HESI EXIT PRACTICE QUESTIONS AND
RATIONALE (2)
Theginursegihasgicompletedgigivinggidischargegiinstructionsgitogiagiclientgiwhogihasgihadgiagitotalgijointgireplacem
ntgi(TJR)giofgithegikneegiwithgiagimetalgiprostheticgisystem.giTheginursegideterminesgithatgithegiclientgiunderstan
sgithegiinstructionsgiifgithegiclientgimakesgiwhichgistatement?
gi1."Changesgiingithegishapegiofgithegikneegiaregiexpected."gi
2."Fever,giredness,giandgiincreasedgipaingiaregiexpected."gi
3."Allgicaregiversgishouldgibegitoldgiaboutgithegimetalgiimplant."gi
4."Bleedinggigumsgiorgiblackgistoolsgimaygioccur,gibutgithisgiisginormal."gi-gianswer--3gi
AgiTJRgiisgialsogiknowngiasgiagitotalgijointgiarthroplastygi(TJA).giThegiclientgimustgiinformgiothergicaregiversgiofgit
gipresencegiofgithegimetalgiimplantgibecausegicertaingitestsgiandgiproceduresgiwillgineedgitogibegiavoided.giAfter
talgikneegireplacement,githegiclientgishouldgireportgisignsgiandgisymptomsgiofgiinfectiongiandgianygichangesgiing
egishapegiofgithegiknee.giThesegicouldgiindicategidevelopinggicomplications.giWithgiagimetalgiimplant,githegiclien
maygibegiongianticoagulantgitherapygiandgishouldgireportgiadversegieffectsgiofgithisgitherapy,giincludinggibleedi
gifromgiagivarietygiofgisources,giandgithegiclientgiwillgineedgiantibioticgiprophylaxisgiforgiinvasivegiprocedures.
Theginursegiisgicaringgiforgiagiclientgiaftergithegiapplicationgiofgiagiplastergicastgiforgiagifracturedgileftgiradius.giThe
ursegishouldgisuspectgiimpairmentgiwithgithegineurovasculargistatusgiofgithegiclient'sgicastedgiextremitygiifgiwhic
ifindingsgiareginoted?giSelectgiallgithatgiapply.
gi1.Capillarygirefillgiisgilessgithangi3gisecondsgi2.Pulsesgipresentgiandgiwithgiswollen,gipinkgifingersgi
3.Clientgireportgiofgisevere,gideep,giunrelentinggipaingi
4.Clientgireportgiofgipaingiasginursegiassessesgifingergimovementgi
5.Clientgireportgiofginumbnessgiandgitinglinggisensationgiingithegifingersgi-gianswer--3,gi4,gi5gi
Thegipressuregiingicompartmentgisyndrome,giifgiunrelieved,giwillgicausegipermanentgidamagegitoginervegiandgi
usclegitissuegidistalgitogithegipressure.giCirculatorygidamagegimaygiresultgiinginecrosis.giNervegiandgimusclegida
agegimaygiresultgiingipermanentgicontractures,gideformitygiofgithegiextremity,giandgifunctionalgiimpairment.giNo
malgicapillarygirefillgitimegiisgi3gisecondsgiorgiless.giPinkgiappearancegiandgiagipulsegiindicategiadequategibloodg
ow;giswellinggiisgiexpectedgiaftergiagifracture.giClientgireportgiofgisevere,gideep,giunrelentinggipain;giclientgirepo
ofginumbnessgiandgitinglinggisensation;giandgiclientgireportgiofgipaingiasgitheginursegiassessesgifingergimoveme
giaregiindicativegiofgidevelopment giofgicompartmentgisyndrome.
Agiclientgiwithgiagi4-day-
oldgilumbargivertebralgifracturegiisgiexperiencinggimusclegispasms.giWhichgiaregiinterventionsgitogiaidgithegiclie
iingirelievinggithegispasm?giSelectgiallgithatgiapply.
gi1.Icegi
2.Heatgi
3.Analgesicsgi
4.Musclegirelaxersgi
5.Intermittentgitractiongi-gianswer--2,gi3,gi4,gi5gi
Heat,gianalgesics,gimusclegirelaxers,giandgitractiongiallgimaygibegiusedgitogirelievegithegipaingiofgimusclegispasm
ngithegiclientgiwithgiagivertebralgifracture.giIcegiisgiappliedgitogiagipainfulgisitegionlygiforgithegifirstgi48gitogi72gihoursg
ependinggiongithegihealthgicaregiprovider'sgipreference)giaftergiangiinjury.giApplicationgiofgiicegitogithegispinegiof
clientgicouldgibegiuncomfortablegiandgicouldgiresultgiingifeelingsgiofgibeinggichilled.
