Thyroid

UserShantell Shoemaker

CourseMedical/Surgical Nursing II - Spring 2015

TestUnit 3 Exam 3 2015

Started3/3/15 8:02 AM

Submitted3/3/15 8:29 AM

StatusCompleted

Attempt Score38 out of 44 points

Time Elapsed26 minutes out of 1 hour.

Instructions

Question 1 1 out of 1 points

The nurse is receiving the morning shift report. Which patient does the nurse assess first?

Selected Answer: c. The patient who reports increased pain and swelling after an arthroscopy

Answers: a. The patient who is verbalizing mild discomfort after an electromyography (EMG)

b. The patient who refuses to drink more fluids after a nuclear medicine scan

c. The patient who reports increased pain and swelling after an arthroscopy

d. The patient who wants to know information about a magnetic resonance imaging (MRI) test scheduled in 3 hours

Response Feedback: The patient who should be the first priority is the one who is reporting increased pain and swelling after arthroscopy; this could indicate complications from the surgery. The patient with mild discomfort after an EMG should be assessed for pain, but mild discomfort is common for this procedure. Pain medication can then be administered. After a nuclear medicine scan, the patient must increase fluids to flush out the radioisotope used in the scan. The nurse could then visit with the patient who had questions about the upcoming MRI.


An older adult patient is two days postoperative for an above-knee amputation of the right leg and reports pain in the right foot. Which priority medication does the nurse administer?

Selected Answer: a. IV calcitonin

Answers: a. IV calcitonin

b. IV meperidine

c. 600 mg of ibuprofen

d. 650 mg of acetaminophen

Response Feedback: The patient is experiencing phantom limb pain. IV infusions of calcitonin during the week after amputation can reduce phantom limb pain. Ibuprofen and acetaminophen will not assist in decreasing the patients pain. Meperidine is contraindicated in the older adult due to the risk of inducing seizures.


The charge nurse on the orthopedic unit receives the morning shift report. Which patient will the nurse assess first?

Selected Answer: c. A patient with a compound fracture of the right ulna who has a white blood cell (WBC) count of 14,000

Answers: a. A patient with osteomyelitis who has an elevated erythrocyte sedimentation rate (ESR)

b. A patient with osteoarthritis who has a height loss of 3 inches.

c. A patient with a compound fracture of the right ulna who has a white blood cell (WBC) count of 14,000

d. A patient with a right below-the-knee (BKA) amputation who has a hemoglobin and hematocrit (H&H) of 12/42

Response Feedback: The patient with a compound fracture should not have an infection, which a WBC of 14,000 indicates; this patient requires immediate intervention.We would expect a patient with osteomyelitis to have an elevated ESR (sed rate) as this lab is proportional to inflammation.The H&H is within normal limits.Height loss can be an expected manifestation of osteoporosis of the spine (Dowagers hump.kyphosis)


A patient is in Bucks traction for a fracture of the left femur. Which priority action will the nurse take to evaluate the effectiveness of the Bucks traction?

Selected Answer: a. Ask about left hip muscle spasm pain level.

Answers: a. Ask about left hip muscle spasm pain level.

b. Assess for hip contractures.

c. Monitor for hip dislocation.

d. Check the peripheral pulses.

Response Feedback: Bucks traction keeps the leg immobilized and reduces 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 Bucks traction.


A patient is admitted with burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

Selected Answer: d. Notify the health care provider and prepare for endotracheal intubation.

Answers: a. Document the results and continue to monitor the patient's respiratory rate.

b. Encourage the patient to cough and auscultate the lungs again.

c. Reposition the patient in high-Fowlers position and reassess breath sounds.

d. Notify the health care provider and prepare for endotracheal intubation.

Response Feedback: The patients history and clinical manifestations suggest airway edema/closure and the health care provider will immediately be notified so that intubation can rapidly be done. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema and closure. Continuing to monitor is inappropriate because immediate action should occur.


A 70 kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula, calculate the volume of lactated Ringers solution that the nursing staff will administer during the first 24 hours. Record whole number ONLY.

Selected Answer: 8,400

Correct Answer: 8,400

Answer range +/- 0 (8400.0 - 8400.0)

Response Feedback: 8400 mLThe Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours.


