Question 1

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling. The health care provider diagnoses a lateral ankle sprain. Which interventions does the nurse include in the discharge instructions? Select all that apply.

Accepted Answer

A sprain is a stretch and/or tear of a ligament. Treatment for a sprained ankle includes: Rest - Activity should be stopped and movement limited for 24-48 hours to promote healing. The health care provider may prescribe no weight-bearing on the joint for 48 hours, and crutches may be required. Rest - Activity should be stopped and movement limited for 24-48 hours to promote healing. The health care provider may prescribe no weight-bearing on the joint for 48 hours, and crutches may be required. Ice (cold, cryotherapy) - Cold therapy or an ice pack should be applied for 10-15 minutes every hour for the first 24-48 hours. Vasoconstriction helps to reduce pain, inflammation, and swelling. Ice should not be applied directly to the skin. Ice (cold, cryotherapy) - Cold therapy or an ice pack should be applied for 10-15 minutes every hour for the first 24-48 hours. Vasoconstriction helps to reduce pain, inflammation, and swelling. Ice should not be applied directly to the skin. Compression (eg, ACE wrap, splint) - Pressure/compression can help prevent edema and promote fluid return (Option F). Compression (eg, ACE wrap, splint) - Pressure/compression can help prevent edema and promote fluid return (Option F). Elevation - The extremity should be kept elevated above the heart on pillows for 24-48 hours to help reduce swelling by promoting fluid return (Option C). Elevation - The extremity should be kept elevated above the heart on pillows for 24-48 hours to help reduce swelling by promoting fluid return (Option C). Analgesia - Mild analgesia with a nonsteroidal anti-inflammatory drug (eg, ibuprofen) can be taken every 6 hours as needed to relieve pain and reduce swelling (Option E). Analgesia - Mild analgesia with a nonsteroidal anti-inflammatory drug (eg, ibuprofen) can be taken every 6 hours as needed to relieve pain and reduce swelling (Option E). Exercise rehabilitation program - This should be initiated as soon as possible after the injury (ie, when pain subsides) to restore range of motion, flexibility, and strength and prevent reinjury (Option B). Exercise rehabilitation program - This should be initiated as soon as possible after the injury (ie, when pain subsides) to restore range of motion, flexibility, and strength and prevent reinjury (Option B). (Option A) Cold therapy or ice should be used initially; after the first 24-48 hours, moist heat can be applied for 20-30 minutes at a time to reduce swelling, with a cooldown between applications. (Option D) Rest is indicated during the acute injury phase (24-48 hours). After this acute phase, the client is encouraged to use the extremity and move the joint to improve circulation and reduce swelling as long as the joint is protected with some type of immobilizer (eg, brace, tape, splint). Educational objective: Treatment for a sprained joint consists of Rest, Ice, Compression, and Elevation (RICE) for the first 24-48 hours following the injury, mild analgesia with a nonsteroidal anti-inflammatory drug, and an exercise rehabilitation program when pain subsides.

Question 2

The office nurse for an orthopedic health care provider receives 4 telephone messages. Which client does the nurse call back first?

Accepted Answer

The nurse should call the client with the knee replacement first. Cramping calf pain can indicate the presence of a deep vein thrombosis (DVT), which can occur following joint replacement surgery despite prophylactic anticoagulation. This symptom needs immediate intervention with diagnostic testing (eg, venous Doppler study) as a venous embolus can lead to a pulmonary embolus, which is potentially life-threatening. (Option B) Itching is to be expected due to drying of the skin under the cast. The nurse can suggest directing the air from a hair dryer on a cool setting under the cast to help relieve itching. This is not a potentially life-threatening event. (Option C) This client is most likely using the crutches incorrectly or they are not fitted correctly. Pressure on the ulna or radial nerves can lead to numbness and tingling of the fingers and hand weakness. This symptom needs intervention, but it is not potentially life-threatening. (Option D) Pain and swelling are to be expected with an anterior cruciate ligament injury and are treated with RICE (rest, ice, compression, elevation) for 24-48 hours. Pain and a feeling of tightness can indicate an effusion that may require aspiration, but the condition is not potentially life-threatening. Educational objective: Cramping calf pain following joint replacement surgery can indicate the presence of a venous thrombosis and needs immediate intervention with diagnostic testing as the condition is potentially life-threatening.

