Combo with "Test 2 Combo with "Diabetes chapter 51 respiratory ch 20" and 9 others" and 2 others

A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse’s most plausible conclusion based on this assessment finding?
The patient’s insulin levels are inadequate.
Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating
A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes?
Fasting plasma glucose greater than or equal to 126 mg/dL
Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL, or a fasting plasma glucose greater than or equal to 126 mg/dL.
A patient newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline would be important to teach the patients at this class?
Most calories should be derived from carbohydrates.
recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein
A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that which of the following nonpharmacologic measures will decrease the body’s need for insulin?
Exercise
Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels.
A medical nurse is caring for a patient with type 1 diabetes. The patient’s medication administration record includes the administration of regular insulin three times daily. Knowing that the patient’s lunch tray will arrive at 11:45, when should the nurse administer the patient’s insulin?
11:15
Regular insulin is usually administered 20-30 min before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.
A patient has just been diagnosed with type 2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient?
A biguanide
Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective
A diabetes nurse educator is teaching a group of patients with type 1 diabetes about “sick day rules.” What guideline applies to periods of illness in a diabetic patient?
Do not eliminate insulin when nauseated and vomiting
Rather, they should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent, small portions of carbohydrates.
The nurse is discussing macrovascular complications of diabetes with a patient. The nurse would address what topic during this dialogue?
The fact that patients with diabetes have an elevated risk of myocardial infarction
Myocardial infarction and stroke are considered macrovascular complications of diabetes,
while the effects on vision and renal function are considered to be microvascular.
A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individual’s risk for developing diabetes?
Lose weight, if obese.
Obesity is a major modifiable risk factor for diabetes.
A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia and is subsequently diagnosed with diabetes. Based on the fact that the child’s pancreatic beta cells are being destroyed, the patient would be diagnosed with what type of diabetes?
Type 1 diabetes Beta cell destruction is the hallmark of type 1 diabetes
A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the patient the etiology of type 1 diabetes, what process should the nurse describe?
“Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down.”
Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia
. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia.
. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not “make” glucose
An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as suggestive of diabetes?
“Lately, I drink and drink and can’t seem to quench my thirst.”
Classic clinical manifestations of diabetes include the “three Ps”: polyuria, polydipsia, and polyphagia
A diabetes educator is teaching a patient about type 2 diabetes. The educator recognizes that the patient understands the primary treatment for type 2 diabetes when the patient states what?
“I will make sure to follow the weight loss plan designed by the dietitian.”the primary treatment of type 2 diabetes is weight loss.
A diabetes nurse educator is presenting the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADA’s recommendations include?
50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein
An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient’s daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?
Fluid and electrolyte replacement
The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration
A nurse is caring for a patient with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the patient’s ability to prepare and self-administer insulin?
Observe the patient drawing up and administering the insulin.
Nurses should assess the patient’s ability to perform diabetes related self-care as soon as possible during the hospitalization or office visit to determine whether the patient requires further diabetes teaching.
An elderly patient comes to the clinic with her daughter. The patient is a diabetic and is concerned about foot care. The nurse goes over foot care with the patient and her daughter as the nurse realizes that foot care is extremely important. Why would the nurse feel that foot care is so important to this patient?
Avoiding foot ulcers may mean the difference between institutionalization and continued independent living.
The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important
A diabetic educator is discussing “sick day rules” with a newly diagnosed type 1 diabetic. The educator is aware that the patient will require further teaching when the patient states what?
I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours.”
The nurse must explanation the “sick day rules” again to the patient who plans to stop taking insulin when sick
Which of the following patients with type 1 diabetes is most likely to experience adequate glucose control?
A patient who adheres closely to a meal plan and meal schedule
A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test, which reveals gestational diabetes. The patient is shocked by the diagnosis, stating that she is conscientious about her health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor?
The effects of hormonal changes during pregnancy
A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur?
Middle-aged or older people with either type 2 diabetes or no known history of diabetes
HHS occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes.
A nurse is caring for a patient newly diagnosed with type 1 diabetes. The nurse is educating the patient about self-administration of insulin in the home setting. The nurse should teach the patient to do which of the following?
Avoid using the same injection site more than once in 2 to 3 weeks.
A patient with type 2 Dm achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the patient has required insulin injections on 2 occasions. nurse would identify what likely cause for this short-term change in treatment?
Stress has likely caused an increase in the patient’s blood sugar levels
During periods of physiologic stress, such as surgery, blood glucose levels tend to increase, because levels of stress hormones epinephrine, norepinephrine, glucagon, cortisol, and growth hormone
A physician has explained to a patient that he has developed diabetic neuropathy in his right foot. Later that day, the patient asks the nurse what causes diabetic neuropathy. What would be the nurse’s best response?
The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years.”
The etiology of neuropathy may involve elevated blood glucose levels over a period of years
A patient with type 2 diabetes has been managing his blood glucose levels using diet and metformin Glucophage Following an ordered increase in the patient’s daily dose of metformin, the nurse should prioritize which of the following assessments?
Reviewing the patient’s creatinine and BUN levels
Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the patient’s renal function
A patient with a longstanding diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the patient for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis?
Infection Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections
A patient has been brought to the emergency department by paramedics after being found unconscious. The patient’s Medic Alert bracelet indicates that the patient has type 1 diabetes and the patient’s blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention?
IV administration of 50% dextrose in water
for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia
A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote?
Always carry a form of fast-acting sugar
A nurse is teaching basic “survival skills” to a patient newly diagnosed with type 1 diabetes. What topic should the nurse address?
Recognition of hypoglycemia and hyperglycemia
A nurse is conducting a class on how to self-manage insulin regimens. A patient asks how long a vial of insulin can be stored at room temperature before it “goes bad.” What would be the nurse’s best answer?
“If you are going to use up the vial within 1 month it can be kept at room temperature.”
If a vial of insulin will be used up within 1 month, it may be kept at room temperature
A patient has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the patient and will implement a program of health education. What is the nurse’s priority action?
Assess the patient’s readiness to learn.
Before initiating diabetes education, the nurse assesses the patient’s and family’s readiness to learn
A student with diabetes tells the school nurse that he is feeling nervous and hungry. The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer?
Half of a cup of juice, followed by cheese and crackers
Initial treatment for hypoglycemia is 15 g concentrated carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, or 0.5 cup juice. After initial treatment, the nurse should follow with a snack including starch and protein, such as cheese and crackers, milk and crackers, or half of a sandwich.
A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patient’s initial phase of treatment?
Maintaining and monitoring the patient’s fluid balance
In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin.
A patient has been living with type 2 diabetes for several years, and the nurse realizes that the patient is likely to have minimal contact with the health care system. In order to ensure that the patient maintains adequate blood sugar control over the long term, the nurse should recommend which of the following?
Participation in a support group for persons with diabetes
Participation in support groups is encouraged for patients who have had diabetes for many years as well as for those who are newly diagnosed.
A patient with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the patient?
Avoid hot-water bottles and heating pads.
High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided.
A diabetes nurse is assessing a patient’s knowledge of self-care skills. What would be the most appropriate way for the educator to assess the patient’s knowledge of nutritional therapy in diabetes?
Ask the patient to keep a food diary and review it with the nurse.
Reviewing the patient’s actual food intake is the most accurate method of gauging the patient’s diet
The most recent blood work of a patient with a longstanding diagnosis of type 1 diabetes has shown the presence of microalbuminuria. What is the nurse’s most appropriate action?
Teach the patient about actions to slow the progression of nephropathy.
Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular complication are warranted
A nurse is assessing a patient who has diabetes for the presence of peripheral neuropathy. The nurse should question the patient about what sign or symptom that would suggest the possible development of peripheral neuropathy?
The presence of a tingling sensation
Although approximately half of patients with diabetic neuropathy do not have symptoms, initial symptoms may include paresthesias
prickling, tingling, or heightened sensation) and burning sensations (especially at night). Cold and intense pain are atypical early signs of this complication
A diabetic patient calls the clinic complaining of having a “flu bug.” The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient?
Try to eat small amounts of carbs, if possible.”
For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates
including foods usually avoided, such as juices, regular sodas, and gelatin. Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.
A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? Select all that apply
Glycosuria
Dehydration
Hypernatremia
Hyperglycemia
In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes.
. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space
With glycosuria and dehydration, hypernatremia and increased osmolarity occur.
A patient is having her tonsils removed. The patient asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response?
“The tonsils help to guard the body from invasion of organisms.”
The tonsils, the adenoids, and other lymphoid tissue encircle the throat
These structures are important links in the chain of lymph nodes guarding the body from invasion of organisms entering the nose and throat.
The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what? Shunting
Shunting appears to be the main cause of hypoxia after thoracic or abdominal surgery and most types of respiratory failure
The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?Perform a swallowing assessment
Coughing after food intake may indicate aspiration of material into the tracheobronchial tree; a swallowing assessment is thus indicated
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patient’s chest and hears wheezing throughout the lung fields. What might this indicate?The patient has a narrowed airway.
Wheezing is a high-pitched, musical sound that is often the major finding in a patient with bronchoconstriction or airway narrowing
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patient’s blood?An arterial blood gas (ABG) study
ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids?Presence of a cough and gag reflex
After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours.
A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? Tidal volume
Tidal volume refers to the volume of air inspired and expired with a normal breath.
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patient’s arterial oxygen saturation (SaO2). What procedure will best accomplish this? Pulse oximetry
A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patient’s resonating chamber in speech? Paranasal sinuses
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position?
