HURST CORRECT TEST PAPER QUESTIONS AND
ANSWERS SURE A+
✔✔for a total hip replacement what kind of pre-op care is given? - ✔✔- bucks traction is
used freq pre op to mobilize the fracture
✔✔what are some nursing considerations when dealing with post op care of a total hip
replacement? - ✔✔- monitor drains ( dont want fluid to accumlate in the tissue)
- over bed trapeze to build upper body strength
position : want neutral rotation ---> toes pointed to the ceiling
- limit flexion; want extension of hip
abduction or adduction? abduction
✔✔what exercise can the client do while still confined to bed w/ a total hip replacment ?
- ✔✔- isometric
✔✔what is the purpose of the trochanter roll ? - ✔✔To prevent external rotation.
**Document all this stuff in Nurse's notes**
✔✔is it okay to sleep on the operated side of a totaly hip replacement? - ✔✔- no
✔✔is hydration important with a total hip replacement client? - ✔✔- yes
✔✔is it okay to give pain meds in the operative hip of a total replacement hip? - ✔✔no
✔✔what kind of complications can only experience when dealing with a total hip
replacement - ✔✔- dislocations
- infection
- avascular necrosis
- immobility problems
✔✔dislocation complications - ✔✔circulatory and nerve damage
,✔✔what are some S/S of dislocation complications ? - ✔✔- shortening of leg, abnormal
rotation, cant move extremity and pain
✔✔what are some infection complications when dealing with hip replacement ? - ✔✔-
prophylatic antibiotics ( just like with a heart valve replacement)
- remove indwelling catheters and drains as soon as possible ( these serve as a portal
for infection)
✔✔avascular necrosis complications when dealing with hip replacement? - ✔✔- death
of tissue due to poor circulation
✔✔what is the best exercise to do when a pt has a replacement hip? -
✔✔walking/swimming/rocking
avoid flexion: low chairs, traveling long distances, sitting more than 30 min
✔✔amputations are performed at the most what? - ✔✔- distal point that will heal
✔✔the surgeon tries to prevent the __________ or elbow - ✔✔knee
✔✔what is some immediate post op care following a amputation - ✔✔keep a tournique
at bedside
- prevent knee contractures how? extension
✔✔what is the first intervention to decrease phantom pain ? - ✔✔- diversional activity ,
then pain meds
✔✔when is phantom pain seen more in ? - ✔✔- AKA ( above knee amputation )
✔✔when does phatom pain usually subside? - ✔✔- 3 months
✔✔why is limb shaping important ? - ✔✔- for prostetics
✔✔how you want the stump shaped at the end? - ✔✔- round and smaller
✔✔what is worn under the prosthesis? - ✔✔- limb sock
✔✔why is it important to strength the upper body after amputation ? - ✔✔- they will be
using crutches or a walker to ambulate
✔✔is it okay to massage a stump? - ✔✔yes
- massaging promotes circulation and decreases tenderness
✔✔how do you teach a client to toughen the stump? - ✔✔- press into a soft pillow
,- then a firm pillow
- then the bed
- then a chair
✔✔how does one use a walker? - ✔✔- walk into the walker
✔✔crutches should be ___________ below the __________ to decrease risk of
brachial nerve damage - ✔✔1-2 in
- axilla
✔✔when on crutches how should one rest body weight on hands or axilla? - ✔✔- hands
✔✔when walking up and down stairs with crutches, its up with the good leg and down
with the ___________ leg - ✔✔bad
✔✔when using a cane you should use which side of the body to walk? - ✔✔- strong
✔✔the nurse is caring for a client that has metabolic acidosis secondary to acute renal
failure. what is the inital client repsonse to this problem?
1. resp. rate increases to blow off acid
2. resp. rate decreases to conserve acid and buffer the kidneys response
3. kidneys will excrete hydrogen and retain bicarb
4. sodium will shift to cells and buffer the hydrogens - ✔✔1. resp. rate increases to blow
off acid
✔✔pH- 7.30
paO2-91
paCO2- 50
HCO3- 24
1. resp. alkalosis
2. resp. acidosis
3. metabolic alkalosis
4. metabolic acidosis - ✔✔2. resp acidosis
✔✔a client is hospitalized hundreds of miles from home for a bone marrow transplant.
the client is in a protective environment while undergoing intense chemotherapy. the
clients sibilings come to visit and has obv manifestations of an URI. which nursing
action would be most app. at this time?
