1.

At which of the following times would the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? a. At bedtime b. On arising c. Immediately after a meal d. On an empty stomach Ans: C drugs that cause gastric irritation, such as ibuprofen (Motrin), are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should used warmth and stretching until he gets food in his stomach. 2. When preparing a teaching plan for the client with osteoarthitis who is taking celexocib (Celebrex), the nurse expects to explain that the major advantage of celecoxib over diclofenac (Voltaren) is that celecoxib is less likely to produce which of the following? a. Hepatotoxicity b. Renal toxicity c. Gastrointestinal (GI) bleeding d. Nausea and vomiting Ans: C the major advantage of celecoxib (Celebrex), the new generation of cyclooxygenase-2 (COX-2) inhibitors, over diclofenac (Voltaren), a COX-1 inhibitor, is that celecoxib is less likely to produce GI problems such as ulcers and bleeding. There is no evidence of less hepatotoxicity, renal toxicity, or nausea and vomiting with COX-2 inhibitors. 3. The client diagnosed with osteoarthritis states, My friend takes steroid pills for her rheumatoid arthritis. Why dont take steroids for my osteoarthritis? The nurses response to the client is based on an understanding of which of the following? a. Intra-articular corticosteroid injections are used to treat osteoarthritis b. Oral corticosteroids can be used in osteoarthritis c. A systemic effect is needed in osteoarthritis d. Rheumatoid arthritis and osteoarthritis are two similar diseases Ans: A- Rheumatoid arthritis and osteoarhtritis are two different diseases. Cortecosteroids are used for patient with osteoarthritis to obtain a local effect. Therefore, they are given only via intra-articular injection. Oral cortecosteroids are avoided because they can cause an acceleration of osteoarthritis. 4. In preparation for total knee surgery, a 200-pound client with osteoarthritis is being discharged from the hospital to lose weight to reduce the risks of anesthesia. In conjunction with a weight loss program, which of the following exercises would the nurse recommend as best if t he client has no contraindications? a. Weight lifting b. Walking c. Aquatic exercise d. Tai chi exercise Ans: C When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allow the client o burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote a healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the clients osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be best exercise

for this client to help with weight loss. 5. The physician recommends a total hip replacement for a client with osteoporosis who reports increasingly severe pain in the left hip. The nurse would initiate the preoperative teaching plan for the client, beginning with which of the following? a. Teaching how to prevent hip flexion b. Demonstrating coughing and deep breathing techniques c. Showing the client what an actual hip prosthesis looks like d. Assessing the clients fears about the procedure Ans: D- before implementing teaching plan, the nurse should determine the clients fears about the procedure. Only then the client begin to hear what the nurse has to share about the individualized teaching plan designed to meet the clients needs. In the preoperative period, the clients needs to learn how to correctly prevent hip flexion and to demonstrate coughing and deep breathing. However, this teaching can be effective only after the clients fear has been assessed. and addressed. Although the client may appreciate seeing what a hip prosthesis looks like, so as to understand the new body part, this is not a necessity. 6. After the client undergoes a total knee replacement for severe osteoarthritis, which of the following assessment findings would lead the nurse to suspect possible nerve damage? a. Numbness b. Bleeding c. Dislocation d. Pinkness Ans: A- The urse would suspect a nerve damage if numbness is present. However, the damage is short term and related to edema or long term and related to permanent nerve damage would not be clear at this point. The nurse need to continue to assess the clients neurovascular status, including pain, pallor, pulselessnes, parenthesis, and paralysis (the five Ps). Bleeding would suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would suggest adequatwe circulation to area. Numbness would suggest neurologic damage. 7. After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and inability to move the extremity. The nurse interprets these findings as indicating which of the following? a. A developing infection b. Bleeding in the operative site c. Joint dislocation d. Glue seepage into soft tissue Ans: C The joint has dislocated when the client with total joint prosthesis develops sudden severe pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness erythema, and possibly drainage and separation of the wound. Bleeding could be external (eg. Blood visible from the wound or on the dressing) or internal and manifested by signs of shock (eg. Pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue dries into hard fixed form before the wound is closed 8. Which of the following would the nurse assess in a client with an intracapsular hip fracture? a. Internal rotation b. Muscle flaccidity c. Shortening of affected leg