A patient is receiving fluid resuscitation after a burn. Which finding indicates that fluid resuscitation is adequate for this patient?

Selected Answer: a. Urine output = 50 mL/hr

Answers: a. Urine output = 50 mL/hr

b. Hematocrit = 60%Heart rate = 130 beats/min

c. Heart rate = 130 beats/min

d. Increased peripheral edema

Response Feedback: The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate, as well as laboratory values, to more normal levels.


The RN has assigned a patient who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN?

Selected Answer: c. Wash hands on entering the patients room.

Answers: a. Have the patient cough and breathe deeply.

b. Assess wounds for signs of infection.

c. Wash hands on entering the patients room.

d. Administer the prescribed tetanus toxoid vaccine.

Response Feedback: Infection can occur when microorganisms from another person or from the environment are transferred to the patient. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.


After receiving change-of-shift report, which of these patients will the nurse assess first?

Selected Answer: c. A patient with smoke inhalation who has wheezes and altered mental status

Answers: a. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

b. A patient with abdominal burns who is describing a level 8 (0 to 10 scale) pain

c. A patient with smoke inhalation who has wheezes and altered mental status

d. A patient with full-thickness leg burns who has a dressing change scheduled

Response Feedback: ABCs = lets be most concerned about the patient showing respiratory compromise after smoke inhalation.All other answers are typical and routine manifestations, certainly need attention, but not more important than compromised airway and signs of hypoxia (altered mental status).


The patient had a right below-the-knee amputation (BKA) 3 days ago. Which priority intervention does the nurse implement?

Selected Answer: a. Place the patient in the prone position three to four times a day.

Answers: a. Place the patient in the prone position three to four times a day.

b. Put the prosthetic limb on when ambulating the patient.

c. Maintain the patients right leg in Buck traction.

d. Keep the residual limb elevated on two pillows.

Response Feedback: The prone position will help stretch the hamstring muscle, which will help prevent flexion contractures that may lead to problems when fitting the patient for a prosthetic limb. The residual limb should be elevated for 24 hours only to decrease post-op edema, but after that, elevation on pillows would induce contractures. The patient will not be fitted for a prosthetic limb until 4-6 weeks after surgery.


A patient has a new left femur fracture. Which information obtained by the nurse is most important to report to the health care provider?

Selected Answer: b. Prolonged capillary refill of the left foot

Answers: a. Outward pointing toes on the left foot

b. Prolonged capillary refill of the left foot

c. Complaints of left thigh pain

d. Bruising of the left thigh

Response Feedback: Prolonged capillary refill may indicate complications such as arterial damage or compartment syndrome. The other findings are typical with a left femur fracture.


A patient is prescribed Ranitidine (Zantac) for extensive burn injuries sustained 5 days ago. Which nursing assessment will best evaluate the effectiveness of the medication?

Selected Answer: a. Stool for occult blood

Answers: a. Stool for occult blood

b. Calorie count

c. Bowel sounds

d. Stool frequency

Response Feedback: H2 blockers are given to prevent Curlings ulcer in the patient who has suffered burn injuries. H2 blockers do not impact on bowel sounds, stool frequency, or appetite.


The nurse assesses a patient with a below-knee amputation. Which assessment of the skin flap requires immediate action?

Selected Answer: d. Pale and cool to the touch

Answers: a. Dark pink and dry to the touch

b. Pink and slightly moist to the touch

c. Pink and warm to the touch

d. Pale and cool to the touch

Response Feedback: The skin flap should appear pink in a light-skinned person and not discolored in a darker-skinned person. The area should feel warm but not hot. Pale and cool skin could indicate inadequate blood flow to the area. The nurse would notify the provider.


A patient is admitted after a thermal burn injury and has the following vital signs:blood pressure, 70/40; heart rate, 140 beats/min; and respiratory rate, 25 breaths/min. He is pale, and it is difficult to find pedal pulses. Which action will the nurse take first?

Selected Answer: c. Begin intravenous fluid resuscitation.

Answers: a. Obtain an electrocardiogram (ECG).

b. Obtain a complete blood count (CBC).

c. Begin intravenous fluid resuscitation.

d. Check pulses with a Doppler device.