Turn the patient to enable assessment of all the patient’s lung fields.
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurse’s respiratory assessment findings would be most consistent with this diagnosis?
Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
Assessment findings consistent with a pleural effusion include affected lung fields being dull to percussion and absence of breath sounds
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patient’s room. The nurse asks the patient when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take?
Discard the specimen and assist the patient in obtaining another specimen.Sputum samples should be submitted to the laboratory as soon as possible.
The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patient’s sternum. This patient’s health record should note the presence of what chest deformity?A funnel chest
A funnel chest occurs when there is a depression in the lower portion of the sternum, and this may lead to compression of the heart and great vessels, resulting in murmurs.
The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance?
Emphysema High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, in conditions such as emphysema.
A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patient’s physician because these symptoms are suggestive of what?
Infection
The nature of the sputum is often indicative of its cause. A profuse amount of purulent sputum thick and yellow, green, or rust-colored or a change in color of the sputum is a common sign of a bacterial infection
. Pink-tinged mucoid sputum suggests a lung tumor. Profuse, frothy, pink material, often welling up into the throat, may indicate pulmonary edema
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
Crackles reflect underlying inflammation or congestion and are often present in such conditions as pneumonia, bronchitis, and congestive heart failure
A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure?
The maximal volume of air exhaled from the point of maximal inspiration
Vital capacity is measured by having the patient take in a maximal breath and exhale fully through a spirometer
While assessing an acutely ill patient’s respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?
Biot’s respiration
Biot’s respiration is characterized by periods of normal breathing three to four breaths followed by varying periods of apnea (usually 10 seconds to 1 minute
The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess
Confusion and lethargy
Lidocaine may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort during a bronchoscopy
After the procedure, the nurse will assess for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine administered during the procedure.
While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurses auscultates. The nurse notes that the patient’s voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented?
Egophony
This finding would be documented as egophony, which can be best assessed by instructing the patient to repeat the letter E. The distortion produced by consolidation transforms the sound into a clearly heard A rather than E
The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, “What exactly is this test for?” What would be the nurse’s best response?
A PFT measures how much air moves in and out of your lungs when you breathe.”
PFTs are routinely used in patients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction.
Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange
A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?
Adequate flow of blood through the pulmonary circulation.
Pulmonary perfusion is the actual blood flow through the pulmonary circulation.
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis?
Their location over a specific area of the lung
A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?
Perfusion
Perfusion is influenced by alveolar pressure
A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe?
It lubricates the movement of the thorax and lungs.
The visceral pleura cover the lungs; the parietal pleura line the thorax.
The visceral and parietal pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with each breath.
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?
Impaired gas exchange
The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange.
The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend?
An adequate ventilation-perfusion ratio
Adequate gas exchange depends on an adequate ventilation-perfusion ratio.
The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurse’s postprocedure care?
Maintaining the patient’s chest tube
Chest tube drainage is required after mediastinotomy
The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following?
Shortness of breath
Follow-up care in the health care facility and at home involves monitoring the patient for shortness of breath which might indicate a pneumothorax
A gerontologic nurse is analyzing the data from a patient’s focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change?
Decreased diffusion capacity for oxygen
The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate?
Faint breath sounds with prolonged expiration
The breath sounds of the patient with emphysema are faint or often completely inaudible. When they are heard, the expiratory phase is prolonged.
The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be order to assess for what in this patient?
Chest wall invasion
MRI is used to characterize pulmonary nodules; to help stage bronchogenic carcinoma assessment of chest wall invasion
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample?
First thing in the morning
Sputum samples ideally are obtained early in the morning before the patient has had anything to eat or drink.
The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what?
Asthma Sibilant wheezes are commonly associated with asthma
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure?
Withhold food and fluids for several hours before the test.
Food and fluids are withheld for 4 to 8 hours before the test to reduce the risk of aspiration when the cough reflex is blocked by anesthesia
A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state?
The patient’s tissue demands may be met, but she will be unable to respond to physiological stressors.
With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiological stresses that increase tissue oxygen demand
A medical patient rings her call bell and expresses alarm to the nurse, stating, “I’ve just coughed up this blood. That can’t be good, can it?” How can the nurse best determine whether the source of the blood was the patient’s lungs?
Try to see if the blood is frothy or mixed with mucus.
Though not definitive, blood from the lung is usually bright red, frothy, and mixed with sputum.
The nurse is completing a patient’s health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?
Do you currently smoke, or have you ever smoked?”
Smoking the single most important contributor to lung disease, exceeds the significance of environmental, occupational, and genetic factors.
A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment?
On a scale from 1 to 10, how bad would rate your shortness of breath?”Gauging the severity of the patient’s dyspnea is an important part of the nursing process
The nurse has assessed a patient’s family history for three generations. The presence of which respiratory disease would justify this type of assessment?Asthma
Asthma is a respiratory illness that has genetic factors. Sleep apnea, pneumonia, and pulmonary edema lack genetic risk factors.
The client has been diagnosed with diabetes mellitus type 1. He asks the nurse what this means. What is the best response by the nurse?
Without insulin you will develop ketoacidosis (DKA).”
“The endocrine function of your pancreas is to secrete insulin, but it isn’t working.””It means your pancreas cannot secrete insulin.”
The physician orders insulin lispro (Humalog), 10 units for the client. When will the nurse administer this medication? 5 minutes before a meal
The onset of action for insulin lispro Humalog is 10 to 15 minutes so it must be given when the client is eating
The physician writes orders for the client with diabetes mellitus. Which order would the nurse validate with the physician?
Lantus insulin is usually prescribed in once-a-day dosing so an order for BID dosing should be validated with the physician.
A client with diabetes mellitus type 1 is found unresponsive in the clinical setting. Which nursing action is a priority?Treat the client for hypoglycemia.
When a client with diabetes mellitus type 1 is found unresponsive, the nurse should focus on and treat for hypoglycemia, as this is more likely than hyperglycemia.
The nurse makes a home visit to a client with diabetes mellitus. During the visit, the nurse notes that the client’s 3-month supply of insulin vials that were delivered a week ago are not refrigerated. What is the best action by the nurse at this time?
Vials can be stored at room temperature up to one month. For longer storage, they should be refrigerated.
The nurse has finished teaching a client with diabetes mellitus how to administer insulin. The nurse evaluates that learning has occurred when the client makes which statement?
“I should only use a calibrated insulin syringe for the injections.”
To ensure the correct insulin dose, a calibrated insulin syringe must be used.
A client with DM is taking oral agents, and is scheduled for a diagnostic test that requires him to be NPO and to have contrast dye. What is the best plan by the nurse with regard to giving the client his oral medications?
notify the client’s physician and request orders.
The client has diabetes mellitus type 2. The nurse has taught the client about the illness and evaluates that learning has occurred when the client makes which statement?
My cells cannot use the insulin my pancreas makes.”
The client has type 1 diabetes and receives insulin. He asks the nurse why he can’t just take pills instead. What is the best response by the nurse?
Insulin can’t be in a pill because it is destroyed in stomach acid.”
The nurse teaches a class for the public about diabetes mellitus. Which individual does the nurse assess as being at highest risk for developing diabetes?
The 42-year-old client who is 50 pounds overweight
Obesity increases the likelihood of developing diabetes mellitus due to overstimulation of the endocrine system.
The client injects his insulin as prescribed, but then gets busy and forgets to eat. What is the nurse’s most likely assessment finding?
the client will have moist skin
The client receives metformin Glucophage What will the best plan by the nurse include with regard to patient education with this drug?
It decreases sugar production in the liver.
It reduces insulin resistance.
The client has diabetes type 1 and receives insulin for glycemic control. The client tells the nurse that she likes to have a glass of wine with dinner. What will the best plan by the nurse for client education include?
The alcohol could predispose you to hypoglycemia.
The client has type 1 diabetes mellitus and receives insulin. Which laboratory test will the nurse assess?
Insulin causes potassium to move into the cell and may cause hypokalemia.
The physician orders intravenous (IV) insulin for the client with a blood sugar of 563. The nurse administers insulin lispro Humalog intravenously (IV). What does the best evaluation by the nurse reveal?
Regular insulin is the only insulin that can be given intravenously
Insulin is released when
blood glucose increases.
What is the primary function of the islets of Langerhans in the pancreas?
Secretion of glucagon and insulin
Which sign or symptom is most typical of an untreated client with type 1 diabetes?
Fatigue is a typical sign/symptom of type 1 DM due to sustained hyperglycemia.
The nurse understands that which of the following drugs falls under the classification of biguanides?
Metformin HCI is the only drug that falls within the classification of biguanides.
The mechanism of action of regular insulin is to
The action of regular insulin is to promote entry of glucose into the cells, thereby lowering glucose.
The mother of a 4-year-old boy states, “I can’t believe my son has type 1 diabetes. We eat well and I was so careful during the pregnancy. What could have caused this?” How should the nurse respond?
Are there others in your family that have type 1 diabetes?”
We are not certain what causes type 1 diabetes.”
“It is thought to be a combination of factors.”
A client, newly diagnosed with type 1 diabetes, says, “I have heard this is a bad disease. What complications could I have?” How should the nurse respond?
Problems with arteries can occur that may cause such problems as heart disease, stroke, kidney disease, or blindness.”
You could have nerve problems that lead to numbness or tingling in your feet or hands.”