d. Absence of pain in the fracture area Ans: C- With an intracapsular hip fracture, the affected leg is shorter than the unaffected leg because of the muscle spasms and external rotation. The client also experiences severe pain in the region of the fracture. 9. When developing the plan of care for an older adult client with a hip fracture, which of the following chronic health problems would the nurse be lest likely to assess in the client? a. Hypertension b. Cardiac decompensation c. Pulmonary disease d. Multiple sclerosis Ans: D Multiple sclerosis would be the least likely chronic health problem for an older adult with a hip fracture, Typically, multiple sclerosis is consider a severe crippling disorder of young adults. Hypertension is a common chronic health problems in older adults. Cardiac decompensation is common on older adults; it arises from cardiac musculature changes and age-related changes in the heart. This comorbid condition can complicate the treatment and care when the older adult experiences a hip fracture. Pulmonary disease commonly arises from agerelated changes in the respiratory system. These comorbid conditions can complete the treatment and care when the other adult experiences a hip fracture. 10. When teaching a client with an extracapsular hip fracture scheduled for surgical internal fixation with the insertion of a pin, the nurse bases the teaching on the understanding that this surgical repair is the treatment of choice for which of the following reasons? a. Hemorrhage at the fracture site is prevented b. Neurovascular impairment risk is decreased c. The risk for infection at the site is lessened d. The client is able to be mobilized sooner Ans: D insertion of a pin for the internal fixation of a extracapsular fractured hip provides good fixation of the fracture. The fracture is site is stabilized and fractured bone ends are well approximated. As result, the client is able to be mobilized sooner, thus reducing the risks of complications related to immobility. Internal fixation with a pin insertion does not prevent hemorrhage or decrease the risk for neurovascular impairment, potential complications associated with any joint or bone surgery. It does not lessen the clients risk infection at the site. 11. A client with an extracapsular hip fracture returns to the nursing unit after internal fixation and pin insertion with a drainage tube at the incision site. Her husband asks, Why does she have this tube inserted in her hip? Which of the following responses by the nurse demonstrates understanding of the primary purpose for this drainage tube? a. The tube helps us to detect a wound infection early on. b. This way we wont have to irrigate the wound. c. Fluid wont be allowed to accumulate at the site. d. We have a way to administer antibiotics into the wound. Ans: C the primary purpose of the drainage tube is to prevent fluid accumulation in the wound. Fluid when it accumulates creates dead space. Elimination of the dead space by keeping the wound free of fluid greatly enhances wound healing and helps prevent abscess formation. Although the characteristics of the drainage from the tube, such as a change in color or appearance, may suggest a possible infection, this is not the tubes primary purpose. The drainage tube does not eliminate the need for wound irrigation or provide a way to instill antibiotics into the wound.

12. When assessing a client who has just received a femoral head prosthesis, which of the following would alert the nurse to the possibility of neurologic a. Decreased distal pulse b. Inability to move c. Diminished capillary refill d. Coolness to the touch Ans: B being unable to move the affected leg suggest neurologic impairment. A decrease in the distal pulse, diminished capillary refill, and coolness to touch of the affected extremity suggest vascular compromise. 13. A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which of the following activities would the nurse instruct the client to avoid? a. Crossing the legs while sitting down b. Sitting on a raised commode seat c. Using an abductor splint while lying on the side d. Rising straight from a chair to a standing position Ans: A any activity or position that causes flexion, adduction, or internal rotation of greater than 90 degrees should be avoided until the soft tissue surrounding the prosthesis has stabilized, at approximately 6 weeks. Crossing the feet while sitting down can lead to dislocation of the femoral head from the hips socket. Sitting on a raised commode seat prevents hip flexion and adduction. Using an abductor splint while side-lying keeps the hip joint in abduction, thus preventing adduction and possible dislocation. Rising straight from a chair to a standing position is acceptable for this client because this action avoids hip flexion, adduction, and internal rotation of greater than 90 degrees. 14. The nurse encourages the client who has had a femoral head prosthesis placement to use which of the following types of chairs to sit in during the first 6 to 8 weeks after surgery? a. A desk-type swivel chair b. A padded upholstered chair c. A high-backed chair with armrests d. A recliner with an attached footrest Ans: C a high-backed straight chair with armrests is recommended to help keep the client in the best possible alignment after surgery for a femoral head prosthesis placement. Use of this type of chair helps to prevent dislocation of the prosthesis from the socket. A desk-type swivel chair, padded upholstered chair, or recliner should be avoided because it does not provide for good body alignment and can cause the overly flexed femoral head to dislocate. 15. While assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning, which of the following would pose the greatest hazard to the client as a risk for falling at home? a. A 4-year-old cooker spaniel b. Scatter rugs c. Snack tables d. Rocking chairs Ans: B although pets and furniture such as snack tables and rocking chairs may pose a problem, scatter rugs are the single greatest hazard in the home, especially for elderly people who are ensure and unsteady with walking. Falls have been found to account for almost half of the accidental deaths that occur in the home. The risk for falls is further compounded by the clients need for crutches. 16. Which of the following activities would the nurse instruct the client with low

