MULTIPLE CHOICE

1. Which postoperative order does the nurse clarify with the surgeon before discharging the client who just had arthroscopic surgery on the right knee?

a.            Keep the right leg elevated on a soft pillow for 12 hours.

b.            Maintain non–weight bearing by right leg for 48 hours.

c.             Use ice on the knee for 24 hours.

d.            Administer two tablets of oxycodone/APAP (Tylox) every 4 hours for pain.

ANS: D

Each tablet of Tylox has 5 mg oxycodone with 500 mg acetaminophen. If the client took two tablets every 4 hours, the client would ingest a total of 6000 mg of acetaminophen, well over the safe maximum dose of 4000 mg in 24 hours. The rest of the orders are appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Interactions/Side Effects)

MSC: Integrated Process: Nursing Process (Planning)

2. An occupational therapist is treating a client with rheumatoid arthritis. Which assessment finding in the client does the nurse share with the occupational therapist?

a.            Difficulty sleeping because of pain in the knees and elbows

b.            Difficulty tying shoelaces and doing zippers on clothing

c.             Swollen knees with crepitus and limited range of motion

d.            Generalized joint stiffness that is worse in the early morning

ANS: B

The functional assessment helps nurses and therapists measure how functional the client is with activities of daily living, including dressing. The occupational therapist can assist the client to explore clothing options that are easier to manage with arthritic fingers. The other findings would not necessarily need to be shared with the occupational therapist for the treatment plan.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Collaboration with Interdisciplinary Team)

MSC: Integrated Process: Nursing Process (Assessment)

3. The nurse is caring for a client who is to have a computed tomography (CT) scan of the leg. Which assessment question does the nurse ask the client before the procedure?

a.            “Do you have any metal clips, plates, or pins in your body?”

b.            “Have you had anything to eat or drink in the last 6 hours?”

c.             “Do you have someone to drive you home after the procedure?”

d.            “Do you have any allergies to shrimp, scallops, or other seafood?”

ANS: D

IV contrast that contains iodine may be required for CT scans to rule out malignancy. The client should be assessed for allergy to shellfish, which contain high amounts of iodine. The other questions are not relevant when a CT scan is to be obtained.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Error Prevention) MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is assessing a client who reports severe knee pain after a fall. Which question does the nurse ask to determine the radiation of the pain?

a.            “What makes the pain better or worse?”

b.            “Are you able to bear any weight on the knee at all?”

c.             “Does the pain move to another area from your knee?”

d.            “How would you rate the pain on a scale of 1 to 10?”

ANS: C

To determine radiation of the pain, the nurse asks the client if the pain moves to another area from the knee. The other questions address the amount, functional impact, and alleviating or aggravating factors of the pain.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1111

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Assessment)

5. Which instruction does the nurse give to the client before he or she has electromyography (EMG)?

a.            “Make sure that you have someone to drive you home after the test.”

b.            “Do not eat or drink anything for at least 6 hours before the test.”

c.             “You will have to avoid heavy lifting for 24 hours following the test.”

d.            “Do not take your cyclobenzaprine (Flexeril) on the 2 days before the test.”

ANS: D

Electromyography (EMG) testing measures nerve signal transmission to and through muscles. Skeletal muscle relaxants such as Flexeril can affect test results and should be avoided for at least 2 days before the test. The other instructions are not relevant before EMG testing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC: Integrated Process: Teaching/Learning

6. The nurse is caring for a client with prostate cancer. Which laboratory finding indicates to the nurse that the cancer has metastasized to the bone?

a.            Serum calcium, 21.6 mg/dL

b.            Creatine kinase, 55 U/mL

c.             Alkaline phosphatase, 45 IU/mL

d.            Lactate dehydrogenase, 120 U/L

ANS: A

Metastasis of tumor to bone results in release of calcium into the bloodstream, causing an elevation of the serum calcium level (normal range, 9 to 10.5 mg/dL). The other laboratory values are within normal limits and do not indicate metastasis to the bone.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)