“One of the most serious complications is diabetic ketoacidosis.”
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A client has been prescribed e. What medication education should the nurse provide?
“You should take this medication twice each day.”
You may develop diarrhea while taking this drug.”
“This drug will help you secrete more insulin.”
A nurse has provided education regarding type 2 diabetes to a newly diagnosed client. Which statements would the nurse interpret as indicating need for additional education?
Well, at least the medications I will be on will help me lose weight.”
“I can take an oral medication and will never have to inject myself.”
“I don’t run the risk of blindness and kidney disease like type 1 diabetics.”
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A nurse is reviewing the blood work of a client who has recently begun treatment for type 2 diabetes. Which results would indicate that the client is on target with therapy?
HBA1C level is 6.3%.
Fasting blood glucose is 100 g/dL.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?
Dyspnea and substernal pain
Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period.
Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?
The cough reflex is depressed.
Disadvantages include suppression of the patient’s cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop,
What would the critical care nurse recognize as a condition that may indicate a patient’s need to have a tracheostomy?A patient requires permanent ventilation
A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient.
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate?Monitor cuff pressure every 8 hours.
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient?How to splint the incision when coughing
Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel.
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for?
Removing excess air and fluid
Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood.
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove air from the pleural space
Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood.
A patient’s plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?
Assist the patient into a position that will allow gravity to move secretions.
Postural drainage is usually performed two to four times per day. The patient uses gravity to facilitate postural draining.
The skin should be covered with a cloth or a towel during percussion to protect the skin
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
Monitor the pressure in the cuff at least every 8 hours
Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours
by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?
Baseline arterial blood gas (ABG) levels
Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patient’s closed chest-drainage system. What should the nurse conclude?
The system has an air leak.
Constant bubbling in the chamber often indicates an air leak and requires immediate assessment and intervention.
A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient?
Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.
If the patient uses an alternative method of communication, he will feel in better control and likely be less frustrated
The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patient’s high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurse’s best response?
CPAP allows a lower percentage of oxygen to be used with a similar effect.
Prevention of oxygen toxicity is achieved by using oxygen only as prescribed
The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment?
The patient desires a portable oxygen delivery system that can deliver 2 L/min.
They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%
While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?
When adventitious breath sounds are auscultated
Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present.
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?
Removal from the ventilator, tube, and then oxygen
The process of withdrawing the patient from dependence on the ventilator takes place in three stages: the patient is gradually removed from the ventilator, then from the tube, and, finally, oxygen.
The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?
Pulmonary function studies
Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue
The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge?
Perform shoulder exercises five times daily.
The nurse emphasizes the importance of progressively increased activity
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order?
Venturi mask
The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive
The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patient’s needs?
Nasal cannula
A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?
Maintaining a patent airway
The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse’s first step in the suctioning process?
Assess the patient’s lung sounds and SAO2 via pulse oximeter.
Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patient’s level of oxygenation
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?
Stable vital signs and ABGs
Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?
20 cm H2O
The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?
Correct and safe use of oxygen therapy equipment
The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patient’s discharge teaching?
How to perform diaphragmatic breathing
Diaphragmatic breathing is a helpful technique to prepare for proper use of the small-volume nebulizer
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall?
Between 15 and 20 mm Hg
The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan?
Signs of pulmonary infection
The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client?
Teach him how to perform huffing.
The technique of “huffing” may be helpful for the patient with diminished expiratory flow rates or for the patient who refuses to cough because of severe pain
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply.
Chest trauma resulting in pneumothorax
Post thoracotomy
Spontaneous pneumothorax
Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax
The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?
Signs and symptoms of respiratory complications
A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, “I am recovering so slowly. I really thought I would be better by now.” What nursing action should the nurse prioritize?
Provide emotional support to the patient and family
The recovery process may take longer than the patient had expected, and providing support to the patient is an important task for the home care nurse.
A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?
Correct use of incentive spirometry
Instruction in the use of incentive spirometry begins before surgery to familiarize the patient with its correct use
A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patient’s family wants to know why the endotracheal tube cannot be left in place. What would be the nurse’s best response?
When an endotracheal tube is left in too long it can damage the lining of the windpipe.”
The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis?COPD
The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient’s airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed?
Wait several minutes and then repeat suctioning.
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?
Measure the patient’s oxygen saturation
The patient’s response to suctioning is usually determined by performing chest auscultation and by measuring the patient’s oxygen saturation
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?
Chest auscultation
Chest auscultation should be performed before and after postural drainage in order to evaluate the effectiveness of the therapy
A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient?
Breathe in deeply through the spirometer, hold your breath briefly, and then exhale.”
The patient should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth,
and hold the breath at the end of inspiration for about 3 seconds. The patient should then exhale slowly through the mouthpiece
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax.
The nurse observes that the water level in the water seal rises and falls in rhythm with the patient’s respirations. How should the nurse best respond to this assessment finding?
Document that the chest drainage system is operating as it is intended.
Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent
The nurse is providing patient teaching to a young mother who has brought her 3-month-old infant to the clinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent the transmission of organisms to her infant during the cold season?
Handwashing remains the most effective preventive measure to reduce the transmission of organisms
A patient visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the patient to perform which of the following?
Increase fluid intake.
For a patient diagnosed with acute sinusitis, the nurse should instruct the patient that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage.
The nurse is creating a plan of car for a patient diagnosed with acute laryngitis. What intervention should be included in the patient’s plan of care?
Encourage the patient to limit speech whenever possible.
Management of acute laryngitis includes resting the voice, avoiding irritants
resting, and inhaling cool steam or an aerosol. Fluid intake should be increased.
A patient comes to the ED and is admitted with epistaxis. Pressure has been applied to the patient’s midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding?
Silver nitrate application
If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used.
The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?
Ineffective airway clearance related to airway alterations
The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home?
A humidification system
The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer?
Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer
The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn Nasalcrom daily. In providing education for this patient, how should the nurse describe the action of the medication?
It inhibits the release of histamine and other chemicals
Cromolyn Nasalcrom inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis
The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the student’s nose continues to bleed. Which intervention should the nurse next implement?
Insert a tampon in the affected nare
The ED nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from her nose. What should the ED nurse suspect?
Fracture of the cribriform plate
Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid.
A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform?
Apply ice and keep the patient’s head elevated.
The occupational health nurse is obtaining a patient history during a pre-employment physical. During the history, the patient states that he has hereditary angioedema. The nurse should identify what implication of this health condition?
It can cause life-threatening airway obstruction
Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema.
The nurse is conducting a presurgical interview for a patient with laryngeal cancer. The patient states that he drinks approximately six to eight shots of vodka per day. It is imperative that the nurse inform the surgical team so the patient can be assessed for what?
Delirium tremens
Considering the known risk factors for cancer of the larynx, it is essential to assess the patient’s history of alcohol intake
The nurse is explaining the safe and effective administration of nasal spray to a patient with seasonal allergies. What information is most important to include in this teaching?
Overuse of nasal spray may cause rebound congestion
As a clinic nurse, you are caring for a patient who has been prescribed an antibiotic for tonsillitis and has been instructed to take the antibiotic for 10 days. When you do a follow-up call with this patient, you are informed that the patient is feeling better and is stopping the medication after taking it for 4 days.
What information should you provide to this patient?Finish all the antibiotics to eliminate the organism completely.
A nurse practitioner has provided care for three different patients with chronic pharyngitis over the past several months. Which patients are at greatest risk for developing chronic pharyngitis?
Patients who are habitual users of alcohol and tobacco
Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, suffer from chronic chough, and habitually use alcohol and tobacco.
The perioperative nurse has admitted a patient who has just underwent a tonsillectomy. The nurse’s postoperative assessment should prioritize which of the following potential complications of this surgery?
Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage
A 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem?
Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring
The nurse is caring for a patient in the ED for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis?
Humidify the indoor environment.
Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose bleeding, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages
The nurse is caring for a patient who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment?
Assessment of swallowing ability
A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration.
The nurse is performing the health interview of a patient with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the patient about her current medication regimen. Which medication would put the patient at a higher risk for recurrent epistaxis?
Beconase should be avoided in patients with recurrent epistaxis, glaucoma, and cataracts
The nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurse’s assessment addresses the patient’s general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient?
Protein level
Albumin level
Glucose level
The nurse also assesses the patient’s general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the patient’s nutritional status
The nurse is teaching a patient with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this patient about preventing possible drug interactions?
Read drug labels carefully before taking OTC medications.
The nurse is caring for a patient who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the patient asks, “Will this chronic infection hurt my new kidney?” What should the nurse know about chronic rhinosinusitis in patients who have had a transplant?
Taking immunosuppressive drugs can contribute to chronic rhinosinusitis
The nurse is caring for a patient with a severe nosebleed. The physician inserts a nasal sponge and tells the patient it may have to remain in place up to 6 days before it is removed. The nurse should identify that this patient is at increased risk for what?
Toxic shock syndrome
Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome
A nursing student is discussing a patient with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for patients with viral pharyngitis?
Symptom management is the main focus of medical and nursing care.
The nurse is providing patient teaching to a patient diagnosed with acute rhinosinusitis. For what possible complication should the nurse teach the patient to seek immediate follow-up?
Periorbital edema
A patient states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to what factor
The virus is shed for 2 days prior to the emergence of symptoms.Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase
It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis?
Use of warm saline gargles or throat irrigations can relieve symptoms.