,Theginursegiisgicaringgiforgiagiclientgiwhogihadgisurgerygitogirepairgiagifracturedgileft-
sidedgihipgiusinggiagiposteriorgiapproach.giIngiimplementinggihipgiprecautions,giwhichgiactiongishouldgitheginurs
teachgithegiclientgitogiavoid?
gi1.Crossinggilegsgiatgithegianklegi
2.Usinggiangielevatedgitoiletgiseatgi3.Placinggiagipillowgibetweengithegilegsgi4.Keepinggithegilegsgiabductedgifro
ithegimidlinegi-gianswer--1gi
Followinggisurgerygitogirepairgiagifracturedgihipgiusinggiagiposteriorgiapproach,giclientgieducationgishouldgiinclu
githegifollowing:giavoidinggicrossinggithegilegsgiatgithegianklegiorgithegiknee,giusinggiangielevatedgitoiletgiseat,gipla
nggiagipillowgibetweengithegilegsgiwhilegilyinggidowngiforgithegifirstgi6giweeks,gikeepinggithegilegsgiabductedgifrom
hegimidline,giandgikeepinggithegihipgiingiagineutralgipositiongiatgiallgitimes.
Angioldergiclientgiisgidiagnosedgiwithgiosteoporosis.giTheginursegiteachesgithegiclientgiaboutgiself-
caregimeasures,giknowinggithatgithegiclientgiisgimostgiatgiriskgiforgiwhichgiproblemgiasgiagiresultgiofgithisgidisorder
fgithegibones?
gi1.Anemiagi
2.Fracturesgi
3.Infectiongi
4.Musclegisprainsgi-gianswer--2
Thegiclientgiisgimostgiatgiriskgiforgifracturesgiasgiagiresultgiofgiosteoporosis.giAlthoughgiothergicomplicationsgican
ccur,gifracturegiisgithegigreatestgiconcern.giAnemiagiandgiinfectiongicangioccurgiwithgibonegimarrowgidisorders,
ndgimusclegisprainsgiaregiunrelatedgitogiosteoporosis.
Agiclientgiwithgiaginewgimedicationgiprescriptiongiforgiallopurinolgiasksgitheginurse,gi"Igiknowgithisgiisgiforgigout,gib
ihowgidoesgiitgiwork?"giTheginursegiplansgitogireplygibasedgiongiwhichgimedicationgiaction?
gi1.Allopurinolgidecreasesgiuricgiacidgiproduction.gi
2.Allopurinolgireducesgithegiproductiongiofgifibrinogen.gi
3.Allopurinolgidecreasesgithegiriskgiofgisulfagicrystalgiformationgiingithegiurine.gi4.Allopurinolgipreventsgiinfluxgio
calciumgiionsgiduringgicellgidepolarization.gi-gianswer--1
Allopurinolgiisgiclassifiedgiasgiangiantigoutgimedication.giItgidecreasesgiuricgiacidgiproductiongibygiinhibitinggithe
anthinegioxidasegienzyme,giandgiitgireducesgiuricgiacidgiconcentrationsgiingibothgiserumgiandgiurine.giThegiothe
optionsgiaregiincorrect.
Theginursegiisgicaringgiforgiagiclientgidiagnosedgiwithgiosteitisgideformansgi(Paget'sgidisease).giWhichgidoesgith
nursegiidentifygiasgithegicausegiofgithegiclient'sgistoopedgiposturegiandgibowinggiofgilowergiextremities?
gi1.Musclegimetabolismgiandgigrowthgi2.Bonegiresorptiongiandgiregenerationgi3.Nervousgisystemgiimpulsegitr
smissiongi4.Jointgiintegritygiandgisynovialgifluidgiproductiongi-gianswer--2
Paget'sgidiseasegiisgicharacterizedgibygiskeletalgideformitiesgiresultinggifromgiabnormalgibonegiresorptiongifol
wedgibygiabnormalgiregeneration.giItgiisginotgicausedgibygiproblemsgiwithgimuscle,ginervousgisystem,giorgijointgi
nctioning.