1. do not allow the sibiling to visit, and do not upset the client by mentioning the sibilings
visit
2. allow the sibiling to wave at the client through the window or door, then offer the use
of the unit phone so they can talk
, 3. allow the sibiling to visit after donning a sterile gown, mask, and gloves, but prohinit
physical contact - ✔✔2. allow the sibiling to wave at the client through thr window or
door, then offer to use the unit phone so they can talk
✔✔a client is admitted to the medical unit with a diagnosis of addisons disease? what
nursing interventions should the nurse implement for this client? select all that apply
1. monitor for decreased K levels
2. assist the client to select food low in NA
3. administer fludrocortisone as prescribed
4. monitor I & O
5. record daily weight - ✔✔3. administer fludrocortisone as prescribed
4. monitor i & O
5. record daily weights
✔✔which statements made by a client after receiving education regarding bleeding
precautions would indicate to the nurse that teaching was successful? select all that
apply
1. i cannot shave while i am at risk for bleeding
2. it is important to gargle with a commercial mouthwash three times a day
3. stool softeners will help prevent rectal bleeding
4. prior to sexual intercourse, i will use water based lubricant
5. i will use a soft toothbrush - ✔✔3. stool softeners will help prevent rectal bleeding
4. prior to sexual intercourse, i will use water base lube
4. i will use a soft toothbrush
✔✔a client is reporting shortness of breath and neck pressure following a
thyroidectomy. what is the priority nursing intervention?
1. elevate the head of bed, and remove the dressing, and stay with the client
2. call a code, open the trach set, and position the client supine
3. have the client say " EEE" to check for laryngeal integrity and assess Chvosteks sign
4. call the primary healthcare provider and assess vital signs - ✔✔1. elevate the head of
the bed, remove the dressing, and stay with the client
✔✔the nurse observes a client in the manic phase of bipolar disorder in group therapy.
the client has interrupted the counselors group session multiple times and states " i
already know this information dealing with others when you are down. " which nursing
action is app.?
1. ask the client to walk with the nurse to get a snack
2. ask the group to reflect on the clients behavior to determine if it is app.
3. ask the group to tell the client how they feel about the disruptions
4. instruct the client to perform jumping jacks to get rid of some energy - ✔✔1. ask the
client to walk with the nurse to get a snack
✔✔which client should the nurse identify as being HIGHEST risk for suicide ?
1. seventy six year old widower with chronic renal failure
ANSWERS SURE A+
✔✔for a total hip replacement what kind of pre-op care is given? - ✔✔- bucks traction is
used freq pre op to mobilize the fracture
✔✔what are some nursing considerations when dealing with post op care of a total hip
replacement? - ✔✔- monitor drains ( dont want fluid to accumlate in the tissue)
- over bed trapeze to build upper body strength
position : want neutral rotation ---> toes pointed to the ceiling
- limit flexion; want extension of hip
abduction or adduction? abduction
✔✔what exercise can the client do while still confined to bed w/ a total hip replacment ?
- ✔✔- isometric
✔✔what is the purpose of the trochanter roll ? - ✔✔To prevent external rotation.
**Document all this stuff in Nurse's notes**
✔✔is it okay to sleep on the operated side of a totaly hip replacement? - ✔✔- no
✔✔is hydration important with a total hip replacement client? - ✔✔- yes
✔✔is it okay to give pain meds in the operative hip of a total replacement hip? - ✔✔no
✔✔what kind of complications can only experience when dealing with a total hip
replacement - ✔✔- dislocations
- infection
- avascular necrosis
- immobility problems
✔✔dislocation complications - ✔✔circulatory and nerve damage
,✔✔what are some S/S of dislocation complications ? - ✔✔- shortening of leg, abnormal
rotation, cant move extremity and pain
✔✔what are some infection complications when dealing with hip replacement ? - ✔✔-
prophylatic antibiotics ( just like with a heart valve replacement)
- remove indwelling catheters and drains as soon as possible ( these serve as a portal
for infection)
✔✔avascular necrosis complications when dealing with hip replacement? - ✔✔- death
of tissue due to poor circulation
✔✔what is the best exercise to do when a pt has a replacement hip? -
✔✔walking/swimming/rocking
avoid flexion: low chairs, traveling long distances, sitting more than 30 min
✔✔amputations are performed at the most what? - ✔✔- distal point that will heal
✔✔the surgeon tries to prevent the __________ or elbow - ✔✔knee
✔✔what is some immediate post op care following a amputation - ✔✔keep a tournique
at bedside