The nurse is doing discharge teaching in the ED with a patient who had a nosebleed. What should the nurse include in the discharge teaching of this patient
In case of recurrence, apply direct pressure for 15 minutes.
The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?
Keep a complete suction setup at the bedside.
A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication?
Sinus infections
Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections
A mother calls the clinic asking for a prescription for Amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?
I’ll certainly inform the doctor, but if it is a cold, antibiotics won’t be used because they do not affect the virus.”
The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?
The patient’s airway patency
The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development?
Rapidly assess the patient and notify the surgeon about the patient’s bleeding.
The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?
Tracheoesophageal puncture
Tracheoesophageal puncture is simple and has few complications
A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patient’s nutrition during treatment?
A liquid or soft diet
A liquid or soft diet is provided during the acute stage of the disease, depending on the patient’s appetite and the degree of discomfort that occurs with swallowing
A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, “Does this kind of cancer tend to spread to other parts of the body?”
What is the nurse’s best response?
This cancer usually does not spread to distant sites in the body.”
The nurse is performing preoperative teaching with a patient who has cancer of the larynx. After completing patient teaching, what would be most important for the nurse to do?
Provide the patient with audiovisual materials about the surgery.
A patient’s total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture.
What action should the nurse describe to the patient when teaching him about this process?
Fitting for a voice prosthesis
In patients receiving transesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth
The structure that is responsible for returning oxygenated blood to the heart is the Pulmonary vein.
Chemical receptors that stimulate inspiration are located in the Aorta.
The nurse knows that the primary function of the alveoli is to Carry out gas exchange.
The nurse knows that anemia will result in Hypoxemia.
Patients who are anemic do not have the same level of oxygen-carrying capacity.
The process of exchanging gases through the alveolar capillary membrane is known as Diffusion.
A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find
Decreased tidal volumes.
A C4 injury would result in damage to the phrenic nerve and would cause a decrease in inspiratory lung expansion. Accessory muscles will also be damaged by a C4 injury
The patient may exhibit decreased perfusion and increased hemoglobin to compensate for hypoxemia.
The nurse would expect to see increased ventilations if a patient exhibits Decreased pH.
Retained CO2 creates H+ byproducts that lower pH. This sends a chemical signal to increase respiratory rate and would result in increased ventilation
The nurse recommends that a patient install a carbon monoxide detector in the home because
Carbon monoxide tightly bonds to hemoglobin, causing hypoxia.
Carbon monoxide has a higher affinity for hemoglobin; therefore, oxygen is not able to bond to hemoglobin and be transported to tissues.
While performing an assessment, the nurse hears crackles in the patient’s lung fields. The nurse also learns that the patient is sleeping on three pillows. What do these symptoms most likely indicate? Left-sided heart failure
The nurse knows that a myocardial infarction is an occlusion of what blood vessel?Coronary artery
Myocardial blood flow is unidirectional; the nurse knows that the correct pathway is which of the following?Right atrium, right ventricle, left atrium, left ventricle
The nurse caring for a patient with ischemia to the left coronary artery would expect to find Decreased afterload.
Normal cardiac output is 4 to 6 L/min in a healthy adult at rest. Which of the following is the correct formula to calculate cardiac output?Stroke volume Heart rate
A patient’s heart rate increased from 80 bpm to 160 bpm. The nurse knows that what will follow is a(n) Decrease in cardiac output.
The nurse is careful to monitor a patient’s cardiac output because this helps the nurse to determine
Peripheral extremity circulation.
A nurse is assisting a patient with ambulation. The patient becomes short of breath and begins to complain of sharp chest pain. Which action by the nurse is the first priority?
Have the patient sit down in the nearest chair.
A patient has inadequate stroke volume related to decreased preload. The nurse anticipates ? Verifying that the blood consent form has been signed.
When caring for a patient with atrial fibrillation, the nurse is most concerned with which vital sign?
Oxygen saturation
The nurse would expect a patient with right-sided heart failure to have which of the following?
Peripheral edema
The P wave is represented by which portion of the conduction system?
SA node
Which statement by the patient indicates an understanding of atelectasis?
“It is important to do breathing exercises every hour to prevent atelectasis.”
The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the
Oral mucosa.
A nurse is caring for a patient whose temperature is 100.2° F. The nurse expects this patient to hyperventilate owing to
Increased metabolic demands.
What assessment finding is the earliest sign of hypoxia?
Restlessness
A 5-year-old who has strep throat was given aspirin for fever. The nurse knows to expect which change in the child’s respiratory pattern?
Hyperventilation to decrease serum levels of carbon dioxide
A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery. Upon assessment, the nurse expects to find Crackles in the lungs.
A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what he should eat for breakfast, what should the nurse recommend?A cup of nonfat yogurt with granola, and a handful of dried apricots
Upon auscultation, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is
Regurgitation of the mitral valve.
A nurse caring for a patient with COPD knows that which oxygen delivery device is most appropriate?
Nasal cannula
The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change?Decreased lung defense mechanisms may cause ineffective airway clearance.
The nurse determines that an elderly patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?
Encourage the patient to stay up to date on all vaccinations.
The nurse would expect which change in cardiac output for a patient with fluid volume overload?
Increased preload
A nurse is caring for a patient with COPD who is in recovery for a myocardial infarction. Which of the following nursing actions is the priority?Place the patient on continuous cardiac monitoring.
The nurse expects a patient with angina pectoris to
Experience feelings of indigestion after eating a heavy meal.
A nonmodifiable risk factor for lung disease is
Allergies.
The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal that the patient could achieve?
Sleeping on two to three pillows at night
A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105, blood pressure of 156/90, and a respiration rate of 30. Which nursing diagnosis is the priority for this patient?
Impaired gas exchange
Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?
Assist patient to cough, turn, and deep breathe every 2 hours.
The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician?
Hemoptysis
A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic?
“Your body isn’t receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult.”
A patient with a pneumothorax had a chest tube inserted and was placed on low constant suction. Which finding requires immediate action by the nurse?
No bubbling is present in the suction control chamber of the drainage device.
The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?
Administering humidified oxygen through a tracheostomy collar
The nurse is educating a student nurse on caring for a patient with a chest tube. The nurse knows that teaching has been effective when the student states
“I should report if I see continuous bubbling in the water-seal chamber.”
Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?
Ineffective airway clearance
The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is to
Limit the length of suctioning to 10 to 15 seconds.
The nurse is assessing a patient with a right pneumothorax. Which finding would the nurse expect?
Absence of breath sounds on the right side
The nurse knows that a closed suction device would be most appropriate for which patient?
A 75-year-old with aspiration pneumonia following a stroke
While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. What is the nurse’s first nursing action?
Insert a spare tracheostomy without the obturator.
The client tells the nurse that her symptoms have become worse since she has been using oxymetazoline (Afrin) for nasal congestion. What is the best assessment question for the nurse to ask?
How long have you been using the medication?”
Oxymetazoline (Afrin) can cause rebound congestion if used for too long, so length of treatment is the best assessment question
Which assessment finding, by the nurse, is a priority concern when a client receives pseudoephedrine Sudafed? Heart rate 82 and irregular
Pseudoephedrine may cause dysrhythmias
The elderly client receives diphenhydramine (Benadryl) for allergies. The nurse completes medication education and evaluates that learning has occurred when the client makes which statement?
“Drowsiness is common but should lessen within a few doses.”: Drowsiness is a common adverse effect of antihistamines. The client should develop a tolerance to this effect within a few doses.
The nurse completes medication education for the client receiving antihistamines. The nurse evaluates that learning has occurred when the client makes which statement?”This medication could make me very sleepy.”
Sedation is a common side effect of antihistamines.
The nursing instructor teaches the nursing students about the major functions of the upper respiratory tract. What will the best plan by the nursing instructor include?
The nose warms the air before it reaches the lungs.
The nasal mucosa is the first line of immunological defense.Activation of the sympathetic nervous system constricts arterioles in the nose.
The client has allergic rhinitis and asks the nurse what causes this. How should the nurse respond? You inherited the predisposition for this.”
It can occur after exposure to animal dander.”
Tobacco smoke causes it in some people.”
“Exposure to pollens from weeds and grass cause an allergic response in some people.”
The nursing instructor teaches the student nurses about histamine receptors and evaluates that further instruction is needed when the students make which statement?
“H1-receptors are found in the stomach.”
The client receives diphenhydramine (Benadryl) to control allergic symptoms. Which common symptom does the nurse teach the client to report to the physician?
Urinary hesitancy
Urinary hesitancy is an anticholinergic effect of diphenhydramine (Benadryl) and should be reported to the physician.
The client receives beclomethasone Beconase intranasally as treatment for allergic rhinitis. He asks the nurse if this drug is safe because it is a glucocorticoid. What is the best response by the nurse?
“Intranasal glucocorticoids produce almost no serious adverse effects.”
The nurse teaches the client about the difference between oral and nasal decongestants. The nurse evaluates that learning has been effective when the client makes which statement?
Oral decongestants can cause hypertension.”
A mother asks the nurse when she should give her child cough medicine. What is the best response by the nurse
When he has a dry cough and cannot rest.”
Dry, hacking, and nonproductive cough is irritating to the membranes of the throat and deprives the client of much needed rest, so a cough medicine would be warranted in this case.
The physician prescribes fluticasone Flonase for the client. The nurse would hold the drug and contact the physician with which assessment finding?The client is pregnant.
This is a class C drug so effects on pregnancy are not known; the client should not receive this drug.