Response Feedback: Hypovolemic shock is a common cause of death in the emergent phase of patients with serious injury. Fluids can treat this problem. ECG and CBC will be taken to ascertain whether a cardiac or bleeding problem is causing these vital signs. However, these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery, but this is not an immediate nursing action.


A patient is in the emergency department after being rescued from a house fire. After the initial assessment, the patient develops a loud, brassy cough. What intervention by the nurse takes priority?

Selected Answer: a. Apply oxygen and continuous pulse oximetry.

Answers: a. Apply oxygen and continuous pulse oximetry.

b. Allow the patient to suck on small quantities of ice chips.

c. Request an antitussive medication from the physician.

d. Have the respiratory therapist provide humidified room air.

Response Feedback: Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the patient oxygen. patients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.


A patient has a new order for an open magnetic resonance imaging (MRI). Which information indicates that the nurse will consult with the health care provider before scheduling the MRI?

Selected Answer: c. The patient has a pacemaker.

Answers: a. The patient wears a hearing aid.

b. The patient is allergic to shellfish.

c. The patient has a pacemaker.

d. The patient is claustrophobic.

Response Feedback: Patients with permanent pacemakers cannot have MRI because of the force exerted by the magnetic field on metal objects (it could cause the pacemaker to malfunction). An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Because contrast medium will not be used, shellfish allergy is not a contraindication to MRI.


A patient has an open reduction and internal fixation (ORIF) of left lower leg fracture and reports constant severe pain in the leg, which is unrelieved by the administered morphine. Pulses are faintly palpable and the foot is cool. Which action will the nurse take next?

Selected Answer: d. Check the patients blood pressure.

Answers: a. Notify the health care provider.

b. Reposition the left leg on pillows.

c. Assess the incision for redness.

d. Check the patients blood pressure.

Response Feedback: The patients clinical manifestations suggest compartment syndrome and delay in diagnosis and treatment may lead to severe functional impairment. This is a medical emergency...time is crucial. The data do not suggest problems with blood pressure or infection. Elevation of the leg will decrease arterial flow and further reduce perfusion.


An older adult patient is hospitalized with osteomyelitis and is ordered bed rest with bathroom privileges with the affected foot elevated on two pillows. The nurse places highest priority on which intervention?

Selected Answer: d. Ambulate the patient to the bathroom every 2 hours.

Answers: a. Perform frequent position changes and range-of motion exercises.

b. Allow the patient to dangle legs at the bedside every 2 to 4 hours.

c. Ask the patient about preferred activities to relieve boredom.

d. Ambulate the patient to the bathroom every 2 hours.

Response Feedback: This is an older adult now on bedrest, therefor promoting circulation (preventing pressure)and activity in unaffected limbs is indicated.


A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, what is the nurses priority action?

Selected Answer: a. Handle the cast with the palms of the hands.

Answers: a. Handle the cast with the palms of the hands.

b. Keep the patients left arm in a dependent position.

c. Cover the cast with a small blanket to absorb the dampness.

d. Place gauze down the cast for itching..

Response Feedback: Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. Nothing is to be put inside the cast to scratch the itch!. The cast should not be covered until it is dry because heat builds up during drying.


An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility will take?

Selected Answer: c. Remove nonadherent clothing and watch

Answers: a. Cover the affected area with dry, sterile dressings

b. Place cool compresses on the area of exposure

c. Remove nonadherent clothing and watch

d. Apply an alkaline solution to the affected area

Response Feedback: Get the clothes and jewelry off....only the nonadherant....we don't want to debride by pulling anything adherant off the burn patient. the patient will start to third-space fluids so get watch off before it can become a touniquet. Then we would flush with water....not an alkaline soln.


A patient receives teaching about axillary crutch safety. Which observations by the nurse indicate that the teaching has been effective? Select all that apply.

c. The patient uses the three-point gait

e. The patients elbows are at no more than 30 degrees of flexion

Answers: a. The patient does not lean on crutches to support body weight

b. The patient borrows anothers crutches

c. The patient uses the three-point gait

d. The patient ascends stairs leading with the affected leg

e. The patients elbows are at no more than 30 degrees of flexion


A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which of these actions will the nurse take first?