Question 3

A client is seen in the ambulatory care center for treatment of a second episode of acute gout. Which lifestyle modifications would help prevent future exacerbations? Select all that apply.

Accepted Answer

Gout is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications (Option A). Suggested modifications include: Increasing fluid intake (2 L/day) to help eliminate excess uric acid (Option C) Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines, shellfish) Limiting alcohol intake, especially beer (Option E) Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates (Option B) It is unpalatable and impractical to avoid all foods containing protein. The risk of developing gout increases with high dietary purine intake but not necessarily with protein intake. Low-fat dairy products are good sources of protein that are associated with a reduced risk of gout. (Option D) Increasing intake of meat, especially organ meats, will not prevent future gout attacks but may precipitate them. Educational objective: Weight loss and dietary modifications may reduce the frequency of acute episodes of gout. These strategies include increasing fluids, limiting daily alcohol consumption, and avoiding organ meats and seafood to reduce purine load.

Question 4

The nurse is preparing a symptom management teaching plan for a client diagnosed with carpal tunnel syndrome. Which instruction is appropriate to include in the teaching plan?

Accepted Answer

11ecbb05_ca08_60be_b433_3984222f3ab9_MD0009_00 Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by median nerve compression within the carpal tunnel at the wrist. Nerve compression can occur due to inflammation of the tendons; narrowing or compression of the carpal tunnel; or wrist flexion or extension. Symptoms of CTS are often exacerbated during sleep due to prolonged and unintentional wrist flexion. Most clients with CTS can conservatively manage symptoms with wrist immobilization splints (Option D). Splinting and immobilization of the wrist (particularly during sleep) reduces pain by preventing flexion or extension and subsequent nerve compression. Clients with CTS may require surgery to permanently relieve symptoms. (Options A and C) Instructing clients to perform repetitive hand exercises or wear elastic compression hose could worsen symptoms of CTS by increasing median nerve compression. (Option B) Although educating clients to avoid tobacco and caffeinated products is appropriate to improve general health, avoidance of such substances does not impact symptoms of CTS. Educational objective: Carpal tunnel syndrome (CTS) is pain and paresthesia of the hand caused by compression of a median nerve within the carpal tunnel of the wrist. Clients with CTS are taught to wear wrist immobilization splints, particularly at night, to prevent wrist flexion and subsequent nerve compression to reduce symptoms.

Question 5

The nurse is caring for a client with a fractured femur. Which nursing intervention is most effective in helping reduce the risk for fat emboli?

Accepted Answer

11ecbb05_ca0a_d1c1_b433_6bdd07e9e620_MD0009_00 Fat embolism syndrome (FES) is a life-threatening condition that has no specific treatment. Therefore, prevention, early diagnosis, and immediate management of symptoms are critical. When a long bone is fractured, pressure within the bone marrow leads to release of fat globules into the bloodstream. These combine with platelets (fat embolus) and can travel to the brain, lungs, and kidneys, leading to small-vessel occlusion and tissue ischemia. Therefore, early stabilization of the injury and surgery as soon as possible to repair long bone (eg, humerus, radius, ulna, femur, tibia, fibula) fractures is recommended to reduce further injury to soft tissue. The nurse should minimize movement of the injured extremity to reduce the risk for fat emboli. (Options A and D) Prophylactic anticoagulation, use of intermittent pneumatic compression devices, and early ambulation help reduce the risks for venous thromboembolism (eg, deep vein thrombosis, pulmonary embolus) but not fat emboli. (Option B) Frequent use of incentive spirometry prevents atelectasis and pneumonia. Educational objective: Minimizing movement of a fractured long bone and early stabilization of the injury with surgery reduce the risk for fat emboli.

Question 6

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply.