The client is very frustrated that pseudoephedrine is no longer stocked on pharmacy shelves. The client does not like to go the pharmacy counter to obtain the drug. What is the best response by the nurse?
This is frustrating, but hopefully it will decrease the amount of methamphetamine being produced.”
Pseudoephedrine (Sudafed) is a major ingredient in the production of methamphetamine
The client takes diphenhydramine (Benadryl), but forgets to tell the physician about this drug when a monoamine oxidase inhibitor drug is prescribed for depression. What will the best assessment by the nurse reveal?
The client may develop a hypertensive crisis.
The combination of diphenhydramine (Benadryl) and a monoamine oxidase inhibitor (MAOI) drug can result in a hypertensive crisis.
The upper respiratory tract (URT) consists of the nose, nasal cavity, pharynx, and paranasal sinuses. It undergoes a process sometimes referred to as
air conditioning.
Antihistamines block the actions of histamine at the
H1 receptor site.
The H1 receptor site is the site for blocking histamine with the use of antihistamines.
Oral decongestants differ from intranasal decongestants in that oral decongestants
.have more systemic effects
Which of the following over-the-counter (OTC) antihistamine combinations contains an analgesic property?
Actifed Plus contains acetaminophen.
Centrally acting antitussives, such as opioids, are used to
relieve severe cough.
The main classification for a prototype drug, such as fexofenadine (Allegra), is a/n
typical second-generation H1-receptor antagonist.
A client calls the nurse help-line and says, “My friend and I have been swimming and drinking beer all day and he took a couple of swigs of Robitussin DM dextromethorphan about 15 minutes ago.
Now he is acting funny and seeing things.” What should the nurse consider when formulating a response?
A client with chronic bronchitis is to start receiving breathing treatments with Acetylcysteine (Mucomyst). Which information should the nurse include in teaching about this medication?
. “This drug is designed to break down and thin the mucus in your lungs.”
“You might experience nausea while using this drug.”
A client has been prescribed the opioid combination drug Hycomine Compound for control of cough. This drug contains hydrocodone, phenylephrine, chlorpheniramine, and acetaminophen. Which instructions should the nurse provide as part of medication education?
“Take this drug exactly as indicated.”
Do not make important decisions or operate machinery while taking this drug.”
Taking too much of this drug can cause oversedation. It also contains acetaminophen which should be taken only as directedThe hydrocodone component of this drug will make the client drowsy and may impact the ability to make decisions.
The client is prescribed a nasal decongestant spray. What information should the nurse include when educating the client about how to use this medication?
“Blow your nose immediately before using the medication.”
“Limit your use of this spray to no more than 5 days.”
“Since you are using more than one type of nasal spray, be sure to wait 5-10 minutes between administrations.”
“You should spit out any excess spray that drains into your mouth.”
A client is prescribed an intranasal corticosteroid. What should the nurse include in client education about this drug?
“You may feel a burning sensation when using this drug.”
. “This medication may dry out your nasal passages enough to cause nosebleed.”
. “Do not eat licorice while taking this drug.”
The client receives albuterol Proventil via inhaler. He asks the nurse why he can’t just take a pill. What is the best response by the nurse?
“When you inhale the drug the blood supply in your lungs picks it up rapidly, resulting in quicker effects.”
The nurse teaches a medication class on bronchodilators for clients with asthma. The nurse evaluates that learning has occurred when the clients make which statement?
The medication widens the airways because it stimulates the fight-or-flight response of the nervous system.”
During the fight-or-flight response, beta2-adrenergic receptors of the sympathetic nervous system are stimulated, the bronchiolar smooth muscle relaxes, and bronchodilation occurs.
The client asks the nurse why she must continue taking her asthma medication even though she has not had an asthma attack in several months. What is the best response by the nurse?
The medication is still needed to decrease inflammation in your airways and help prevent an attack.”
Effective treatment of asthma includes long-term treatment to prevent attacks and decrease inflammation, as well as short-term treatment when an attack occurs.
The nurse plans to teach an adolescent about inhalation therapy as part of the treatment plan for the client’s asthma. What does the best plan by the nurse include?
Inhalation therapy is effective because it goes to the direct site of action in the respiratory tract.
A client receives theophylline Theo-Dur and calls the clinic to say he has had nausea and vomiting for two days. What is the best action by the nurse?
Tell the client to come to the clinic for an assessment.Nausea and vomiting are symptoms of theophylline toxicity; the client needs to come to the clinic for an assessment.
The nurse teaches the client about the use of a metered-dose inhaler (MDI) and spacer. The nurse evaluates that additional teaching is required when the client makes which statement?
I should keep the spacer moist between uses by storing it in a plastic zipbag.”The spacer and inhaler should be rinsed with water and allowed to air-dry.
The client receives beclomethasone (Beconase). What will the best assessment by the nurse include?
Assess the client’s mouth for any sign of fungal infection.
Assess if the client has blown his nose prior to administration of nasal spray.
Assess if the client has had a change in taste.
Assess the client for any hoarseness or change in voice.
The client receives ipratropium Atrovent via inhalation for the treatment of chronic asthma. The nurse plans to do medication education with the client. What will the best plan by the nurse include?
Report any increased dyspnea.
Report any changes in urinary pattern.
Use the medication consistently, not occasionally.
The client receives isoproterenol (Isuprel) via inhalation. The nurse determines that the client is experiencing a side effect of this medication when reviewing which laboratory test?
Glucose of 145
The physician has ordered ipratropium (Atrovent) for the client. What is a priority assessment question for the nurse to ask prior to administering this medication?
“Do you have glaucoma?”
Anticholinergic drugs can worsen narrow angle glaucoma.
The client receives zafirlukast (Accolate) as treatment for asthma. The nurse has completed medication education and evaluates that learning has occurred when the client makes which statement?
“This medication decreases the inflammation in my lungs.”
Zafirlukast (Accolate) prevents airway edema and inflammation by blocking leukotriene receptors in the airways.
The physician has prescribed cromolyn (Intal) for the client with asthma. The nurse plans to do medication education. What will the best plan by the nurse include?
This medication will help prevent asthma attacks.
By reducing inflammation, cromolyn (Intal) is able to prevent asthma attacks.
The nurse is preparing to administer beclomethasone Beconase to several clients. For which client would the nurse hold the drug and contact the physician?
The client who has methicillin resistant Staphylococcus aureus (MRSA)Glucocorticoids can mask the signs of infection, and are contraindicated if active infection is present.
The client receives ipratropium (Atrovent). She tells the nurse she is going to stop it because of the bitter taste in her mouth after using the medication. What is the best response by the nurse?
You can decrease that side effect by rinsing your mouth after use.”Ipratropium (Atrovent) produces a bitter taste
Bronchoconstriction in the airways is stimulated by parasympathetic nervous system.
The nurse understands that one advantage of inhaled pulmonary drugs over oral drugs is that inhaled drugs allow for quick absorption.
Which of the following is true regarding dry powder inhalers (DPI)? The device is activated by inhalation
Leukotriene modifiers are primarily used for prophylaxis of asthma symptoms.Leukotriene modifiers are used primarily for prophylaxis and reducing inflammatory components.
Which of the following statements is true regarding asthma?It has both inflammatory and bronchoconstriction components
Asthma has an inflammatory and a bronchoconstriction component
The nurse would observe for fungal infection of the throat with which class of medications? Glucocorticoids
Glucocorticoids weaken the immune system and cause candidiasis of the throat.
Which of the following is an adverse effect of a beta-adrenergic agonist? Tachycardia
Tachycardia is common, along with restlessness.
A nurse is explaining the process of respiration to a client. Which information should be given?
“Moving air in and out of the lungs is really called ventilation.”
Exchange of oxygen and carbon dioxide occurs across a thin capillary membrane.
Respiration is not effective without perfusion.
Your basic respiratory drive is determined by your brain.
A client says, “My doctor told me that I have COPD and might develop emphysema. I always thought I had chronic bronchitis.” How should the nurse respond to this statement?
COPD is either asthma, chronic bronchitis, or emphysema, or a combination of those disorders.
“As COPD progresses it becomes emphysema.”
“Both diagnoses are correct.”
A client diagnosed with COPD says, “I don’t see why I need to stop smoking. The damage to my lungs is already done.” How should the nurse respond to this statement?
“If you stop smoking now your COPD may not get worse as fast.”
Your symptoms might not be as bad if you aren’t smoking.”
Smoking cessation has been shown to result in fewer respiratory symptoms.Smoking cessation has been shown to slow the progression of COPD.
A client has been prescribed a leukotriene modifier. Which assessment finding would cause the nurse to question this prescription?
The client reports drinking two or three mixed alcohol drinks each day.
The client has chronic hepatitis C.
An 8-year-old child was just diagnosed with asthma. Which assessment questions should the nurse ask the child and parents?
Standard Text: Select all that apply.
“Have you eaten any new foods?” “Are you exposed to anyone who smokes?”
“Have you had your carpet cleaned lately?”
“Has there been a change in laundry products recently?”
A nurse on the orthopedic unit is assessing a patient’s peroneal nerve. The nurse will perform this assessment by doing which of the following actions? Pricking the skin between the great and second toe
The nurse will evaluate the sensation of the peroneal nerve by pricking the skin centered between the great and second toe.
A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability in the United States. The nurse should focus on what health problem? Arthritis
The leading cause of musculoskeletal-related disability in the United States is arthritis.