Agiclientgihasgibeengidiagnosedgiwithgigout,giandgitheginursegiprovidesgidietarygiinstructions.giTheginursegidete
inesgithatgithegiclientgineedsgiadditionalgiteachinggiifgithegiclientgistatesgithatgiitgiisgiacceptablegitogieatgiwhichgifo
?
gi1.Carrotsgi
2.Tapiocagi
3.Chocolategi
4.Chickengilivergi-gianswer--4gi
Livergiandgiothergiorgangimeatsgishouldgibegiomittedgifromgithegidietgiofgiagiclientgiwhogihasgigoutgibecausegiofgit
rgihighgipurinegicontent.giPurinesgiaregiagiformgiofgiprotein.giThegifoodgiitemsgiidentifiedgiingithegiothergioptionsgic
tainginegligiblegiamountsgiofgipurinesgiandgimaygibegiconsumedgifreelygibygithegiclientgiwithgigout.
,DiagnosticgistudiesgiaregiprescribedgiforgiagiclientgiwithgisuspectedgiPaget'sgidisease.giIngireviewinggithegiclien
girecord,githeginursegiwouldgiexpectgitoginotegithatgithegihealthgicaregiprovidergihasgiprescribedgiwhichgilaborato
istudy?
gi1.Plateletgicountgi
2.Alkalinegiphosphatasegi
3.Whitegibloodgicellgicountgi
4.Completegibloodgicellgicountgi-gianswer--2
Paget'sgidiseasegiisgiagichronicgimetabolicgidisordergiingiwhichgibonegiisgiexcessivelygibrokengidowngiandgirefo
ed.giThegiresultgiisgibonegithatgiisgistructurallygidisorganized,gicausinggibonegitogibegiweakgiwithgiincreasedgirisk
orgibowinggiofgilonggibonesgiandgifractures.giDiagnosticgilaboratorygifindingsgiforgiPaget'sgidiseasegiincludegian
levatedgiserumgialkalinegiphosphatasegilevelgiandgielevatedgiurinarygihydroxyprolinegiexcretion.giThegiremain
ggioptionsgiaregiunrelatedgitogidiagnosticgievaluationgiofgithisgidisease.
Agiclientgiisgitogireceivegiagiprescriptiongiforgimethocarbamol.giTheginursegiprovidesgiinstructionsgitogithegiclient
boutgithegimedication.giWhichgiclientgistatementgiwouldgiindicategiagineedgiforgifurthergieducation?
gi1."Mygiurinegimaygiturngibrowngiorgigreen."gi2."Igimightgigetgisomeginasalgicongestiongifromgithisgimedication."
3."Thisgimedicationgiisgiprescribedgitogihelpgirelievegimygimusclegispasms."gi
4."Ifgimygivisiongibecomesgiblurred,giIgidon'tgineedgitogibegiconcernedgiaboutgiit."gi-gianswer--4gi
Methocarbamolgiisgiagimusclegirelaxantgithatgiworksgibygiblockingginervegiimpulsesgi(orgipaingisensations)githa
aregisentgitogithegibrain.giThegiclientgineedsgitogibegitoldgithatgithegiurinegimaygiturngibrown,giblack,giorgigreen.giO
ergiadversegieffectsgiincludegiblurredgivision,ginasalgicongestion,giurticaria,giandgirash.giThegiclientgineedsgitogi
giinstructedgitoginotifygithegihealthgicaregiprovidergiifgithesegiside/adversegieffectsgioccur.
Theginursegiisgiplanninggimeasuresgitogiincreasegibedgimobilitygiforgiagiclientgiingiskeletalgileggitraction.giWhichg
mgishouldgitheginursegiconsidergitogibegimostgihelpfulgiforgithisgiclient?
gi1.Televisiongi
2.Fracturegibedpangi
3.Overheadgitrapezegi
4.Readinggimaterialsgi-gianswer--3gi
Thegiusegiofgiangioverheadgitrapezegiisgiextremelygihelpfulgiforgiagiclientgitogimovegiaboutgiingibedgiandgitogigetgio
andgioffgithegibedpan.giThisgidevicegihasgithegigreatestgivaluegiingiincreasinggioverallgibedgimobility.giTelevision
ndgireadinggimaterials,gialthoughgihelpfulgiingireducinggiboredomgiandgiprovidinggidistraction,gidoginotgiincreas
bedgimobility.giAgifracturegibedpangiisgiusefulgiingireducinggidiscomfortgiwithgielimination.