Accepted Answer

The primary treatment goal for elderly clients with osteoporosis is to prevent bone fracture, especially hip fracture. Teaching to increase bone mineral density and prevent bone loss (resorption) includes: Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast]) Calcium and Vitamin D supplementation (Options A & D) Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls Weight-bearing exercise (eg, walking, dancing) and resistance training (eg, weights) ≥3 times a week for 30 minutes, as increasing mechanical stress on bone increases bone density (Option E) Interventions to prevent falls and resulting hip fracture include: Maintain bed in low and locked position Ensure that call light and personal belongings are within reach Orient client and ensure use of non-skid footwear, eyeglasses and hearing aids, and assist devices if needed Keep environment well-lit and free of clutter (Option B) A client should not be placed on bed rest solely for the prevention of falls. Immobilization actually increases fracture risk due to bone resorption, a condition called disuse osteoporosis. The nurse should encourage and assist with mobility and weight-bearing exercises to prevent muscle atrophy and bone resorption. (Option C) The client may actually incur more injury from a fall if trying to climb over side rails to get out of bed. The nurse should utilize bed alarms if the client is prone to getting out of bed without assistance. Educational objective: An osteoporosis-related fall is the most common cause of hip fracture in the elderly. Interventions to reduce the risk of fall and hip fracture include bisphosphonate medication, calcium and vitamin D supplements, mobility and weight-bearing exercise, smoking cessation, and avoiding excessive use of alcohol.

Question 7

An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10. What should be the nurse's first action?

Accepted Answer

11ecbb05_ca07_9d6d_b433_ddc71fb69c8b_MD0009_00 A Colles' fracture is a type of wrist fracture (distal radius fracture) that causes a characteristic dinner fork deformity of the wrist. It usually occurs when the client tries to break a fall with an outstretched arm or hand, and lands on the heel of the hand. It is one of the most common fractures in women age >50 and is related to osteopenia or osteoporosis. While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED), nursing interventions should include: Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This is the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or arterial/nerve damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is compromised, urgent reduction of the fracture is indicated. Administering analgesia to promote comfort (Option A). Applying an ice pack to the wrist to help reduce edema and inflammation (Option B). Elevating the extremity on a pillow above heart level to reduce edema (Option D). Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion. Educational objective: While a client with a traumatic wrist fracture is undergoing evaluation by the HCP in the ED to determine appropriate treatment, the nurse assesses circulation, sensation, and movement of the affected hand, and then performs nursing interventions to reduce pain and edema.

Question 8

The nurse is assessing a diabetic client for pain following right total knee replacement surgery.  The client reports "numbness and tingling" in the bilateral lower extremities.  Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe.  Which action should the nurse take?

Accepted Answer

11ecbb05_ca03_ccdc_b433_2153f2b5ee34_MD0009_00 Numbness and tingling in both lower extremities are classic examples of neuropathic pain. The common causes of bilateral peripheral neuropathy include the following: Diabetic neuropathy - most common; distribution is usually sock-and-glove pattern Autoimmune neuropathy - Guillain-Barré syndrome Toxic neuropathy - alcohol use Establishing that the sensations the client is experiencing were present before surgery indicates whether this is a complication of surgery. Because the sensation is bilateral and the surgery was on the right knee, the "numbness and tingling" are probably baseline diabetic neuropathy. This should be confirmed by gathering more information from the client (Option B). (Option A) Diabetic neuropathy is not usually treated with traditional post-surgical medications such as opioids. Medications for diabetic neuropathy are usually given on a fixed, timed schedule and include duloxetine, pregabalin, amitriptyline, and gabapentin. If the client uses an as-needed medication, it is important to ask for more information before administering it. The client should be asked whether the pain is baseline and what medication is taken. (Option C) The nurse should question any abnormal finding, whether expected or unexpected. Questioning the client further would allow the nurse to gather more information and confirm that the client's "numbness and tingling" do not indicate a more serious situation. (Option D) It is not necessary to notify the HCP immediately. Bilateral pedal pulses and normal capillary refill indicate sufficient blood flow to the extremities. Educational objective: The nurse should assess for causes of pain and rule out serious complications as part of a pain assessment. Sensations of "numbness and tingling" indicate diabetic neuropathy but should be confirmed as baseline for the client before continuing the assessment.

Question 9

The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which assessment findings would the nurse most likely expect? Select all that apply.