Selected Answer: d. Auscultate the patients lung sounds.

Answers: a. Determine the extent and depth of the burns.

b. Infuse the ordered IV solution.

c. Administer the ordered opioid pain medications.

d. Auscultate the patients lung sounds.

Response Feedback: A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured. ABCs.


The nurse is estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patients total body surface area (TBSA) has been injured? Record whole number ONLY.

Selected Answer: 27

Correct Answer: 27

Answer range +/- 0 (27.0 - 27.0)

Response Feedback: When using the rule of nines, the posterior trunk is considered to cover 18% of the patients body and each arm is 9%.


A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, Im sorry that Im still alive. My life will never be normal again. Which response by the nurse is best?

Selected Answer: d. It is true that your life may be different. What concerns you the most?

Answers: a. Most people recover after a burn and feel satisfied with their lives.

b. Why do you feel that way? You will be able to adapt as your recovery progresses.

c. It is really too early to know how much your life will be changed by the burn.

d. It is true that your life may be different. What concerns you the most?

Response Feedback: "What concerns you most?" is open-ended and will facilitate the patient to verbalize feelings/offer clarification etc.


A patient sustains a burn injury from exposure to a high-voltage current while working on an electrical power line. What is the priority nursing assessment?

Selected Answer: d. Extremity movement

Answers: a. Peripheral pulses

b. Pupil reaction to light

c. Oral temperature

d. Extremity movement

Response Feedback: All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data also are necessary but not as essential as determining cervical spine status.


A patient has pain after a burn injury. Which intervention by the nurse is most appropriate to reduce a patients pain?

Selected Answer: a. Administering morphine sulfate 4 mg intravenously

Answers: a. Administering morphine sulfate 4 mg intravenously

b. Administering morphine sulfate 4 mg intramuscularly

c. Avoiding tactile stimulation near the burned area

d. Applying ice to the burned area for 20 minutes

Response Feedback: Drug therapy for pain management requires opioid and non-opioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. Tactile stimulation can be used for pain management. For the patient to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area.


A patient develops acute onset confusion, tachypnea, and anterior chest wall petichiae two days after a crushed pelvis injury. What is the nurses first action?

Selected Answer: d. Assess oxygen saturation.

Answers: a. Assess patient pain level.

b. Take the blood pressure.

c. Check pupil reaction to light.

d. Assess oxygen saturation.

Response Feedback: The patients history and clinical manifestations suggest a fat embolus. The most important assessment is oxygenation (acute onset confusion = hypoxia). The other actions also are appropriate but will be done after the nurse assesses gas exchange.


A patient has osteoporosis and receives dietary teaching by the nurse. The nurse determines that dietary teaching has been successful when the patient selects which highest-calcium meal?

Selected Answer: d. A sardine (3 oz.) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk

Answers: a. A two-egg omelet with 2 oz. of American cheese, one slice of whole wheat toast, and a half grapefruit

b. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple

c. Chicken stir-fry with 1 cup each onions, green peas, and steamed rice

d. A sardine (3 oz.) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk

Response Feedback: Sardines,skim milk and yogurt are high in calcium. The other choices do not contain as much high calcium foods.


A young patient has a thermal burn from scalding (see exhibit). What intervention by the nurse takes priority?

Selected Answer: a. Administer analgesics.

Answers: a. Administer analgesics.

b. Apply lotion to keep hand moist.

c. Pierce blisters prior to dressing hand.

d. Secure clean dressing with adhesive tape.

Response Feedback: This is a very painful burn. Superficial partial thickness. Analgesics help relieve pain and decrease anxiety for subsequent dressing changes or any further intervention. Gauze should be inserted between fingers because burned surfaces should not touch. As healing takes place, webbing will from between burned surfaces that are touching. Netting rather than tape should be used to hold dressing in place because it expands easily, and tape can be painful to remove. Blisters are not pierced, and lotions are not applied.


Which patient is most appropriate for the burn unit charge nurse to assign to an registered nurse (RN) staff nurse who has floated from the hospital medical unit?

Selected Answer: d. A patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN)

Answers: a. A patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns

b. A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration

c. A patient who has just come back to the unit after having a cultured epithelial autograft to the chest

d. A patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN)

Response Feedback: An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings and PN. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.


