1. The nurse is teaching a community health class about
health promotion techniques. Which statement by a student indicates a strategy
to help prevent the development of osteoarthritis?
a. “I will
keep my BMI under 24.”
b. “I will
switch to low-tar cigarettes.”
c. “I will
start jogging twice a week.”
d. “I will
have a family tree done.”
ANS: A
Obesity increases the stress on weight-bearing joints and
contributes to the development of degenerative joint disease. Smoking does not
decrease risk for osteoarthritis. Jogging increases the risk because of
increased wear and tear on the joints. There is a genetic link to
osteoarthritis; creating a family tree might help the client discover if there
is any familial link but will not help prevent the disorder.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Health Promotion and Maintenance
(Self-Care)
MSC: Integrated Process: Teaching/Learning
2. The nurse is teaching a client who has osteoarthritis
ways to slow progression of the disease. Which statement indicates that the
client understands the nurse’s instruction?
a. “I will
eat more vegetables and less meat.”
b. “I will
avoid exercising to minimize wear on my joints.”
c. “I will
take calcium with vitamin D every day.”
d. “I will
start swimming twice a week.”
ANS: D
Swimming is an excellent form of exercise for clients with
arthritis because it involves minimal weight bearing and stress on the joints
from gravity. Eating more vegetables will not decrease the progression of
osteoarthritis. Taking calcium with vitamin D will decrease the risk of
osteoporosis, not osteoarthritis. Gentle exercise is important to help slow
progression of the disease.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Health Promotion and Maintenance
(Self-Care)
MSC: Integrated Process: Teaching/Learning
3. The nurse is working with a client who will be taking 20
mg of prednisone daily for rheumatoid arthritis. Which precautions does the
nurse give the client about taking this medication?
a. “Take
this medication at bedtime because it will make you sleepy.”
b. “Take
calcium and vitamin D supplements daily.”
c. “Eat a
high-fiber diet with lots of lean meats.”
d. “Wash
your face twice a day with an antibacterial soap.”
ANS: B
Long-term steroid use is associated with many complications,
including diabetes, infection, and osteoporosis, among others. The client
should be instructed to take calcium and vitamin D supplements to help prevent
osteoporosis. Prednisone does not cause constipation, so increased fiber would
not be helpful. Prednisone should be taken in the morning because it may
interfere with sleep if taken at bedtime. Washing the face with antibacterial
soap may cause skin dryness and breakdown.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Health Promotion and Maintenance
(Self-Care)
MSC: Integrated Process: Teaching/Learning
4. An older adult client is scheduled for knee replacement
surgery. Which statement by the client indicates a need for further
preoperative instruction?
a. “I need
to keep my leg positioned away from my body.”
b. “I may
have a continuous passive motion machine for a few days.”
c. “I may
need more pain medicine than I did with my hip replacement.”
d. “I
probably can get back to work within 2 to 3 weeks.”
ANS: A
Dislocation is not a problem with knee replacement surgery,
so the client does not need to keep his or her leg abducted. The other
statements indicate accurate understanding of the instructions.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Reduction of Risk Potential—Potential for Complications From Surgical
Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Evaluation)
5. A client returns to the medical-surgical unit after a
total hip replacement with a large wedge-shaped pillow between his legs. The
client’s daughter asks the nurse why the pillow is in place. What is the
nurse’s best response?
a. “It will
help prevent bedsores from developing.”
b. “It will
help prevent nerve damage and foot drop.”
c. “It will
keep the new hip from becoming dislocated.”
d. “It will
prevent climbing out of bed if he becomes confused.”
ANS: C
Adduction of the operative leg beyond the midline could
dislocate the new hip. The wedge pillow will help prevent this from happening.
The wedge will not prevent bedsores from developing because it does not prevent
pressure. The pillow will not prevent foot drop, because it is placed between
the legs. The pillow is not a restraining device, and it will not prevent the
client from climbing out of bed.
DIF: Cognitive Level: Comprehension/Understanding REF: p.
325
TOP: Client Needs Category: Physiological Integrity
(Reduction of Risk Potential—Potential for Complications From Surgical Procedures
and Health Alterations)
MSC: Integrated Process: Communication and Documentation
6. The nurse is caring for a postoperative client on the
medical-surgical unit following a total left hip replacement the previous day.
During the assessment, the nurse notes that the client’s left leg is cool, with
weak pedal pulses. What is the nurse’s first action?
a. Assess
circulatory status of the right leg.
b. Notify
the surgeon immediately.
c. Measure
leg circumference at the calf.
d. Check for
bilateral Homans’ signs.
ANS: A
The symptoms may represent impaired circulation or may be
normal for this client. Before the surgeon is notified, the status of the
nonoperative leg should be assessed and assessment findings on both legs
compared with the client’s baseline. Homans’ sign (pain in the calf on
dorsiflexion of the foot) is not always indicative of a deep vein thrombosis
and should not be evaluated until other assessments are made. Measuring calf
circumference would provide additional data related to deep vein thrombosis.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Reduction of Risk Potential—Potential for Complications From Surgical
Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
7. A client is admitted for a total hip replacement. Past
medical history includes diabetes mellitus type 2, a heart attack 5 years ago,
and allergies to sulfa drugs. The client currently takes insulin on a sliding
scale and celecoxib (Celebrex). Before administering the client’s medications,
which action by the nurse is most appropriate?
a. Take the
client’s blood pressure in both arms.
b. Call the
physician to clarify the orders.
c. Schedule
a preoperative electrocardiogram.
d. Review
the client’s laboratory values.
ANS: B
Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs
are thought to cause serious adverse reactions such as myocardial infarction
and renal problems. This client already has coronary artery disease and a past
myocardial infarction, so the nurse should discuss the order with the physician
before giving the medication. Reviewing laboratory results could indicate renal
impairment, but taking the client’s blood pressure and scheduling an
electrocardiogram (ECG) would not take priority over discussion with the
physician.
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 (Implementation)
Category | ATI |
Release date | 2021-09-14 |
Pages | 22 |
Language | English |
Comments | 0 |
Sales | 0 |
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