Accepted Answer

11ecbb05_ca0c_3153_b433_af8ecc847002_MD0009_00 The most common clinical manifestations of hip fractures include: Ecchymosis and tenderness over the thigh and hip - occur from bleeding into the surrounding tissue as the femur is very vascular and a fracture can result in significant blood loss (>1000 mL) (Option A) Groin and hip pain with weight bearing (Option B) Muscle spasm in the injured area - occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area (Option D) Shortening of the affected extremity - occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward (Option E) Abduction or adduction of the affected extremity depending on location and mechanism of injury. (Option C) The affected extremity is usually externally rotated. Educational objective: The characteristic clinical manifestations of most hip fractures include external rotation, abduction, muscle spasm, and shortening of the affected extremity.

Question 10

The nurse is educating a client recently diagnosed with rheumatoid arthritis about home care and symptom management. Which of the following client statements indicates a need for further teaching?

Accepted Answer

Rheumatoid arthritis (RA) is a chronic, autoimmune disorder characterized by inflammation and damage to synovial joints; progressive fibrosis of joint membranes results in pain, deformity, and stiffness. Over time, remodeling of joint capsules and associated pain reduce the ability to perform activities of daily living (eg, toileting, bathing, dressing) and engage in routine tasks (eg, walking, opening doors). To maximize functional ability and quality of life, the nurse should educate clients with RA about home-care and symptom-management strategies: Perform gentle range-of-motion exercises daily to maintain joint flexibility (Option A). Apply moist heat packs to stiff joints and ice packs to painful joints (Option B). Plan frequent rest periods to reduce fatigue and inflammation of affected joints during activities (Option D). (Option C) Clients with RA should be instructed to sleep and rest in a flat, neutral position. Body aligners or immobilizers may be used to keep joints straight, but prolonged flexion of joints (eg, elevating knees on pillows) increases the risk of contracture and may hasten decline of joint function. Educational objective: Rheumatoid arthritis, a chronic autoimmune disorder, causes inflammation and remodeling of synovial joints, with progressive loss of functional capacity. Clients should be educated to protect the joints with range-of-motion exercises, allow for periods of rest during activities, use moist heat for stiffness and cold packs for pain, and sleep in a flat, neutral position.

Question 11

The nurse is caring for a client who is 12 hours postoperative total hip replacement.  Which nursing intervention is appropriate to help prevent dislocation of the hip prosthesis?

Accepted Answer

11ecbb05_ca0d_1bb4_b433_9d7d88d8d400_MD0009_00 Maintaining the affected extremity in alignment and avoiding adduction and hip flexion are crucial in the initial postoperative period following a total hip replacement to prevent the prosthesis from becoming displaced or dislocated. Placing an abductor wedge pillow between the legs or placing 2-3 pillows between the knees when turning the client from side to side prevents adduction of the operative extremity and reduces the potential for hip prosthesis dislocation. (Option A) The client is instructed not to cross the legs at the ankles or knees to avoid adduction across the midline. (Option B) The head of the bed should be maintained at ≤60 degrees to prevent excessive hip flexion (>90 degrees). (Option D) The client should not sleep or be turned or positioned on the operative side unless directed by the health care provider. When turning is necessary, the operative hip must be kept in abduction; pillows or a trochanter roll should support the entire length of the leg. Educational objective: Interventions to help prevent dislocation of a hip prosthesis following total hip replacement surgery include positioning the client supine with the head of the bed elevated ≤60 degrees, with the affected extremity in a neutral position; placing an abductor pillow wedge between the legs when turning the client to the unaffected side; and instructing the client to avoid crossing the legs.

Question 12

A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the client's plan of care? Select all that apply.