- prevent knee contractures how? extension
✔✔what is the first intervention to decrease phantom pain ? - ✔✔- diversional activity ,
then pain meds
✔✔when is phantom pain seen more in ? - ✔✔- AKA ( above knee amputation )
✔✔when does phatom pain usually subside? - ✔✔- 3 months
✔✔why is limb shaping important ? - ✔✔- for prostetics
✔✔how you want the stump shaped at the end? - ✔✔- round and smaller
✔✔what is worn under the prosthesis? - ✔✔- limb sock
✔✔why is it important to strength the upper body after amputation ? - ✔✔- they will be
using crutches or a walker to ambulate
✔✔is it okay to massage a stump? - ✔✔yes
- massaging promotes circulation and decreases tenderness
✔✔how do you teach a client to toughen the stump? - ✔✔- press into a soft pillow
,- then a firm pillow
- then the bed
- then a chair
✔✔how does one use a walker? - ✔✔- walk into the walker
✔✔crutches should be ___________ below the __________ to decrease risk of
brachial nerve damage - ✔✔1-2 in
- axilla
✔✔when on crutches how should one rest body weight on hands or axilla? - ✔✔- hands
✔✔when walking up and down stairs with crutches, its up with the good leg and down
with the ___________ leg - ✔✔bad
✔✔when using a cane you should use which side of the body to walk? - ✔✔- strong
✔✔the nurse is caring for a client that has metabolic acidosis secondary to acute renal
failure. what is the inital client repsonse to this problem?
1. resp. rate increases to blow off acid
2. resp. rate decreases to conserve acid and buffer the kidneys response
3. kidneys will excrete hydrogen and retain bicarb
4. sodium will shift to cells and buffer the hydrogens - ✔✔1. resp. rate increases to blow
off acid
✔✔pH- 7.30
paO2-91
paCO2- 50
HCO3- 24
1. resp. alkalosis
2. resp. acidosis
3. metabolic alkalosis
4. metabolic acidosis - ✔✔2. resp acidosis
✔✔a client is hospitalized hundreds of miles from home for a bone marrow transplant.
the client is in a protective environment while undergoing intense chemotherapy. the
clients sibilings come to visit and has obv manifestations of an URI. which nursing
action would be most app. at this time?
1. do not allow the sibiling to visit, and do not upset the client by mentioning the sibilings
visit
2. allow the sibiling to wave at the client through the window or door, then offer the use
of the unit phone so they can talk
, 3. allow the sibiling to visit after donning a sterile gown, mask, and gloves, but prohinit
physical contact - ✔✔2. allow the sibiling to wave at the client through thr window or
door, then offer to use the unit phone so they can talk
✔✔a client is admitted to the medical unit with a diagnosis of addisons disease? what
nursing interventions should the nurse implement for this client? select all that apply
1. monitor for decreased K levels
2. assist the client to select food low in NA
3. administer fludrocortisone as prescribed
4. monitor I & O
5. record daily weight - ✔✔3. administer fludrocortisone as prescribed
4. monitor i & O
5. record daily weights
✔✔which statements made by a client after receiving education regarding bleeding
precautions would indicate to the nurse that teaching was successful? select all that
apply
1. i cannot shave while i am at risk for bleeding
2. it is important to gargle with a commercial mouthwash three times a day
3. stool softeners will help prevent rectal bleeding
4. prior to sexual intercourse, i will use water based lubricant
5. i will use a soft toothbrush - ✔✔3. stool softeners will help prevent rectal bleeding
4. prior to sexual intercourse, i will use water base lube
4. i will use a soft toothbrush
✔✔a client is reporting shortness of breath and neck pressure following a
thyroidectomy. what is the priority nursing intervention?
1. elevate the head of bed, and remove the dressing, and stay with the client
2. call a code, open the trach set, and position the client supine
3. have the client say " EEE" to check for laryngeal integrity and assess Chvosteks sign
4. call the primary healthcare provider and assess vital signs - ✔✔1. elevate the head of
the bed, remove the dressing, and stay with the client
✔✔the nurse observes a client in the manic phase of bipolar disorder in group therapy.
the client has interrupted the counselors group session multiple times and states " i
already know this information dealing with others when you are down. " which nursing
action is app.?
1. ask the client to walk with the nurse to get a snack
2. ask the group to reflect on the clients behavior to determine if it is app.
3. ask the group to tell the client how they feel about the disruptions
4. instruct the client to perform jumping jacks to get rid of some energy - ✔✔1. ask the
client to walk with the nurse to get a snack
✔✔which client should the nurse identify as being HIGHEST risk for suicide ?
1. seventy six year old widower with chronic renal failure