A patient suffers a 45% total body surface area (TBSA) burn and is intubated. Twelve hours later, bowel sounds are absent in all four abdominal quadrants. What is the nurses best action?

Selected Answer: a. Prepare to insert a nasogastric (NG) tube.

Answers: a. Prepare to insert a nasogastric (NG) tube.

b. Reposition the patient on the right side.

c. Document the finding.

d. Administer a laxative.

Response Feedback: Decreased or absent peristalsis is a frequent response during the resuscitative/emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. The result is often a paralytic ileus. patients who have burns greater than 25% TBSA or who are intubated generally need to have an NG tube inserted.


A patient has a possible left lower leg fracture. What is the nurses initial action?

Selected Answer: d. Splint the lower leg.

Answers: a. Obtain information about the tetanus immunization status.

b. Elevate the left leg.

c. Check the popliteal, dorsalis pedis, and posterior tibial pulses and sensation.

d. Splint the lower leg.

Response Feedback: The initial nursing action should be assessment of the neurovascular status of the injured leg. (ABCs = circulation) After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.


A patient has experienced an electrical injury of the lower extremities. The nurse obtains which priority assessment data from this patient?

Selected Answer: b. Range of motion in all extremities

Answers: a. Heart rate, rhythm, and electrocardiogram (ECG)

b. Range of motion in all extremities

c. Orientation to time, place, and person

d. Respiratory rate and pulse oximetry

Response Feedback: The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electrical current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites (iceberg effect). Early cardiac damage from electrical injury includes irregular heart rate and rhythm, and ECG changes. Range-of-motion and neurologic assessments are important; however, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.


A patient has chronic osteomyelitis. Which nursing intervention is most effective in preventing transfer of the wounds organism to other patients?

Selected Answer: d. Contact precautions

Answers: a. Irrigating the wound as needed

b. Leaving the wound open to air

c. Restriction of visitors

d. Contact precautions

Response Feedback: In the presence of wound drainage, Contact Precautions may be used to prevent the spread of the offending organism to other patients and health care personnel. Restricting visitors does not prevent transfer. One visitor could possibly transfer the bacteria to another surface. Irrigating the wound would not destroy the organism. The wound should be covered to prevent transfer of the organism.


A patient with osteoporosis is administered alendronate (Fosamax). What is the nurses first action?

Selected Answer: d. Assist the patient to sit up at the bedside.

Answers: a. Administer the ordered calcium carbonate.

b. Ask about any leg cramps or hot flashes.

c. Assure the patient has recently eaten.

d. Assist the patient to sit up at the bedside.

Response Feedback: To avoid esophageal erosions, the patient taking bisphosphonates should be upright for at least 30 minutes after taking the medication. Fosamax should be taken on an empty stomach, not after taking other medications or eating. Leg cramps and hot flashes are not side effects of bisphosphonates.


An older patient is admitted after falling down the stairs. Which assessment findings require immediate intervention? Select all that apply.

b. Dark brown urine

c. Potassium, 6.0 mEq/L

d. Blood pressure, 80/50 mm Hg

Answers: a. Heart rate, 90 beats/min

b. Dark brown urine

c. Potassium, 6.0 mEq/L

d. Blood pressure, 80/50 mm Hg

e. Urine output, 50 mL/hr

Response Feedback: Low blood pressure could indicate hypovolemia, which occurs with crush syndrome. Hyperkalemia and dark brown urine (myoglobulinemia) also may indicate crush syndrome. A heart rate of 90 beats/min is within normal limits; urine output of 50 mL/hr is also a normal finding.


The patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack is best for the nurse to offer to a patient?

Selected Answer: d. Chocolate milkshake

Answers: a. Strawberry gelatin

b. Whole wheat bagel

c. Chunky applesauce

d. Chocolate milkshake

Response Feedback: A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.


A patient with facial burns has received instruction on the facial pressure garment. Which statement indicates that the patient understands these instructions?

Selected Answer: d. My scars should be less severe with the use of this mask.

