Level 2 - RNSG 1443 - Exam 1 Review Questions
The nurse is preparing a client who sustained a hip fracture for discharge. The nurse should teach the client to avoid which of the following groups of activities to prevent dislocation of the hip?
A. crossing legs, bending at hips, and sitting on...
Level 2 - RNSG 1443 - Exam 1 Review
Questions
The nurse is preparing a client who sustained a hip fracture for discharge. The nurse
should teach the client to avoid which of the following groups of activities to prevent
dislocation of the hip?
A. crossing legs, bending at hips, and sitting on low toilet seats
B. taking leisurely walks, low chair seats, and bending at hips
C. using reachers for applying shoes and socks, and sitting in chairs with arms
D. all exercises, bedrest, and using raised toilet seats - Answer- A.
crossing legs, bending at hips, and sitting on low toilet seats
A client in traction slides down in the bed so that the feet touch the foot of the bed.
What should the nurse do to ensure that the pull of traction remains uninterrupted?
A. release the weights, pull the client up in bed, and then reapply weights
B. ask the physician for a change in the amount of weight ordered
C. move the client up in bed without releasing the pull of traction on the extremity
D. elevate the client's feet on a pillow
. - Answer- C.
move the client up in bed without releasing the pull of traction on the extremity
The nurse is assessing a casted extremity of a patient. Which sign is indicative of
infection?
A. Dependent edema
B. Diminished distal pulse
C. Presence of a "hot spot" on the cast
D. Coolness and pallor of the extremity
. - Answer- C. Presence of a "hot spot" on the cast
Signs and symptoms of infection under a casted area include odor or purulent
drainage from the cast or the presence of "hot spots," which are areas of the cast
that are warmer than others. The health care provider should be notified if any of
these occur.
Signs of impaired circulation in the distal limb include coolness and pallor of the skin,
diminished distal pulse, and edema.
A patient being measured for crutches asks the nurse why the crutches cannot rest
up underneath the arm for extra support. The nurse responds that knowing that
which would most likely result from this improper measurement?
,A. A fall and further injury
B. Injury to the brachial plexus nerves
C. Skin breakdown in the area of the axilla
D. Impaired range of motion while the patient ambulates
. - Answer- B. Injury to the brachial plexus nerves
Crutches are measured so that the tops are two to three fingerwidths from the
axillae. This ensures that the client's axillae are not resting on the crutch or bearing
the weight of the crutch, which could result in injury to the nerves of the brachial
plexus.
Although the conditions in options 1, 3, and 4 can occur, they are not the most likely
result from resting the axilla directly on the crutches.
The nurse has conducted teaching with a patient in an arm cast about the s/s of
compartment syndrome. The nurse determines that the client understands the
information if the client states that he or she should report which of the early
symptom of compartment syndrome?
A. Cold, bluish-colored fingers
B. Numbness and tingling of the fingers
C. Pain that increases when the arm is dependent
D. Pain that is out of proportion to the severity of the fracture - Answer- B. Numbness
and tingling of the fingers
The earliest symptom of compartment syndrome is paresthesia (numbness and
tingling in the fingers). Other symptoms include pain unrelieved by opioids, pain that
increases with limb elevation, and pallor and coolness to the distal limb.
Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture,
along with other symptoms associated with the pain, is not an early manifestation.
Which of following would indicate that your patient is in metabolic acidosis?
A. high pH, high HCO3
B. low pH, low pCO2
C. low pH, low HCO3
D. high pH, low pCO2 - Answer- C.
low pH, low HCO3
The nurse assesses for hyperkalemia in a patient with which of the following
problems?
A. renal failure
B. nausea and vomiting
C. excessive laxative use
D. loop diuretic use
,. - Answer- A.
renal failure
A patient with hypotension is in the emergency department being evaluated. The
patient's sodium level has come back at 149 mmol/L. What interventions by the
nurse would be most appropriate in caring for this patient? Select all that apply.
A. Administer hypertonic solution IV as ordered
B. Perform neurological assessments at least every four hours
C. Limit oral intake of sodium
D. Encourage the patient to use incentive spirometry
E. Provide pain medication as ordered prn - Answer- B. Perform neurological
assessments at least every four hours
C. Limit oral intake of sodium
.
Mrs. Brown had just received the diagnosis of colon cancer from her
gastroenterologist. She is crying and visibly upset when the nurse enters her room.
What is the best response from the nurse?
a. I understand that you are upset. Would you like me to arrange for you to meet with
someone who has had the same diagnosis and treatment plan?
b. Would you like to share what is troubling you or would you rather I just sit with you
for a while? Extend your hand to her but wait for her response before responding or
sitting quietly by her waiting for her response.
c. I'm sorry you are feeling so overwhelmed by your diagnosis. I will explain
everything the doctor just told you and the options he gave you. Where would you
like me to begin?
d. Hand Mrs. Brown the teaching materials for her particular type of cancer that
outlines the treatment plans and the preparation for her next appointment. Sit with
her and wait for her respo - Answer- B.
Would you like to share what is troubling you or would you rather I just sit with you
for a while? Extend your hand to her but wait for her response before responding or
sitting quietly by her waiting for her response.
.
What are the items on the CAUTION MODEL/ Seven Danger Signs of Cancer?
Select all that apply:
a. Lump in the breast
b. Change in a wart
c. Hoarseness
d. New onset bladder irritability or incontinence
e. A sore that does not heal
, f. Nipple discharge
h. Dysphagia
i. Nagging cough that won't go away
j. Obvious change in a mole
k. Thickening or change in texture of the skin
l. Change in bowel pattern - Answer- All of the above
What assessment data would cause the nurse to suspect infection in a patient that is
immunosuppressed?
a. Nausea, vomiting
b. Temperature 100.4F or greater
c. Tingling in the fingers or toes
d. Nose bleeds
. - Answer- B.
Temperature 100.4F or greater
.
The nurse is caring for a patient with a massive burn injury and possible
hypovolemia. Which assessment data will be of most concern to the nurse?
A. Blood pressure is 90/40 mm Hg.
B. Urine output is 30 mL over the last hour.
C. Oral fluid intake is 100 mL for the last 8 hours.
D. There is prolonged skin tenting over the sternum. - Answer- A
The blood pressure indicates that the patient may be developing hypovolemic shock
as a result of intravascular fluid loss due to the burn injury. This finding will require
immediate intervention to prevent the complications associated with systemic
hypoperfusion.
The poor oral intake, decreased urine output, and skin tenting all indicate the need
for increasing the patients fluid intake but not as urgently as the hypotension.
A patient who has a small cell carcinoma of the lung develops syndrome of
inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care
provider about which assessment finding?
A. Reported weight gain
B. Serum hematocrit of 42%
C. Serum sodium level of 120 mg/dL
D. Total urinary output of 280 mL during past 8 hours - Answer- C
Hyponatremia is the most important finding to report. SIADH causes water retention
and a decrease in serum sodium level. Hyponatremia can cause confusion and other
central nervous system effects. A critically low value likely needs to be treated.
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