back pain to avoid? a. Keeping light objects below the level of the elbows when lifting b. Leaning forward while bending the knees c. Exceeding prescribed exercise program d. Sleeping on the side with legs flexed Ans: C the client with low back should not exceed prescribed exercises even though they may think, If this will make me well, double will make me well quicker. When exceeding prescribed exercise programs, the clients muscle may be unconditioned and easily tired, leading to injury and increased pain. To use proper body mechanics when lifting light objects, the client should bring the item close to the center of gravity, which occurs when the object is kept below the level of the elbows. Leaning forward while bending the knees allows for the muscles of the thigh to be used instead of those of the lower back. Sleeping on the side with the legs flexed is appropriate because the spine is kept in a neutral position without twisting or pulling on muscles. 17. A client was brought to the hospital because he could not get out of bed because of low back pain radiating down to his right heel and lateral foot. When developing the clients plan of care, which of the following categories of medication would the nurse anticipate the physicians ordering? a. Angiotensin-converting enzyme (ACE) inhibitors - adrenergic blocking b. agents c. Nonsteroidal anti-inflammatory drugs (NSAIDs) d. Barbiturates Ans: C for the client who has back pain radiating down to his right heel and lateral foot, suggesting radiculopathy of a herniated disc at L5-S1, typically the physician would order NSAIDs, oral analgesics, and muscle relaxants. ACE inhibitors are indicated for clients with hypertension and those -blockers are with heart failure unresponsive to conventional therapy. indicated for clients with cardiovascular disorders, such as hypertension and angina, and also for migraine prophylaxis. Barbiturates are central nervous system depressants, they are indicated for clients with seizure or insomnia and for those being prepared for surgery. 18. A client with a ruptured intervertebral disc at L4-5 stands with a flattened spine slightly tilted forward and slightly flexed to the affected side. The nurse interprets this finding as indicating which of the following? a. Motor changes b. Postural deformity c. Alteration of reflexes d. Sensory changes Ans: B standing with a flattened spine slightly titled forward and slightly flexed to the affected side indicates a postural deformity. Motor changes would include findings such as hypotonia or muscle weakness. Absent or diminished reflexes related to the level of herniation would indicate alteration in reflexes. Sensory changes would include findings such as paresthesia and numbness related to the specific tract of the herniation. 19. Which of the following positions would be most comfortable for a client with a ruptured disc at L5-S1 right? a. Prone b. Supine with the legs flexed c. High fowlers d. Right Sims Ans: B a supine position with the clients legs flexed is the most comfortable position because it allows for the disc to recess off of the nerve, thus alleviating the pressure and pain. The prone position cause hyperextension of the spine and

