected Paget's disease. In reviewing the client's record, the nurse would expect to note that the health care provider has prescribed which laboratory study? ✓ Alkaline phosphatase 147) A hospitalized client has been diagnosed with osteomyelitis of the left tibia. The nurse determines that this condition is most likely a result of which event in the client's recent history? ✓ Open trauma to the left leg 148) A nursing student is providing health maintenance education to a client with osteitis deformans (Paget's disease). Which statement by the client indicates a need for further education? ✓ "Because I have no symptoms, my disease is not progressing." 149) An older client is diagnosed with osteoporosis. The nurse teaches the client about self-care measures, knowing that the client is most at risk for which problem as a result of this disorder of the bones? ✓ Fractures 150) The nurse provides instructions to a client with bilateral deformities of the joints of the fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response? ✓ Autoimmune 151) A client has been diagnosed with osteomalacia, or adult rickets. The nurse should anticipate that the health care provider will include a new prescription for which vitamin supplement? ✓ D 152) A client is having a plaster cast placed on the lower extremity that will extend from mid-thigh to the center of the foot. Which instruction should be given to the client before hospital discharge? ✓ The need to notify the health care provider immediately if the client notices numbness or swelling or if the foot becomes cold and pale 153) A client is complaining of knee pain. The knee is swollen, reddened, and warm to the touch. The nurse interprets that the client's signs and symptoms are compatible with which conditions? Select all that apply. ✓ Infection ✓ Recent injury ✓ Inflammation 154) The nurse witnesses a client sustain a fall and suspects that the right leg may be broken. The nurse should take which priority action?