Accepted Answer

11ecbb05_ca0a_5c90_b433_078f2c6c3ee6_MD0009_00 Buck traction is a type of skin traction used to immobilize hip fractures and reduce pain and spasm until the client can undergo surgical repair of the fracture. A traction boot is applied to the leg, below the fracture site. A weight gently and continuously pulls on the leg and hip, helping maintain alignment of the limb. The nurse should ensure that the traction boot is fitted properly and that the limb remains straight in a neutral position (Option C). Skin traction exerts pressure on nerves, blood vessels, and soft tissue. The nurse should frequently assess neurovascular status (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin integrity in the limb to which the boot is applied (Options A and D). Overall pain level and efficacy of administered pain medications should be monitored closely, as increasing pain in the limb in traction may indicate neurovascular compromise (Option B). (Option E) Side-to-side repositioning of the client in Buck traction can cause injury. Side-to-side position changes cause the affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain and contribute to neurovascular and orthopedic compromise. Educational objective: Buck traction is used to immobilize hip fractures and reduce pain and spasm until the fracture can be repaired surgically. The nurse caring for a client in Buck traction should frequently assess the neurovascular status and skin integrity of the affected limb and maintain it in a straight, neutral position.

Question 13

The nurse provides discharge teaching to a client who had total hip replacement 4 days ago. Which client statement indicates that additional teaching is necessary?

Accepted Answer

To prevent hip prosthesis dislocation following hip arthroplasty, a client must not force the hip into >90 degrees of flexion. Clients should use a chair with armrests and a high firm seat and proceed to place the hands on the armrests for support while lowering themselves onto the seat and when rising from it. Bending forward when getting into a chair creates excessive hip flexion (>90 degrees) and must be avoided. (Option B) The client performs leg exercises 2-3 times a day to help strengthen the muscles surrounding the hip and continues them for several months after discharge. These include isometric quadriceps and gluteal setting, leg raises, and abduction exercises from the supine and standing positions. (Option C) The client must not twist from the waist, reach across the affected extremity, or bend forward >90 degrees when dressing or putting on slippers, shoes, and socks. The client is instructed to use assistive equipment when getting dressed, such as a reacher/grabber, sock puller, or a long-handled shoehorn. (Option D) The client should use a toilet riser or a bedside commode chair with arms to prevent excessive hip flexion when getting on and off the toilet seat. Educational objective: To avoid prosthesis dislocation following hip arthroplasty, key discharge teaching points include performing leg exercises to strengthen the muscles around the hip and avoiding excessive hip flexion (>90 degrees) when sitting, dressing, and toileting.

Question 14

The nurse is assessing a 2-year-old who has a blistered sunburn across the back and shoulders. Which of the following parent statements indicates an appropriate understanding of care for sunburn? Select all that apply.

Accepted Answer

11ecbb05_ca02_bb6b_b433_2596c7221b5b_MD0009_00 Sunburn is a painful inflammatory skin reaction resulting from overexposure to ultraviolet radiation (eg, natural sunlight, tanning beds). Sunburns may be classified as superficial (ie, red, painful) or partial-thickness (ie, blistering, weeping) burns. Severe sunburns may cause systemic symptoms such as fever, chills, nausea, and headache. Sunburns increase insensible fluid loss and place the client at an increased risk for dehydration. Sunburn prevention is important because sunburn may cause permanent skin damage and increases the risk of skin cancers. However, when minor sunburns occur, symptom management includes: Protecting the burned area from further sun exposure (eg, avoid going outside during midday when the sun's rays are hottest) (Option A) Promoting increased fluid intake to avoid dehydration (Option B) Providing pain relief with over-the-counter analgesics such as ibuprofen or acetaminophen (Option C) Reducing inflammation and pain by taking tepid baths; using cool compresses; and applying soothing, protective lotions or gels (eg, aloe vera, calamine) to the sunburned area (Option D) (Option E) Corticosteroid creams (eg, hydrocortisone) have not been shown to reduce symptom severity or healing times. Some preparations can be drying to the skin, which may exacerbate symptoms of sunburn. Educational objective: Sunburn is a painful inflammatory skin reaction that results from overexposure to ultraviolet radiation (eg, sunlight). Care for minor sunburn is symptomatic and involves protecting the burn from further sun exposure, increasing fluid intake, taking mild oral analgesics (eg, acetaminophen), and applying cool compresses and soothing lotions.

Question 15

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures. Which findings does the nurse expect to assess to support this diagnosis? Select all that apply.