Theginursegiisgicaringgiforgiagiclientgiwhogisustainedgiangiopengifracturegiandgiisgidiagnosedgiwithgiacutegiosteom
elitisgiofgithegirightgilowergiextremity.giWhichgiinterventiongishouldgitheginursegiplangitogiperform?
gi1.Applygiicegitogithegiaffectedgiarea.gi2.Performgisterilegidressinggichanges.gi3.Instructgithegiclientgiongileggiex
cises.gi4.Measuregithegileggicircumferencegidaily.gi-gianswer--2
Osteomyelitisgiisgiagiseveregiinfectiongiofgithegibone,gibonegimarrow,giandgisurroundinggisoftgitissue.giClinicalgim
nifestationsgiincludegiconstantgibonegipaingiunrelievedgibygirestgithatgiworsensgiwithgiactivity;giswelling,gitende
ess,giandgiwarmthgiatgithegiinfectiongisite;girestrictedgimovementgiofgithegiaffectedgipart;gifever,ginightgisweats,g
ills,girestlessness,ginausea,giandgimalaise.giOptiongi2giisgithegicorrectgioption,giasgitreatmentgiofgiosteomyelitis
tengiincludesgisurgicalgidebridementgiandgirequiresgisterilegidressinggichanges.giOptiongi1giisgiincorrect,giasgio
eomyelitisgiisgiangiinfectiongiandgiapplyinggiicegitogithegiareagiwillginotgihelpgianygiswellinggiandgimaygicausegivas
constriction.giOptiongi3giisgiincorrect,giasgimovementgiworsensgithegipaingiandgisomegiimmobilizationgiofgithegia
ectedgilimbgi(e.g.,gisplint,gitraction)giisgiusuallygiindicated.giOptiongi4,gimeasuringgileggicircumferencegidaily,giis
otginecessary.
Thegihealthgicaregiprovidergihasgiprescribedgiagilidocainegi5%gipatchgiforgiagiclientgiwithgiagidiagnosisgiofgineckg
ingiduegitogiosteoarthritis.giWhichgishouldgitheginursegitellgithegiclientgiregardinggithisgimedication?
gi1.Thegimedicationgipatchgiwillgiactgiasgiagilocalgianesthetic.gi
2.Thegimedicationgipatchgiactsgibygidecreasinggimusclegispasms.gi
3.Thegimedicationgiisgiprescribedgitogicausegithegiskingitogipeelgibelowgithegipatch.gi
, 4.Applygiagiheatinggipadgitogithegiareagiaftergiapplyinggithegimedicationgipatchgitogiincreasegithegieffectiveness
gianswer--1
Agilidocainegipatchgiprovidesgiagilocalgianestheticgieffectgitogithegisitegiofgiapplication.giThegimedicationgidoesgin
giactgiingiagisystemicgimanner.giItgiisginotgiprescribedgitogicausegithegiskingitogipeel,gisogiifgithisgireactiongioccurs,g
egihealthgicaregiprovidergishouldgibeginotified.giAgiheatinggipadgishouldginotgibegiappliedgibecausegiirritationgior
urninggiofgithegiskingimaygioccur.
Theginursegiwitnessedgiagivehiclegihitgiagipedestrian.giThegivictimgiisgidazedgiandgitriesgitogigetgiup.giAgileggiappe
sgifractured.giWhichgiinterventiongishouldgitheginursegitake?
gi1.Trygitogireducegithegifracturegimanually.gi2.Assistgithegivictimgitogigetgiupgiandgiwalkgitogithegisidewalk.gi
3.Leavegithegivictimgiforgiagifewgimomentsgitogicallgiangiambulance.gi
4.Staygiwithgithegivictimgiandgiencouragegihimgiorgihergitogiremaingistill.gi-gianswer--4gi
Withgiagisuspectedgifracture,githegivictimgiisginotgimovedgiunlessgiitgiisgidangerousgitogiremaingiingithatgispot.giTh
nursegishouldgiremaingiwithgithegivictimgiandgihavegisomeonegielsegicallgiforgiemergencygihelp.giAgifracturegiisgi
tgireducedgiatgithegiscene.giBeforegithegivictimgiisgimoved,githegisitegiofgifracturegiisgiimmobilizedgitogipreventgifu
ergiinjury.
Theginursegihasgisuggestedgispecificgileggiexercisesgiforgiagiclientgiimmobilizedgiingirightgiskeletalgilowergileggitr
tion.giTheginursegideterminesgithatgithegiclientgineedsgifurthergiinstructiongiifgitheginursegiobservesgithegiclientgip
forminggiwhichgiaction?
gi1.Pullinggiupgiusinggithegitrapezegi2.Flexinggiandgiextendinggithegifeetgi3.Doinggiquadriceps-
settinggiandgigluteal-settinggiexercisesgi
4.Performinggiactivegirangegiofgimotiongitogithegirightgianklegiandgikneegi-gianswer--4
Activegirangegiofgimotiongitogithegirightgianklegiandgikneegiwouldgidisruptgiskeletalgitractiongiofgithegirightgilowerg
g.giThegiclientgimaygipullgiupgiusinggithegitrapeze,giperformgiactivegirangegiofgimotiongiwithgiuninvolvedgijoints,gia
dgidogiisometricgimuscle-settinggiexercisesgi(suchgiasgiquadriceps-giandgigluteal-
settinggiexercises).giThegiclientgialsogimaygiflexgiandgiextendgithegifeet.giThesegiexercisesgiaregiwithingitherape
cgilimitsgiforgithegiclientgiingiskeletalgitractiongitogimaintaingimusclegistrengthgiandgirangegiofgimotion.