increased pressure of the disc on the nerve root on the right. A ruptured disc at L5-S1 right is a term commonly used in the analysis of a history and physical examination, magnetic resonance image, or myelogram to identify a ruptured disc compressing the right nerve root exiting the L5-S1 spinous process, as opposed to the central area or the left nerve foot of that spinous process. If the ruptured area of the disc were in the central area of the spinous process, the prone position and hyperextension might relieve the disc pressure on the nerve. A high-Fowlers or sitting position increases the pressure of the disc on the nerve root because of gravity, as does a right Sims position. 20. The client with a herniated intervertebral disc schedule for a myelogram asks the nurse about the procedure. The nurse explains that radiographs will be taken of the clients spine after an injection of which of the following? a. Sterile water b. Normal saline solution c. Liquid nitrogen d. Radiopaque dye Ans: D myelography, used to determine the exact location of a herniated disk, involves the use of radiopaque dye (usually an iodized oil, but in some instances water-soluble compound). In some instances, used for an air-contract study. 21. Which of the following would be inappropriate to include when preparing a client for magnetic resonance imaging (MRI) to evaluate a ruptured disc? a. Informing the client that the procedure is painless b. Taking a thorough history of past surgeries c. Checking for previous complaints of claustrophobia d. Starting an intravenous line at keep-open rate Ans: D an intravenous line is not required for an MRI client has an intravenous line, it is usually converted an intermittent infusion device, such as a heparin to avoid infiltration during transport of the client and completion of the procedure. When a contrast agents used, the client is moved out of the cylinder, the contrast material is injected, and the client is moved back-in. an MRI scan is painless. Typically the staff position, the client with pillows, blankets, ear plugs, and muscle to ensure client comfort, before the procedure started. A history of past surgeries is important, especially if the surgery involved implantation of any metallic devices (eg, implants, clips, pacemakers). Additionally, the nurse needs to assess for any hearing aids, electronic devices, shrapnel, bra hooks, necklace jewelry, credit cards, zippers, or any type of metal that the magnet of the MRI unit would attract. Although open MRI units are now available, they are not in widespread use. Therefore, the nurse needs to check determine whether the client is claustrophobic because this unit is a closed cylinder in which the client hears popular noise. A number of clients develop claustrophobic that causes the procedure to be cancelled. If the clients claustrophobic, the procedure may need to be rescheduled after an open MRI unit is located or made available. 22. A client complaining of numbness from the back of his left buttock to the dorsum of his foot and big toe is scheduled to undergo a laminectomy. The operative consent form states, a left lumbar laminectomy of L3-4. Based on the nurses understanding of the clients complaints and intended surgical procedure which of the following would the nurse do next? a. Have the client sign the consent form b. Call the surgeon c. Change the consent form d. Review the clients history Ans: B based on the clients complaints, the nurse should call the surgeon to verify the location of the surgery. The clients complains indicate radiculopathy of ___ but the consent form states L3-4, radiculopathy L3-4 involves pain radiating

from the back to the tocks to the posterior thigh to the inner calf. The nurse must act as a consent until the correct procedure is identified and confirmed on the consent. The nurse has legal authority or responsibility to change the consent. The history is a source of information, but when the client is coherent and the history if contradictory, the physician should be contacted to clarify the situation. Ultimately, it is the surgeons responsibility to identify the site of surgery specified on the surgical consent form. 23. After a bilateral lumbar laminectomy at L5-S1, which of the following is a priority nursing diagnosis for the client in the immediate postoperative phase? a. Impaired physical mobility related to back pain b. Imbalanced nutrition: less than body requirements related to postoperative status c. Bowel incontinence related to decreased physical activity d. Disturbed body image related to fear of disfiguring surgical scar Ans: A impaired physical mobility related to back pain, muscle spasms, and tissue manipulation is a priority after a laminectomy, because based on individual factors such as the length of time of the disease and previous scarring or injury to the muscles or nerves before the surgery, spasms and pain can be quite severe. Imbalances nutrition: less than body requirements related to inability to eat in the supine position is not a priority problem because the client is encouraged to take fluids as soon as the gag reflex returns, no nausea is present, and bowel sounds begin to return. Bowel incontinence related to decreased physical activity is not a priority problem because the client is encouraged to sit up and to ambulate to the bathroom with assistance as soon as the anesthesia wears off. Disturbed body image related to fear of disfiguring surgical scar should also not be a priority problem because the laminectomy incision is commonly small, possibly as small as 1 inch for a lumbar laminectomy L5-S1 bilateral. 24. Immediately after the lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled? a. Muscles spasms b. Nausea c. Shivering d. Dry mouth Ans: B ondansetron hydrochloride (zofran) is a selective serotonin receptor antagonist tat acts centrally to control the clients nausea in the postoperative phase. It does not control muscle spasms, shivering, or dry mouth. 25. After a laminectomy, the client states, The doctor said that I can do anything I want to. Which of the following activities, if stated by the client, indicates need for further teaching? a. Drying the dishes b. Sitting outside on firm cushions c. Making the bed walking from side to side d. Sweeping the front porch Ans: D sweeping causes a twisting motion, which should be avoided because twisting can cause undue stress on the recently ruptured disc site, muscle spasms, and a potential recurrent disc rupture. Although the client should not bend at the waist, such as when washing dishes at the sink, the client can dry dishes because no bending is necessary. The client can sit in a firm chair that keeps the back anatomically aligned. The client should not twist and pull, so when making the bed, the client should pull the covers up on one side and then walk around to the other side before trying to pull the covers up there. 26. When developing the drainage teaching plan for a client who has undergone a

