Term
Which of the following laboratory values would you expect in a client experiencing prolonged immobility?
1. Elevated calcium
2. Decreased sodium
3. Elevated hemoglobin
4. Elevated potassium |
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Definition
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Term
A client has been on bed rest for several days. The client stands, and the nurse notes that the client's systolic pressure drops 20 mm Hg. Which of the following should the nurse document in the medical record?
1. Rebound hypotension
2. Positional hypotension
3. Orthostatic hypotension
4. Central venous hypotension |
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Definition
| 3. Orthostatic hypotension |
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Term
The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the client that the stockings are used after a surgical procedure to:
1. Prevent varicose veins
2. Prevent muscular atrophy
3. Ensure joint mobility and prevent contractures
4. Facilitate the return of venous blood to the heart |
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Definition
| 4. Facilitate the return of venous blood to the heart |
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Term
You are caring for a client who has osteoporosis. The nurse is teaching her about ways to prevent fractures. Which of the following client statements reflects a need for further education?
1. “I usually go swimming with my family at the YMCA 3 times a week.”
2. “I need to ask my doctor if I need to have a bone mineral density check this year.”
3. “If I don't drink milk at dinner, I will eat broccoli or cabbage to get the calcium that I need in my diet.”
4. “The more frequently I walk, the more likely I will be to fall and break my leg. I think I will get a wheelchair so I don't have to walk any more.” |
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Definition
| 4. “The more frequently I walk, the more likely I will be to fall and break my leg. I think I will get a wheelchair so I don't have to walk any more.” |
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Term
The client at greatest risk for developing adverse effects of immobility is a:
1. 3-year-old child with a fractured femur
2. 78-year-old man in traction for a broken hip
3. 48-year-old woman following a thyroidectomy
4. 38-year-old woman undergoing a hysterectomy |
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Definition
| 2. 78-year-old man in traction for a broken hip |
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Term
A client who was in a car accident and broke his femur has been immobilized for 5 days. When the nurse gets this client out of bed for the first time, a nursing diagnosis related to the safety of this client will be:
1. Pain
2. Impaired skin integrity
3. Altered tissue perfusion
4. Risk for activity intolerance |
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Definition
| 4. Risk for activity intolerance |
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Term
A client had a left-sided cerebral vascular accident 3 days ago and is receiving 5000 units of heparin subcutaneously every 12 hours to prevent thrombophlebitis. The client is receiving enteral feedings through a small-bore nasogastric tube because of dysphagia. Which of the following symptoms requires the nurse to call the health care provider immediately?
1. Hematuria
2. Unilateral neglect
3. Limited ROM in the right hip
4. Coughing up moderate amount clear, thin sputum |
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Definition
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Term
A home care nurse is preparing the home for a client who is going home following a left hip replacement. The client is cooperative and can partially bear weight. What should the nurse order from the home medical supply company to help the client move from the bed to the chair?
1. A trapeze bar
2. A small transfer board
3. A powered standing-assist device
4. An ankle foot orthotic (AFO) for the affected foot
d |
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Definition
| 2. A small transfer board |
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Term
The nurse is caring for a client who has right-sided weakness. The nurse needs to help the client walk. What should the nurse do while walking with the client?
1. Hold the client's left hand while walking
2. Hold the client's right hand while walking
3. Put a gait belt on the client and provide support on the left side
4. Put a gait belt on the client and provide support on the right side |
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Definition
| 4. Put a gait belt on the client and provide support on the right side |
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Term
Before transferring a client from the bed to a stretcher, which assessment data does the nurse need to gather? (Choose all that apply.)
1. The client's weight
2. How cooperative the client is
3. The client's nutritional status
4. The presence of intravenous (IV) tubes |
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Definition
| 1. The client's weight, 2. How cooperative the client is & 4.The presence of intravenous (IV) tubes |
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Term
When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating:
1. A local skin infection requiring antibiotics
2. This client has sensitive skin and requires special bed linen
3. A stage III pressure ulcer needing the appropriate dressing
4. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area |
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Definition
| 4. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area |
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Term
This type of pressure ulcer has an observable pressure-related alteration of intact skin whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching).
1. Stage I
2. Stage II
3. Stage III
4. Stage IV |
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Definition
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Term
When obtaining a wound culture to determine the presence of a wound infection, the specimen should to be taken from the:
1. Necrotic tissue
2. Wound drainage
3. Drainage on the dressing
4. Wound after it has first been cleansed with normal saline |
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Definition
| 4. Wound after it has first been cleansed with normal saline |
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Term
Postoperatively the client with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to:
1. Allow the area to be exposed to air until all drainage has stopped
2. Place several cold packs over the areas, protecting the skin around the wound
3. Cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
4. Cover the area with sterile gauze, place a tight binder over the areas, and ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly |
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Definition
| 3. Cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration |
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Term
Serous drainage from a wound is defined as:
1. Fresh bleeding
2. Thick and yellow
3. Clear, watery plasma
4. Beige to brown and foul smelling |
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Definition
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Term
For a client who has a muscle sprain, localized hemorrhage, or hematoma, what wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?
1. Binder
2. Ice bag
3. Elastic bandage
4. Absorptive diaper |
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Definition
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Term
Interventions to manage a client who is experiencing fecal and urinary incontinence include:
1. Keeping the buttocks exposed to air at all times
2. Use of a large absorbent diaper, changing when saturated
3. Utilization of an incontinence cleanser, followed by application of a moisture barrier ointment
4. Frequent cleansing, application of an ointment, and covering the areas with a thick absorbent towel |
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Definition
| 3. Utilization of an incontinence cleanser, followed by application of a moisture barrier ointment |
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Term
The best description of a hydrocolloid dressing is:
1. A seaweed derivative that is highly absorptive
2. Premoistened gauze, placed over a granulating wound
3. A debriding enzyme that is used to remove necrotic tissue
4. A dressing that forms a gel that interacts with the wound surface |
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Definition
| 4. A dressing that forms a gel that interacts with the wound surface |
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Term
A binder placed around a surgical client with a new abdominal wound is indicated for:
1. Collection of wound drainage
2. Reduction of abdominal swelling
3. Reduction of stress on the abdominal incision
4. Stimulation of peristalsis (return of bowel function) from direct pressure |
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Definition
| 3. Reduction of stress on the abdominal incision |
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Term
Application of a warm compress is indicated:
1. To relieve edema
2. For a client who is shivering
3. To improve blood flow to an injured part
4. To protect bony prominences from pressure ulcers |
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Definition
| 3. To improve blood flow to an injured part |
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