A nurse is providing care for a patient whose pattern of laboratory testing reveals longstanding hypocalcemia. What other laboratory result is most consistent with this finding?An elevated parathyroid hormone level
In the response to low calcium levels in the blood, increased levels of parathyroid hormone prompt the mobilization of calcium and the demineralization of bone
A nurse is caring for a patient whose cancer metastasis has resulted in bone pain. Which of the following are typical characteristics of bone pain?A dull, deep ache that is “boring” in nature
Bone pain is characteristically described as a dull, deep ache that is “boring” in nature
A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis?Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin
include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness, paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling
An older adult patient has symptoms of osteoporosis and is being assessed during her annual physical examination. assessment shows that the patient will require further testing related to a possible exacerbation of her
osteoporosis. nurse should anticipate what diagnostic test?
Bone densitometry is considered the most accurate test for osteoporosis and for predicting a fracture
A patient injured in a motor vehicle accident has sustained a fracture to the diaphysis of the right femur. Of what is the diaphysis of the femur mainly constructed?
Cortical bone
The long bone shaft, which is referred to as the diaphysis, is constructed primarily of cortical bone.
An older adult patient has come to the clinic for a regular check-up. The nurse’s initial inspection reveals an increased thoracic curvature of the patient’s spine. nurse should document the presence of which of the following?
Kyphosis Kyphosis is the increase in thoracic curvature of the spine.
When assessing a patient’s peripheral nerve function, the nurse uses an instrument to prick the fat pad at the top of the patient’s small finger. This action will assess which of the following nerves?
Ulnar
The ulnar nerve is assessed for sensation by pricking the fat pad at the top of the small finger
The results of a nurse’s musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? Lordosis
. Lordosis is an increase in lumbar curvature of the spine.
The human body is designed to protect its vital parts. A fracture of what type of bone may interfere with the protection of vital organs? Flat bones
Fractures of the flat bones may lead to puncturing of the vital organs or may interfere with the protection of the vital organs.
A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure?Wrap the joint in a compression dressing.
Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs
While assessing a patient, the patient tells the nurse that she is experiencing rhythmic muscle contractions when the nurse performs passive extension of her wrist. What is this pattern of muscle contraction referred to as?Clonus
Clonus may occur when the ankle is dorsiflexed or the wrist is extended
A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. This patient’s prolonged immobility creates a risk for what complication?Muscle atrophy
If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy
nurse is caring for a patient who has been scheduled for a bone scan. What should the nurse teach the patient about this diagnostic test?”You’ll be encouraged to drink water after the administration of the radioisotope injection.
“It is important to encourage the patient to drink plenty of fluids to help distribute and eliminate the isotopic after it is injected
nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child’s muscles have greater-than-normal tone. nurse should document the presence of which of the following? Spasticity
A muscle with greater-than-normal tone is described as spastic.
The nurse’s comprehensive assessment of an older adult involves the assessment of the patient’s gait. How should the nurse best perform this assessment?
Instruct the patient to walk away from the nurse for a short distance and then toward the nurse
A clinic nurse is caring for a patient with a history of osteoporosis. Which of the following diagnostic tests best allows the care team to assess the patient’s risk of fracture? Bone densitometry
Bone densitometry is used to detect bone density and can be used to assess the risk of fracture in osteoporosis
A nurse is performing a musculoskeletal assessment of a patient with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. nurse should document the presence of which of the following?
Crepitus is a grating, crackling sound or sensation that occurs as the irregular joint surfaces move across one another, as in arthritic conditions
A patient’s fracture is healing and callus is being deposited in the bone matrix. This process characterizes what phase of the bone healing process?The reparative phase
Callus formation takes place during the reparative phase of bone healing
A child is growing at a rate appropriate for his age. What cells are responsible for the secretion of bone matrix that eventually results in bone growth?Osteoblasts
Osteoblasts function in bone formation by secreting bone matrix.
A nurse is caring for a patient who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure?
Ensuring that there are no metal objects on or in the patient
A nurse is taking a health history on a patient with musculoskeletal dysfunction. What is the primary focus of this phase of the nurse’s assessment?
Evaluating the effects of the musculoskeletal disorder on the patient’s function
A patient is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. What would be most important for the nurse to assess before the patient’s scan?That the patient emptied the bladder
Before the scan, the nurse asks the patient to empty the bladder, because a full bladder interferes with accurate scanning of the pelvic bones
A nurse is explaining a patient’s decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones?
Thyroid hormone Growth hormone Estrogen
Diagnostic tests show that a patient’s bone density has decreased over the past several years. The patient asks the nurse what factors contribute to bone density decreasing. What would be the nurse’s best response?
“For many people, lack of nutrition can cause a loss of bone density.”
A bone biopsy has just been completed on a patient with suspected bone metastases. What assessment should the nurse prioritize in the immediate recovery period?Assessment for pain
Bone biopsy can be painful and the nurse should prioritize relevant assessments.
A nurse is taking a health history on a new patient who has been experiencing unexplained paresthesia. What question should guide the nurse’s assessment of the patient’s altered sensations?
How does the feeling in the affected extremity compare with the feeling in the unaffected extremity?
The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. The nurse should question the patient about her intake of what nutrients?
Calcium Vitamin D
The nurse is performing an assessment of a patient’s musculoskeletal system and is appraising the patient’s bone integrity. What action should the nurse perform during this phase of assessment?
Compare parts of the body symmetrically.
A nurse is performing a nursing assessment of a patient suspected of having a musculoskeletal disorder. What is the primary focus of the nursing assessment with a patient who has a musculoskeletal disorder?
The nursing assessment is primarily a functional evaluation, focusing on the patient’s ability to perform activities of daily living.
A nurse’s assessment of a teenage girl reveals that her shoulders are not level and that she has one prominent scapula that is accentuated by bending forward. The nurse should expect to read about what health problem in the patient’s electronic health record?
Scoliosis is evidenced by an abnormal lateral curve in the spine, shoulders that are not level, an asymmetric waistline, and a prominent scapula, accentuated by bending forward
A patient is receiving ongoing nursing care for the treatment of Parkinson’s disease. When assessing this patient’s gait, what finding is most closely associated with this health problem? Shuffling gait
A variety of neurologic conditions are associated with abnormal gaits, such as a spastic hemiparesis gait stroke, steppage gait lower motor neuron disease, and shuffling gait Parkinson’s disease
A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication?Fever
Following arthroscopy, the patient and family are informed of complications to watch for, including fever
A patient is undergoing diagnostic testing for suspected Paget’s disease. What assessment finding is most consistent with this diagnosis?Altered serum calcium levels
Serum calcium levels are altered in patients with osteomalacia, parathyroid dysfunction, Paget’s disease, metastatic bone tumors, or prolonged immobilization.
A nurse is caring for a patient with a diagnosis of cancer that has metastasized. What laboratory value would the nurse expect to be elevated in this patient?Alkaline phosphatase
Alkaline phosphatase is elevated during early fracture healing and in diseases with increased osteoblastic activity metastatic bone tumors
A patient has had a cast placed for the treatment of a humeral fracture. The nurse’s most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse’s most appropriate action?
Contact the primary care provider immediately
neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis
A patient has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the patient about what process?
Injection of a contrast agent into the knee joint prior to ROM exercises
The nurse’s musculoskeletal assessment of a patient reveals involuntary twitching of muscle groups. How would the nurse document this observation in the patient’s chart?
Fasciculation is involuntary twitching of muscle fiber groups
A patient has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate which of the following? Arthrocentesis
Arthrocentesis joint aspiration is carried out to obtain synovial fluid for purposes of examination or to relieve pain due to effusion.
A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient?The cast will only have full strength when dry
A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength
patient broke his arm in a accident and required application of a cast. Shortly following application, patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture.
What pathophysiologic process caused this complication? Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist
A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?Buck’s extension traction
Buck’s extension is used for fractures of the proximal femur
A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care?
Assess the pin insertion site every 8 hours.The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites.
A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?Keep the patient’s hips in abduction at all times
The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees.
While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?
Risk for Peripheral Neurovascular Dysfunction
The hematoma may cause an interruption of tissue perfusion.
A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?
“Make sure you don’t bring your knees close together.”
A patient with a fractured femur is in balanced suspension traction. The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do
Maintain consistent traction tension while repositioning.
A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse’s best action?
Assess the surgical site and the affected extremity.
A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?
Give the patient a sterile tongue depressor to use for scratching instead of the pencil.
The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis?
Protect the affected leg from internal rotation
A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication?
Compartment syndrome
The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?
Knots in the rope should not be resting against pulleys.because this interferes with traction.
The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction?
Balanced traction allows for greater patient movement and independence than other forms of traction
The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient’s lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?
Increased warmth of the calf
Signs of DVT include increased warmth, redness, swelling, and calf tenderness
A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session?
Reporting signs of impaired circulation
A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patient’s cast care?
Keep your right leg elevated above heart level.”
An elderly patient’s hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse’s priority assessment?Signs of neurovascular compromise
Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment.
A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient’s statements would indicate to the nurse that the patient requires further teaching?
“I will need my husband to assist me in getting off the low toilet seat at home.”
A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have aperoneal nerve injury?
Numbness and burning of the foot
A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action?Applying a cold pack to the injured site
Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed
A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace?
Preventing additional injury,Providing support
Controlling movement
A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient’s dorsalis pedis or posterior tibial pulse and the patient’s foot is pale. What is the nurse’s most appropriate action?