lumbar laminectomy L4-5 left and will be returning to work in 6 weeks, which of the following actions would the nurse encourage the client to avoid? a. Placing one foot on a stepstool during prolonged standing b. Sleeping on the back with support under the knees c. Maintaining average body weight for height d. Sitting whenever possible Ans: D after a lumbar laminectomy L4-5 left, a client who is returning to work should avoid sitting whenever possible, if the client must sit, he or she should sit only in chairs that allows the knees to be higher than the hips and support the arms to maintain correct body alignment and reduce undue stress on the spine. Maintaining good body postures is most important after a lumbar laminectomy L4-5 left. By 6 weeks after the surgery, the client should have regained stamina. To maintain correct body posture, the client should also place one foot on a stepstool during prolonged standing. Sleeping on the back with a support under the knees is effective in maintaining correct body posture. Maintaining an average weight for height is important in maintaining a healthy back because carrying extra weight caused undue stress on back muscles. 27. A male client, who had normal preoperative baseline data except for dysfunction associated with this operative diagnosis, underwent a spinal fusion yesterday. Which of the following nursing assessments would alert the nurse to the development of a possible complication? a. Lateral rotation of the head and neck b. Clear yellowish fluid on the dressing c. Use of the standing position to void d. Nonproductive cough Ans: B clear yellowish fluid on the dressing may be cerebral spinal fluid, this fluid must be tested for glucose to determine whether it is cerebral spinal fluid. If so, the client is at great risk for an infection of the central nervous system, which has a high mortality rate. The patient should be able to laterally rotate the head and neck, which is above the surgical site in the spinal column. During the nursing postoperative neuromuscular-vascular assessment of movement of the head and neck, the nurse should find results consistent with the preoperative baseline status. Using the standing position to void is normal for a male client. Coughing is the bodys defense mechanism to help clear the lungs in response to a sustained deep inspiration for ventilation of the lower lobes of the lungs. A frequent cough could place a strain on the incision site and should be avoided. Also, a productive cough of thick yellow sputum would indicate the complication of a respiratory infection. 28. After a spinal fusion, a client is required to wear a back brace. Which of the following would the nurse expect to do before applying the brace? a. Have the client in bed lying on the side b. Verify with the physician the position to use c. Ask the client to stand with arms held out to the side d. Encourage the client to sit in a straight chair Ans: B the nurse should verify with the surgeon the preferred position to use before applying the brace. Traditionally, the client who had a spinal fusion was asked to lie on the side and log roll onto the brace. Now doctors also have clients stand and sit for the brace application. Therefore, the nurse needs to verify the surgeons preference. 29. After teaching a client required to wear a back brace after a spinal fusion, which of the following client statements indicate effective teaching about skin protection measures with the brace? a. I will apply lotion before putting on the brace. b. I will be sure to pad area around my iliac crest.