Accepted Answer

11ecbb05_ca0b_1fe2_b433_e92084cec026_MD0009_00 FES is a rare, but life-threatening complication that occurs in clients with long bone and pelvis fractures. It can also occur in nontrauma-related conditions, such as pancreatitis and liposuction. It usually develops 24-72 hours following the injury or surgical repair. There are no specific diagnostic tests to identify FES. However, the initial characteristic signs and symptoms include: Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is similar to that of a pulmonary embolus (Option E).Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia (Option A).Petechial rash (eg, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE (Option D).Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction. Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is similar to that of a pulmonary embolus (Option E). Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia (Option A). Petechial rash (eg, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE (Option D). Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction. (Options B and C) Increasing, severe pain unrelieved by opioid analgesia or pain that is disproportionate to the injury and paresthesia (eg, numbness, tingling, burning) of the affected extremity are assessment findings indicative of compartment syndrome. Educational objective: FES presents with a triad of respiratory distress, mental status changes, and petechial skin rash. Fever and thrombocytopenia can also be present.

Question 16

The nurse teaches a client with osteopenia, who is lactose intolerant, how to increase dietary calcium and vitamin D intake. Which lunch food is the best choice?

Accepted Answer

11ecbb05_ca0d_90e5_b433_6d944a19d746_MD0009_00 Osteopenia is more than normal bone loss for the client's age and sex. Adequate dietary intake of calcium and vitamin D is necessary to promote bone growth, prevent resorption (bone loss), and prevent progression to osteoporosis. Milk and milk products are the best sources of calcium. However, other food sources are available for individuals who are lactose intolerant. They include some fish (eg, sardines, salmon, trout), tofu, some green vegetables (eg, spinach, kale, broccoli), and almonds. Good food sources of vitamin D include egg yolks and oily fish (eg, salmon, sardines, tuna). Canned sardines are the best choice as sardines are an excellent source of calcium and vitamin D (Option B). (Options A, C, and D) These foods have only small amounts of calcium per serving and no vitamin D. Educational objective: Sardines are a good alternate dietary source of both calcium and vitamin D for individuals who are lactose intolerant.

Question 17

A client with advanced osteoarthritis is admitted for right total knee arthroplasty. Which characteristic manifestations does the nurse expect to assess in this client? Select all that apply.

Accepted Answer

11ecbb05_ca0f_65a6_b433_1f28d28f65ff_MD0009_00 Osteoarthritis (OA) is a degenerative disorder of the synovial joints (eg, knee, hip, fingers) that causes progressive erosion of the articular (joint) cartilage and bone beneath the cartilage. As the degenerative process continues, bone spurs (osteophytes), calcifications, and ulcerations develop within the joint space, and the "cushion" between the ends of the bones breaks down. Clinical manifestations of OA of the knee include: Pain exacerbated by weight-bearing activities: Results from synovial inflammation, muscle spasm, and nerve irritation (Option D) Crepitus, a grating noise or sensation with movement that can be heard or palpated: Results from the presence of bone and cartilage fragments that float in the joint space (Option A) Morning stiffness that subsides within 30 minutes of arising (Option C) Decreased joint mobility and range of motion Atrophy of the muscles that support the joint (eg, quadriceps, hamstring) due to disuse (Option B) Low-grade fever develops as part of systemic inflammation. OA is typically a noninflammatory, nonsystemic disorder. Occasional OA inflammation is limited to affected joints. (Option E) Serum rheumatoid factor is positive in clients with systemic rheumatoid arthritis. No diagnostic laboratory tests or biomarkers exist for OA. Educational objective: Osteoarthritis is a degenerative disorder of the synovial joints that leads to progressive erosion of the articular (joint) cartilage. Clinical manifestations include pain exacerbated by weight-bearing, crepitus, morning stiffness subsiding within 30 minutes, decreased joint mobility and range of motion, and atrophy of supporting muscles.

Question 18

A client involved in a motor vehicle collision reports severe pelvic and right heel pain. While waiting for imaging, the nurse assesses the client. Which finding should the nurse report to the health care provider immediately?