Promptly inform the primary care provider.
Signs of neurovascular dysfunction warrant immediate medical follow-up.
A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention?Application of a cast
After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone.
A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patient’s affected limb are spastic. How does this change in muscle tone affect the patient’s traction prescription?
Extra weight is needed initially to keep the limb in proper alignment.and overcome the shortening spasms of the affected muscles. As the muscles relax, the weight is reduced to prevent fracture dislocation and to promote healing.
A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient’s care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
Risk for Impaired Skin Integrity
Impaired skin integrity is a high-probability risk in patients receiving traction
nurse is caring for a patient receiving skeletal traction. Due to the patient’s severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention will the nurse provide in order to prevent these complications?
Teach the patient to perform deep breathing and coughing exercises.To prevent these complications, the nurse should educate the patient about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions.
nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
Teach the patient to perform ankle and foot exercises within the limitations of traction The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT
A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?
Autologous blood donation
Autologous blood donations are cost effective and eliminate many of the risks of transfusion therapy
The nurse is helping to set up Buck’s traction on an orthopedic patient. How often should the nurse assess circulation to the affected leg?
Within 30 minutes, then every 1 to 2 hours
A nurse is assessing a patient who is receiving traction. The nurse’s assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding?
The patient’s tibial nerve is functional.
Plantar flexion demonstrates function of the tibial nerve
A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions?
Turning from side to side
however, the patient may shift position slightly with assistance.
A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge?
Patient is able to perform transfers safely.
A nurse is caring for a patient who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the patient faces a high risk of what infectious complication?
Osteomyelitis
A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement?
The physical therapist will likely help you get up using a walker the day after your surgery.”
A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours.
How should the nurse best respond to this assessment finding?Document this as an expected assessment finding.
A nurse is reviewing a patient’s activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?Bending down to put on socks
Bending to put on socks or shoes can cause hip dislocation.
A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patient’s plan of care. What intervention is most justified in the care of this patient?
Use of a pressure-relieving mattress
A nurse is emptying an orthopedic surgery patient’s closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse’s best action?
Inform the surgeon of this finding.The nurse should promptly notify the surgeon of excessive or foul-smelling drainage.
A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurse’s choice of interventions?
Improving the patient’s level of function
A nurse is caring for an adult patient diagnosed with a back strain. What health education should the nurse provide to this patient?
Avoid lifting more than one-third of body weight without assistance
A nurse is discussing conservative management of tendonitis with a patient. Which of the following may be an effective approach to managing tendonitis?
Intermittent application of ice and heat
A patient presents at a clinic complaining of pain in his heel so bad that it inhibits his ability to walk. The patient is subsequently diagnosed with plantar fasciitis. This patient’s plan of care should include what intervention?
Gently stretching the foot and the Achilles tendon
A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis,
the nurse should encourage participants to ensure that they consume the recommended adequate intake of what nutrients? Calcium Vitamin D
A nurse is providing a class on osteoporosis at the local seniors’ center. Which of the following statements related to osteoporosis is most accurate?
Slow discontinuation of corticosteroid therapy can halt the progression of the osteoporosis
A nurse is teaching a patient with osteomalacia about the role of diet. What would be the best choice for breakfast for a patient with osteomalacia?
Cereal with milk, a scrambled egg, and grapefruit
nurse is caring for a patient with Paget’s disease and is reviewing the patient’s most recent laboratory values. Which of the following values is most characteristic of Paget’s disease?
An elevated serum alkaline phosphatase level and a normal serum calcium level
Which of the following patients should the nurse recognize as being at the highest risk for the development of osteomyelitis
An elderly patient with an infected pressure ulcer in the sacral area
Patients who are at high risk of osteomyelitis include those who are poorly nourished, elderly, and obese
A nurse is caring for a patient with a bone tumor. The nurse is providing education to help the patient reduce the risk for pathologic fractures. What should the nurse teach the patient?
Support the affected extremity with external supports such as splints.
A patient presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?
Sciatica
A patient tells the nurse that he has pain and numbness to his thumb, first finger, and second finger of the right hand. The nurse discovers that the patient is employed as an auto mechanic, and that the pain is increased while working.
This may indicate that the patient could possibly have what health problem Carpel tunnel syndrome
A nurse is assessing a patient who reports a throbbing, burning sensation in the right foot. The patient states that the pain is worst during the day but notes that the pain is relieved with rest.
The nurse should recognize the signs and symptoms of what health problem? Morton’s neuroma
A nurse is reviewing the pathophysiology that may underlie a patient’s decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?
Calcitonin
Calcitonin inhibits bone resorption and promotes bone formation,
A patient is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results is most suggestive of this diagnosis?
Low serum calcium and low phosphorus level
An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch.
The patient should undergo diagnostic testing for what health problem? Osteomyelitis When osteomyelitis develops from the spread of an adjacent infection, no signs of septicemia are present, but the area becomes swollen, warm, painful, and tender to touch.
patient returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery?
Delayed wound healing
A nurse is caring for a patient who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure will the nurse implement to control the edema?
Elevate the foot on several pillows.
A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis?
Perform meticulous foot care.
A nurse is planning the care of an older adult patient with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?
Ensuring adequate exposure to sunlight
A patient presents to a clinic complaining of a leg ulcer that isn’t healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is what?
Staphylococcus aureus
S. aureus causes over 50% of bone infections. Proteus, Pseudomonas, and E. coli are also causes, but to a lesser extent.
A nurse is providing care for a patient who has a recent diagnosis of Paget’s disease. When planning this patient’s nursing care, interventions should address what nursing diagnoses?
Impaired Physical Mobility Acute Pain Disturbed Auditory Sensory Perception Risk for Injury
A nurse is caring for a patient who is being assessed following complaints of severe and persistent low back pain. The patient is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain?
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Ultrasound
X-ray
A nurse is reviewing the care of a patient who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug? Cyclobenzaprine
Short-term prescription muscle relaxants cyclobenzaprine Flexeril are effective in relieving acute low back pain.
A nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the management of activity and mobility in this patient?
Stress on the weakened bone must be avoided.
A 32-year-old patient comes to the clinic complaining of shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons and the patient is diagnosed with impingement syndrome.
What action should the nurse recommend in order to promote healing? Support the affected arm on pillows at night.
A patient presents at the clinic with complaints of morning numbness, cramping, and stiffness in his fourth and fifth fingers. What disease process should the nurse suspect?
Dupuytren’s disease
A patient’s electronic health record notes that the patient has hallux valgus. What signs and symptoms would the nurse expect this patient to manifest?
Deviation of a great toe laterally
An older adult woman’s current medication regimen includes alendronate (Fosamax). What outcome would indicate successful therapy? Increased bone mass
Bisphosphonates such as Fosamax increase bone mass and decrease bone loss by inhibiting osteoclast function
A nurse is caring for a patient who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention?
Intermittent application of heat to the patient’s back
A patient has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care?
Constipation Related to Vertebral Fracture
A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe?
Small frame, female gender, and Caucasian ethnicity
A nurse is providing care for a patient who has osteomalacia. What major goal will guide the choice of medical and nursing interventions?
Maintenance of adequate levels of activated vitamin D
A patient has been admitted to the medical unit for the treatment of Paget’s disease. When reviewing the medication administration record, the nurse should anticipate what medications?
Calcitonin
Bisphosphonates
Bisphosphonates are the cornerstone of Paget therapy in that they stabilize the rapid bone turnover.
The health care team is caring for a patient with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What is the usual treatment for osteomalacia caused by malabsorption?
Supplemental calcium and increased doses of vitamin D
patient with diabetes has been diagnosed with osteomyelitis. nurse notes that the patient’s right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. nurse should suspect what type of osteomyelitis?
Osteomyelitis with vascular insufficiency
An orthopedic nurse is caring for a patient who is postoperative day one following foot surgery. What nursing intervention should be included in the patient’s subsequent care?
The foot should be elevated in order to prevent edema.
A nurse is providing discharge teaching for a patient who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend?
Patient’s general condition, balance, and weight-bearing prescription
A patient has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the patient’s shoulder. The projection appears to be at the distal end of the humerus.
The nurse should suspect the presence of which of the following?Osteochondroma
Osteochondroma is the most common benign bone tumor. It usually occurs as a large projection of bone at the end of long bones (at the knee or shoulder).
An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? Bone fracture
Bone fracture is a major complication of osteoporosis that results when loss of calcium and phosphate increases the fragility of bones.
An older adult patient sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize which of the following aspects of care?
Intravenous administration of antibiotics
A child has rickets, and is being treated at the clinic. In addition to taking vitamin D as prescribed, what is the best information the nurse can provide?
Twenty minutes/day in the sun will provide all the vitamin D that is required
The client receives alendronate Fosamax as treatment for osteoporosis. The nurse has completed medication education and evaluates learning has occurred when the client makes which statements?
I cannot lie down for at least 30 minutes after taking the medication”I should call my doctor if I experience heartburn.” “I must take this with a full glass of water.”
The client has osteomalacia and the physician has ordered a treatment to restore calcium balance. What will the nurse plan to administer to the client?
Calcium supplements and vitamin D
The client receives raloxifene (Evista). Which other medication would the nurse hold and validate with the physician? Atorvastatin Lipitor
Antilipids and hormones are the only medications contraindicated with raloxifene (Evista).