c. I can use baby powder under the brace to absorb perspiration. d. I should wear a thin cotton undershirt under the brace. Ans: D the client should wear a thin cotton undershirt under the brace to prevent the brace from abrading directly against the skin. The cotton material also aids in absorbing any moisture, such as perspiration, which could lead to skin irritation and breakdown. Applying lotion is nor recommended before applying the brace because further skin breakdown can result (related to the collection of moisture where microorganisms can grow) and irritants from the lotion can cause further irritation. Applying extra padding (eg, to the iliac crests) is not recommended because the padding can become wrinkled, producing more pressure sites and skin breakdown. Use of baby or talcum powder is not recommended because the irritation from the talcum also can cause irritation and skin breakdown. 30. When developing the teaching plan for a client scheduled for a spinal fusion, which of the following would the nurse expect to include? a. The client typically experiences more pain at the donor site than at the fusion site than at the fusion site b. The surgeon will apply a simple gauze dressing to the donor site c. Neurovascular checks are unnecessary if the fibula is the donor site d. The clients level of activity restriction is determined by the amount of pain Ans: A typically, the do not site causes more pain than the fused site does because inflammation, swelling, and venous oozing around the nerve endings in the donor site, where the subcuticular tissue was removed, occurs during the first 24 to 48 hours postoperatively. After surgery, the surgeon applies a pressure dressing to the donor site to compress the veins that were transected for the removal subcutaneous tissue but that did not stop oozing blood after surgical cauterization during the surgical procedure. Pressure on a transected vein, which is low pressure, stops the oozing and loss of blood from the venous site. When the donor site is the fibula, neurovascular checks must be performed every hour to ensure adequate neurologic function of and circulation to the area. The surgeon, not the degree or amount of pain, specifies activity restrictions. 31. The nurse determines that the client who has had a lumbar laminectomy with a spinal fusion understands his protective instructions when he places his feet in which of the following positions when sitting in a chair? a. On the floor with the feet flat b. On a low footstool c. In any comfortable position with legs uncrossed d. On a high footstool so the feet are level with the chair seat Ans: A a client who has had back surgery should place his feet flat on the floor to avoid strain on the incision. Placing the feet on a low or high footstool or in any other position of comfort with the legs uncrossed increases the pressure on the suture line and increases the inflammation around the involved nerve root, thereby increasing the risk for possible rerupture of the disc site. 32. When developing the plan of care for a client undergoing a lumbar laminectomy, which of the following activities would be contraindicated during the initial postoperative period? a. Assisting with her daily hygiene activities b. Lying flat in bed c. Walking in the hall d. Sitting all afternoon in her room Ans: D after a lumbar laminectomy, a client should not sit for prolonged periods in a chair because of the increased pressure against the nerve root and incision site. Assisting with daily hygiene is an appropriate activity during the initial postoperative period because, as with any surgical procedure, the patient needs

to return to her optimal level of functioning as soon as possible. There is no limitation on the patients participation ion daily hygiene activities except for her individual response of pain, nausea, vomiting, or weakness. Lying flat in bed is appropriate because it does not cause stress on the spinal column where the laminectomy was preformed and the disc tissue was removed. Positions that should be avoided are those that would cause twisting and flexion of the spine. Walking in the hall is an acceptable activity. It promotes good postoperative ventilation, circulation, and return of peristalsis, which are needed for all surgical patients. In addition, walking provides the postoperative lumbar laminectomy patient an opportunity to build u p endurance and muscle strength and to promote circulation to the operative and incision sites for healing without twisting or stressing the, 33. Which of the following exercises would the nurse advise the client to avoid after a lumbar laminetcomy? a. Knee-to-chest lifts b. Hip tilts c. Sit-ups d. Pelvic tilts Ans: C sit-ups are not recommended for the client who has had a lumbar laminectomy, because these exercises place too great a stress on the back. Kneeto-chest lifts, hip tilts, and pelvic tilt exercises are recommended to strengthen back and abdominal muscles. 34. When obtaining the history of a client with peripheral vascular disease who requires an amputation, which of the following would the nurse identify as the least likely factor contributing to the clients peripheral vascular disease? a. Uncontrolled diabetes mellitus for 15 years b. A 20-pack-year history of cigarette smoking c. Current age of 39 years d. A serum cholesterol concentration of 275 mg/dL Ans: C typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease, uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/dL are considered a risk factor for peripheral vascular disease. 35. When assessing the client with severe arterial occlusive disease and gangrene of the left great toe, which of the following findings would the nurse observe in the clients left leg and foot? a. Edema around the ankle b. Loss of hair on the lower leg c. Thin, soft toenails d. Warmth in the foot Ans: B the client with severe arterial occlusive disease and gangrene of the left great toe would have lost the ___ on the leg due to decreased circulation to the ___. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin ___ toenails (ie, thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically the foot would be to cold if a severe arterial occlusion were present. 36. A client with absent peripheral pulses and pain at rest is scheduled for an arterial Droppler study of the affected extremity. Which of the following would the