Accepted Answer

Motor vehicle collisions and motorcycle crashes, followed by falls, are the most common mechanisms for pelvic fractures. The pelvis contains several large vascular structures (eg, internal and external iliac veins and arteries) and abdominal and pelvic organs (eg, small bowel, sigmoid colon, bladder, urethra, uterus, prostate). Therefore, when caring for a client with a fractured pelvis, in addition to pain, the nurse should assess for internal hemorrhage (eg, abdominal distension, vital signs, hematocrit, hemoglobin), paralytic ileus (eg, bowel sounds), neurovascular deficits (eg, extremity circulation, sensation, movement), and abdominal and genitourinary organ injuries (eg, hematuria, urine output <0.5 mL/kg/hr). Abdominal distension could be due to serious intra-abdominal bleeding or injury to the bowel or urinary structures. Absent bowel sounds can indicate the presence of a paralytic ileus related to the trauma and/or a retroperitoneal hematoma; these should be reported to the health care provider (HCP) (Option A). (Options B and D) Tenderness, bruising, and ecchymosis over the injured bones are expected and do not need to be reported to the HCP. However, it would be important to communicate ecchymosis over the suprapubic area to the HCP as this could indicate organ damage and internal hemorrhage. (Option C) Hemoglobin of 11.5 g/dL (115 g/L) and hematocrit of 34% (0.34) are slightly lower than normal and may be from the bleeding. During the acute hemorrhage, hemoglobin and hematocrit can be normal and will take some time to reduce to significant levels. This is a second priority over actual bleeding findings. Educational objective: The pelvis contains vascular structures and pelvic organs. Significant internal hemorrhage is common with pelvic fractures and can manifest as abdominal distension and paralytic ileus.

Question 19

The nurse is caring for a woman with obesity who is 3 days postoperative total hip joint replacement. Which laboratory value is of greatest concern and should be reported to the health care provider (HCP) immediately?

Accepted Answer

Infection is a major complication associated with joint replacement surgery. A client with obesity (body mass index ≥30 kg/m²) is at even greater risk for infection due to inadequate tissue oxygenation as the vascularity of adipose tissue is decreased. This client is also at increased risk for postoperative pneumonia because obesity can lead to impaired pulmonary function, sleep apnea, and obesity hypoventilation syndrome. Leukocytosis can indicate a wound infection or postoperative pneumonia. Therefore, the increased WBC count (>11,000 mm³ [11.0 ×10⁹/L]) is of greatest concern and should be reported to the HCP immediately (Option D). (Option A) The BUN is slightly above the normal limits (6-20 mg/dL [2.1-7.1 mmol/L]) and is not the greatest concern. (Option B) The glucose is elevated (normal, 70-110 mg/dL [3.9-6.1 mmol/L]). However, the recommended random glucose level for hospitalized clients is <180 mg/dL (10 mmol/L); the recommended level before meals is <140 mg/dL (7.8 mmol/L). Obesity is often associated with metabolic syndrome and insulin resistance, and the physiologic stress of surgery can contribute to hyperglycemia as well. Although the nurse will report the glucose level and continue to monitor it, the level is not the greatest concern. (Option C) Decreased hematocrit (normal adult female 35%-47% [0.35-0.47]), and hemoglobin levels (normal 11.7-15.5 g/dL [117-155 g/L]) are to be expected in a client who has undergone joint replacement due to blood loss during the surgery. The nurse will continue to monitor these, but the current levels are not the greatest concern. Educational objective: Infection is a major complication associated with joint replacement surgery, and clients with obesity are at even greater risk. The nurse should notify the HCP immediately of any signs of postoperative wound infection (eg, leukocytosis, fever, increased wound drainage, erythema, increased pain).

Question 20

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction.  The RN intervenes when the GN performs which action?

Accepted Answer

11ecbb05_ca09_4b1f_b433_5db14db352d4_MD0009_00 Buck's skin traction maintains proper alignment of an injured body part by using weights to apply a continuous pulling force. Appropriate actions for a client in Buck's skin traction include: The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding (Option A). Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes (Option C). Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort (Option D). Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity (Option B). Skeletal traction is applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible. Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening situation. Educational objective: To maintain effective pull and avoid interrupting traction, weights should be free-hanging at all times. Proper body alignment should be maintained with the client supine or in semi-Fowler's position (maximum 30 degrees). The nurse should monitor the neurovascular status and skin integrity of the limb in traction.

Exam 1: Adult Health

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The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action?