The client receives hydroxychloroquine sulfate Plaquenil Which test does the nurse tell the client should be done on a regular basis?
Eye exams
The client has gout and receives allopurinol Zyloprim. The nurse has completed medication education and evaluates that learning has occurred when the client makes which statements?
It may take a few days or weeks for me to get the full effect of this medication.”
“I should not drink alcohol while taking this drug.”
“If I develop a skin rash I should contact the prescriber.”
I should take this medication with food.”
The client takes calcium supplements. What is the best instruction by the nurse?
Take your calcium with a meal.”
The nurse assesses the client might be experiencing toxicity from colchicine. Which statement by the client would most likely confirm the nurse’s suspicion?
“I have nausea, vomiting, and abdominal pain every day.”
The client takes a bisphosphonate for osteoporosis. Which assessment is best in determining the effectiveness of the medication?
Bone density scan
The nurse has taught the client with osteoporosis about how to manage the illness. Which statement by the client indicates that she needs additional teaching?
I will take my calcium at bedtime.”
The client has arthritis and has just learned that she is pregnant. What is the best instruction by the nurse?
You could try heat applications and splinting for discomfort.
The nurse teaches a class for college students about osteoporosis. What is the best information to include?
Prevention of osteoporosis begins in early adulthood
The client’s calcium level is low. What will be the nurse’s primary concern?
Seizures
The nurse administers calcium intravenously (IV) to the client. What will a key assessment by the nurse include?
Assess the intravenous (IV) site.
The client receives alendronate (Fosamax) as treatment for osteoporosis. Which symptoms, caused by an adverse effect of the medication, does the nurse teach should be reported to the physician?
Muscle spasms and facial twitching
An important function of calcium is to
regulate nerve transmission.
Which of the following signs are common with hypocalcemia?
Muscle spasms
The symptoms of gout are due to
. buildup of uric acid in the blood.
A client takes calcium three times a day in the form of supplements. The nurse will advise the client to take the drug
with food.
The mechanism of action of selective estrogen receptor modulators (SERMs), such as raloxifene Evista is to
increase bone mass and density.
During a medication history, the client states, “I take the calcium supplement called calcitriol.” How should the nurse respond to this statement?
“Calcitriol is a vitamin D supplement.”
“What other medications do you take?”
A client who has osteoporosis says, “I am exercising more. I go to the gym once a week.” How should the nurse respond?
“What kind of exercises are you doing” “You should try to exercise three to five times a week.””Is there somewhere that you can walk on the days you don’t go to the gym?”
A client states, “I stopped taking my medications for osteoporosis. I couldn’t see how they were helping me any.” How should the nurse respond?
“When did you stop taking the medications?”
“Were there any other reasons that you decided to discontinue the medications?””The results from these medications are hard for you to see.”
A client has been prescribed denosumab Prolia. What medication education should the nurse provide?
Denosumab is given subcutaneously,An adverse reaction of this drug is fatigue.This drug can cause severe hypocalcemia, so it is important to monitor lab values.drug may result in hypercholesterolemia.
“We must monitor your cholesterol while you are taking this drug.””I will give your medication in the form of an injection.”You may feel more fatigued than usual when taking this drug.”Be certain to keep your appointments for follow-up.”
A client is receiving therapy for gout. Which information should the nurse provide?
Limiting or eliminating alcohol consumption is standard treatment for gout.”Increase your fluid intake to 2 to 4 liters each day.””If your joint pain does not improve, let us know.”
The nurse teaches patients about nonpharmacological techniques for pain management. The nurse determines learning has occurred when the patients make which statement(s)?
“Nonpharmacological techniques are a good adjunct to pharmacotherapy.”
“Nonpharmacological techniques may be used in place of drugs.”
The nursing instructor teaches the nursing students about neural mechanisms of pain. What does the nursing instructor teach about substance P?
Substance P controls which pain signals reach the brain.
The patient, addicted to heroin, is being treated for opioid dependence. He has been prescribed methadone (Dolophine). The patient asks how this will help because methadone (Dolophine) is another opioid. What is the best response by the nurse?
Methadone (Dolophine) does not cause euphoria like heroin does.”
The patient has intractable pain, and the physician has proposed a nerve block. The nurse plans to teach the patient about nerve blocks. Which statement would be included in the best plan of the nurse?
A nerve block stops pain transmission along the nerve to stop the pain.
The patient receives morphine for pain. He asks the nurse how it works to relieve pain. What is the best response by the nurse?
. “It stimulates a receptor in your brain that induces pleasure.”
The patient has a patient-controlled analgesia (PCA) pump following surgery. The nurse keeps naloxone Narcan in the patient’s room as per protocol. What does the nurse recognize as the rationale for this protocol?
Naloxone (Narcan) will reverse the effects of the narcotic in the patient-controlled analgesia (PCA) pump if an overdose occurs.
What is a priority assessment question to ask a postsurgical patient prior to administration of an opioid analgesic?
Would you please rate your pain on a scale of 1-to-10?”
The postsurgical patient has an order for morphine 2 mg IV push every 2 hours and propoxyphene 100 (Darvon 100) every 3 hours. He received the morphine 2 hours ago, and is complaining of pain again. What will the best plan of the nurse include?
Plan to assess the patient’s level of pain.
The patient comes to the emergency department with a head injury, broken ribs, and internal bleeding. Opioid analgesics are contraindicated. What does the nurse recognize as the primary rationale for this?
Opioids can mask changes in the patient’s level of consciousness.
The patient receives morphine for pain. Which comment by the patient does the nurse assess to be a side effect of morphine?
“I feel like I am going to throw up.”
The patient receives aspirin. The nurse assesses an adverse effect to this drug when the patient makes which response?
. “There is a constant ringing in my ears.”
The nurse provides care for several patients. For which patient would the nurse assess acetaminophen (Tylenol) to be contraindicated?
A 55-year old who socially drinks alcohol
What is an important instruction for the nurse to give to the patient who is taking acetaminophen (Tylenol)?
“Do not drink alcohol with acetaminophen (Tylenol).”
The patient is to start on sumatriptan Imitrex for migraine headaches. What will the best plan of the nurse include as it relates to this medication?
Plan to teach the patient not to drive until the effects of the medication are known.Plan to teach the patient to avoid pseudoephedrine Sudafed with this medication.The combination could dramatically increase the patient’s blood pressure.
A dull, aching pain is defined as
Visceral pain is defined as a dull, throbbing, or aching pain.
Identify the correct statement regarding the neural mechanism of pain
Alpha fibers are wrapped in myelin; C fibers are not.
Which of the following treatments has the highest potential to provide total pain relief? Neuronal injection of alcohol
Nerve blocks irreversibly stop impulse transmission along the treated nerves.
Identify the correct statement regarding opioid receptors.
Opioid agonists will activate mu and kappa receptors, producing analgesia.
A patient on a morphine patient-controlled analgesic (PCA) IV pump has a respiratory rate of 8, and is difficult to arouse. Which of the following would be the priority intervention?
Administering a medication that blocks mu and kappa receptors
Which of the following is an adverse effect associated with morphine, and would be the priority if present?
All are adverse effects, but respiratory depression is the top priority.
Which patient would be at greatest risk for developing opioid dependence?
24-year-old with sickle-cell anemia
Which statement is accurate concerning the management of migraine headaches?
Vasoconstriction of cranial arteries helps reduce acute headache pain.
For which of the following patients suffering a migraine headache would sumatriptan (Imitrex) be indicated? 27-year-old asthmatic male
Sumatriptan is contraindicated in patients with hypertension, angina, and diabetes. It also is a Pregnancy Category C drug.
Which statement is accurate concerning the use of aspirin (ASA) to treat pain?
Enteric-coated capsules are available to reduce GI side effects.
The nurse has just taken a job in a hospital that cares for an ethnically diverse population and is concerned about being culturally sensitive. How should the nurse plan to manage caring for patients in pain?
Listen carefully as the patient’s comments about pain are translated.Show respect for the patient’s preferences even if they are very different from the nurse’s. Ask questions about the patient’s beliefs and customs regarding pain management
The patient has advanced cancer and is experiencing malignant pain. How should the nurse plan to manage this pain?
Set up a dosing schedule that provides for around-the-clock doses.Augment the patient’s regimen with other pharmaceutical and nonpharmaceutical pain relief measures for breakthrough pain.
patient rings the nurse call button and requests pain medication. Upon assessment, nurse finds the patient sitting up in a chair, watching television with a friend. Vital signs are normal and the patient’s skin is warm and dry.
Which nursing actions are appropriate? Ask the patient to rate his pain on the pain scale.Check to see when the patient last received pain medication.
The home hospice nurse is completing the initial assessment of a patient who is has terminal congestive heart failure. The patient frequently has pain with breathing. What questions should the nurse ask?
“How much pain are you willing to tolerate?”
“Have you ever been addicted to a pain medication?”
“Are there any pain medications you would like to avoid?”
“What things besides drugs help with your pain?”
The patient has been started on morphine sulfate (MS Contin) for chronic back pain resulting from inoperable disk degeneration. What nursing actions are indicated?
Use the prn order of docusate routinely every night. Ask the dietary department to add bran cereal to the patient’s breakfast trays.Review the trending of the patient’s hemoglobin and hematocrit levels.Check the medical record for a prn order for an antiemetic
NSAIDs are often effective for the mild migraines this patient experiences.
Acetaminophen and caffeine together are used for treatment of mild migraines.
Ibuprofen
Acetaminophen and caffeine

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