nurse include when preparing the client for this test? a. Have the client sign a consent form of the procedure b. Administer a pretest sedative as appropriate c. Keep the client tobacco-free for 30 minutes before the test d. Wrap the clients affected foot with a blanket Ans: C the client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arterial. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive narcotic analgesic, not a sedative, to control, the ___ the blood pressure cuffs are inflated during the Droppler studies to determine the ankle-to brachial pressure index. The clients ankle should not be considered with a blanket, because the weight of the blanket on the ishemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet at the affected foot. 37. The client with peripheral arterial disease says, Ive really tried to manage my condition well. Which of the following, if reported by the client during the history, would the nurse determine as appropriate for this client? a. Resting with the legs elevated above the level of the heart b. Walking slowly but steadily for 30 minutes twice a day c. Minimizing activity as much and as often as possible d. Wearing antiembolism stockings at all times when out of bed Ans: B slow, steady walking is a recommended activity in the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the above the heart is an appropriate strategy for reducing venous congestion, wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause t he disease to worsen. 38. Which of the following would the nurse include in the teaching plan for a client with arterial insufficiency to the feet is being managed conservatively? a. Daily lubrication of the feet b. Soaking the feet in warm water c. Applying antiembolism stocking s d. Wearing firm, supportive leather shoes Ans: A daily lubrication, inspection, cleaning, and pattern dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the foot in a warm water should be avoided, because soaking on lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insufficiency typically experiences sensory changes, so that client may be unable to detect water that is too warm, thus placing the client at risk clients with venous insufficiency, are inappropriate for clients for with arterial insufficiency could lead to worsening of the condition. Footwear should be roomy, soft, and protective and allow to circulate. Therefore, firm, supportive leather shoes would be appropriate. 39. While the nurse is providing preoperative teaching, the client says, I hate the idea of being an invalid after they cut off my leg. Which of the following would be the nurses most thermometric response? a. At least you will still have one good leg to use. b. Tell me more about how youre feeling. c. Lets finish the preoperative teaching.

d. Youre lucky to have a wife to care for you. Ans: B encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, At least you will still have one good leg to use, that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term invalid. The nurse needs to focus on this concern and not to try to complete the teaching first before discussing what is on the clients mind. The clients needs, not the nurses needs, must be met first. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the clients wife caring for him may reinforce the clients feelings of helplessness as an invalid. 40. The client asks the nurse, Why cant the doctor tell me exactly how much of my leg hes going to take off? Dont you think I should know that? The nurse responds based on the understanding that the final decision about the level of amputation required depends primarily on which of the following? a. The need to remove as much of the leg as possible b. The adequacy of the blood supply to the tissues c. The ease with which a prosthesis can be fitted d. The clients ability to walk with a prosthesis Ans: B the level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the clients ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant. 41. A client who has a history of mitral valve prolapse tells the nurse during a clinical visit that she is scheduled to get her teeth cleaned. Which of the following replies by the nurse is most appropriate? a. The physician will need to revaluate the status of your heart condition before your dental appointment. b. Be sure to remind your dentist that you have a heart condition. c. It is important for you to care for your teeth because your heart condition makes you more susceptible to developing oral infections. d. We will prescribe a prophylactic antibiotic for you to take before getting your teeth cleaned. Ans: D clients who are at risk for developing infective endocarditis due to cardiac conditions such as mitral valve prolapse must take prophylactic antibiotics before any dental procedure that may cause bleeding. The client is not more susceptible to developing oral infections. Rather, the client is more susceptible to developing endocarditis that results from oral bacteria that enter the circulation during the dental procedure. The physician does not necessarily need to reevaluate the heart condition of a client who is stable, but antibiotics must be prescribed. It is not enough to simply remind the dentist about the heart condition.

42. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the clients daily care? a. Assess the oral cavity each time mouth care is given and record observations b. Use a soft toothbrush to brush the clients teeth after each meal c. Swab the clients tongue, gums, and lips with a soft foam applicator every 2 hours d. Rinse the clients mouth with mouthwash several times a day Ans: B a soft toothbrush should be used to brush the clients teeth after every meal and more often as needed. Mechanical cleansing is necessary to maintain oral health, stimulate gingival, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the nursing assistant. Swabbing with a safe foam applicator does not provide enough friction to cleanse the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use. 43. During the assessment of a clients mouth, the nurse notes the absence of saliva. The client is complaining of pain in the area of t he ear. The client has been NPO for several days because of the insertion of a nasogastric tube. Based on these findings, the nurse suspects that the client may be developing which of the following mouth conditions? a. Stomatitis b. Oral candidiasis c. Parotitis d. Gingivitis Ans: C the lack of saliva, pain near the area of the ear, and the prolonged NPO status of the client should lead the nurse to suspect the development of parotitis, to inflammation of the parotid gland. Parotitis usually develops in cases of dehydration combined with poor oral hygiene or when clients have been NPO for an extended period. Preventive measures include the use of sugarless hard candy or gum to stimulate saliva production, adequate hydration, and frequent mouth care. Stomatitis (inflammation of the mouth) produces excessive salivation and a sore mouth. Oral cadidiasis (thrush) causes bluish-white mouth lesions. Gingivitis can be recognized by the inflamed gingival and bleeding that occur during toothbrushing. 44. The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation? a. Use of alcohol b. Frequent use of mouthwash c. Lack of vitamin B12 d. Lack of regular teeth cleaning by a dentist Ans: A chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless tobacco are other significant risk factors. Additional risk factors include chronic irritation such as a broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and syphilis. Use of mouthwash, lack of vitamin B12 and lack of regular teeth cleaning appointments have not been implicated as primary risk factors for oral cancer. 45. A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. He tells the occupational health nurse at his place of employment that he has not smoked a cigarette for 3 weeks, but is afraid he is going to slip