Answers: a. The mask will help protect my skin from sun damage.

b. Using the mask will keep scars from being permanent.

c. This treatment will help prevent infection.

d. My scars should be less severe with the use of this mask.

Response Feedback: The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not alter the risk for infection.


A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis. The nurse will include which concept in the discharge teaching?

Selected Answer: b. The reason for taking oral antibiotics for 7 to 10 days after discharge

Answers: a. Application of warm packs safely to the leg to reduce pain

b. The reason for taking oral antibiotics for 7 to 10 days after discharge

c. The need for daily aerobic exercise to help maintain muscle strength

d. How to monitor and care for the long-term IV catheter site

Response Feedback: The patient will be on IV antibiotics for several months, and the patient will need to recognize signs of infection at the IV site and how to care for the catheter during daily activities such as bathing. IV antibiotics rather than oral antibiotics are used for acute osteomyelitis. Patients are instructed to avoid exercise and heat application because these will increase swelling and the risk for spreading infection.


A person accidentally cuts off the right big toe with an axe. The persons family member is a nurse. Which priority action will the nurse implement to preserve the big toe so that it could possibly be reattached in surgery?

Selected Answer: b. Put the toe in a clean piece of material and place on ice.

Answers: a. Take no action because the toe cannot be reattached.

b. Put the toe in a clean piece of material and place on ice.

c. Place the right toe in a bowl with crushed ice cubes.

d. Secure the toe in a plastic bag and bring it to the hospital.

Response Feedback: Placing the big toe in material and placing it on ice will help preserve it so that it may be reconnected in surgery. The toe should not be placed directly on ice because this will cause necrosis of viable tissue. A surgeon will attempt to reattach a toe, but not an entire leg.


A patient is at risk for osteoporosis. Which exercise does the nurse recommend to the patient?

Selected Answer: d. Walking 30 minutes three times weekly

Answers: a. Bowling for 1 hour twice weekly

b. Jogging 30 minutes four times weekly

c. High-impact aerobics 45 minutes once weekly

d. Walking 30 minutes three times weekly

Response Feedback: Weight-bearing, nonjarring exercises have been proved to reduce or slow bone loss without causing vertebral compression. High-impact aerobics, jogging, and bowling are activities that actually could cause fracture in a patient with osteoporosis. Walking would be the best choice as an exercise.


The RN has assigned a patient with severe osteoporosis to a LPN. Which information about the care of the patient is most important for the RN to provide the LPN?

Selected Answer: d. Use a lift sheet to reposition the patient.

Answers: a. Position the patient upright to promote lung expansion.

b. Provide passive range of motion (ROM) to all weight-bearing joints.

c. Place a pillow between the patients knees when in the side-lying position.

d. Use a lift sheet to reposition the patient.

Response Feedback: Severe osteoporosis causes such bone density loss that pathologic fractures can easily occur when lifting or pulling a patient. Use of a lift sheet when positioning reduces this risk. Passive range of motion prevents contractures, but active weight-bearing exercise reduces bone resorption and is a better choice if possible. Positioning the patient to promote lung expansion and positioning with a pillow for side-lying are important interventions for any patient. The most important intervention for this patient is to prevent bone fractures.


A patient has burns on both legs. The areas appear white and leather-like. No blisters or bleeding is present, and the patient states that the burns are not painful. What term will the nurse use to document the burn depth?

Selected Answer: a. Full thickness skin destruction

Answers: a. Full thickness skin destruction

b. Deep partial- thickness skin destruction

c. Superficial skin destruction

d. Superficial partial -thickness skin destruction

Response Feedback: The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness burns are deep red to white and painful, and superficial burns are pink to red and are also painful.


A patient has primary osteoporosis. Which instruction is most important for the RN to provide to the nursing assistant assigned to care for the patient?

Selected Answer: b. Clean up clutter in the room.

Answers: a. Perform passive range-of-motion exercises.

b. Clean up clutter in the room.

c. Monitor urinary output.

d. Encourage the patient to bathe herself or himself."

Response Feedback: patients with osteoporosis are at risk for fracture when they fall. Clutter in the room is a risk factor for falls. The other choices have nothing to do with prevention of bone fracture in a patient with primary osteoporosis.

Tuesday, March 3, 2015 11:30:45 AM CST