up and smoke because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the clients comments? a. Dont worry about it. Everybody has difficulty quitting smoking, and you should expect to as well. b. If you increase your self-control, I am sure you will be able to avoid smoking. c. Try taking a couple of days of vacation to relieve the stress of your job. d. It is good that you can talk about your concerns. Try calling a friend when you want to smoke. Ans: D it is important for individuals who are engaged in smoking cessation efforts to feel comfortable with sharing their fears of failure with others and seeking support. Although fewer than 5% of smokers successfully quit on their first attempt, it is not helpful to tell a client that he found anticipate failure. Telling the client to exercise more self-control dose not provide him with support. Taking a vacation to avoid job pressures does not address the issue of fearing he will smoke a cigarette when in a stressful situation. 46. A client who was in a motor vehicle accident has a fractured mandible. Surgery has been performed to immobilize the injury by wiring the jaw. What is the nurses priority in regard to care in the immediate postoperative phase? a. Prevent nausea and vomiting b. Maintain a patent airway c. Provide frequent airway d. Establish a way for the client to communicate Ans: B the priority of care in the immediate postoperative phase is to maintain a patent airway. The nurse should observe the client carefully for signs of respiratory distress. If the client becomes nauseated, antiemetics should be administered to decrease the chance of vomiting with obstruction of the airway and aspiration of vomitus. Providing frequent oral hygiene and an alternative means of communication are important aspects of nursing care, but maintaining a patent airway is most important. 47. A client has returned from surgery during which her jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the assistant on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the assistant? a. Keep the client in a side-lying position with the head slightly elevated b. Do not reposition the client without the assistance of a registered nurse c. The client can assume any position that is comfortable d. Keep the clients head elevated on two pillows at all times Ans: A- immediately after surgery the client should be placed on the side with the head slightly elevated. This position helps facilitate removal of secretions and decreases the likelihood of aspiration should vomiting occur. A registered nurse does not need to be present to reposition the presence of the nurse. Although it is important to elevate the head, there is no need to keep the clients head elevated on two pillows unless that position is comfortable for the client. 48. A client who has had her jaws wired begins to vomit. What should be the nurses first action? a. Insert a nasogastric tube and connect it to suction b. Use wire cutters to cut the wire c. Suction the clients airway as needed d. Administer an antiemetic intravenously Ans: C the nurses first action is to clear the clients airway as necessary.

Inserting a nasogastric tube or administering an antiemetic may prevent future vomiting episodes, but these procedures are not helpful when the client is actually vomiting. Cutting the wires is done only as a last resort or in case of respiratory or cardiac arrest. 49. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicate which of the following? a. An intestinal obstruction has developed b. Additional ulcers have developed c. The esophagus has become inflamed d. The ulcer is perforated Ans: D the body reacts to perforation of an ulcer by immobilizing the area as much as possible. This results in boardlike abdominal rigidity, usually extreme pain. This may occur over several hours or days. It is a medical emergency requiring immediate intervention. An intestinal obstruction would not cause midepigastric pain. Esophageal inflammation or the development of additional ulcers would not cause a rigid, boardlike abdomen. 50. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? a. Ineffective coping related to fear of diagnosis of chronic illness b. Deficient knowledge related to unfamiliarity with significant signs and symptoms c. Constipation related to decreased gastric motility d. Imbalanced nutrition: less than body requirements related to gastric bleeding Ans: B black, tarry stools are an important warning of bleeding in peptic ulcer disease. Digested blood in the stool because it to be black. The odor of the stool is very offensive. Clients with peptic ulcer disease should be instructed to report the incidence of black stools promptly to their primary health care provider.