Agiclientgihasgijustgibeengiadmittedgitogithegihospitalgiwithgiagifracturedgifemurgiandgipelvicgifractures.giTheginurs
shouldgiplangitogicarefullygimonitorgithegiclientgiforgiwhichgisigns/symptoms?
1.Fevergiandgibradycardiagi
2.Fevergiandgihypertensiongi3.Tachycardiagiandgihypotensiongi4.Bradycardiagiandgihypertensiongi-gianswer
3gi
Clientsgiwhogiexperiencegifracturesgiofgithegifemur,gipelvis,githorax,giandgispinegiaregiatgiriskgiforgihypovolemicg
hock.giBonegifragmentsgicangidamagegibloodgivessels,gileadinggitogihemorrhagegiintogithegiabdominalgicavity
ndgithegithigh.giThisgicangioccurgiwithgiclosedgifracturesgiasgiwellgiasgiopengifractures.giSignsgiofgihypovolemicgi
ockgiincludegitachycardiagiandgihypotension.
Theginursegiisgicaringgiforgiagiclientgiwithgiacutegibackgipain.giWhichgiaregithegimostgilikelygicausesgiofgithisgiprob
m?giSelectgiallgithatgiapply.
gi1.Twistinggiofgithegispinegi
2.Curvaturegiofgithegispinegi3.Hyperflexiongiofgithegispinegi
4.Sciaticginervegiinflammationgi5.Degenerationgiofgithegifacetgijointsgi6.Herniationgiofgiangiintervertebralgidisk
gianswer--1,gi3,gi6gi
Acutegibackgipaingiisgisuddengiingionsetgiandgiisgiusuallygiprecipitatedgibygiinjurygitogithegilowergiback,gisuchgiasg
thgihyperflexion,gitwisting,giorgidiskgiherniation.giScoliosisgi(curvature),gisciatica,giandgidegenerativegivertebra
changesgiaregimoregilikelygitogicausegichronicgibackgipain,giwhichgicangibegimoregiinsidiousgiingionsetgiandgimay
alsogibegiaccompaniedgibygidegenerationgiofgithegiintervertebralgidisk.
Agiclientgihasgibeengiongitreatmentgiforgirheumatoidgiarthritisgiforgi3giweeks.giDuringgithegiadministrationgiofgieta
ercept,giwhichgiisgimostgiimportantgiforgitheginursegitogiassess?
gi1.Thegiinjectiongisitegiforgiitchinggiandgiedemagi
RATIONALE (2)
Theginursegihasgicompletedgigivinggidischargegiinstructionsgitogiagiclientgiwhogihasgihadgiagitotalgijointgireplacem
ntgi(TJR)giofgithegikneegiwithgiagimetalgiprostheticgisystem.giTheginursegideterminesgithatgithegiclientgiunderstan
sgithegiinstructionsgiifgithegiclientgimakesgiwhichgistatement?
gi1."Changesgiingithegishapegiofgithegikneegiaregiexpected."gi
2."Fever,giredness,giandgiincreasedgipaingiaregiexpected."gi
3."Allgicaregiversgishouldgibegitoldgiaboutgithegimetalgiimplant."gi
4."Bleedinggigumsgiorgiblackgistoolsgimaygioccur,gibutgithisgiisginormal."gi-gianswer--3gi
AgiTJRgiisgialsogiknowngiasgiagitotalgijointgiarthroplastygi(TJA).giThegiclientgimustgiinformgiothergicaregiversgiofgit
gipresencegiofgithegimetalgiimplantgibecausegicertaingitestsgiandgiproceduresgiwillgineedgitogibegiavoided.giAfter
talgikneegireplacement,githegiclientgishouldgireportgisignsgiandgisymptomsgiofgiinfectiongiandgianygichangesgiing
egishapegiofgithegiknee.giThesegicouldgiindicategidevelopinggicomplications.giWithgiagimetalgiimplant,githegiclien
maygibegiongianticoagulantgitherapygiandgishouldgireportgiadversegieffectsgiofgithisgitherapy,giincludinggibleedi
gifromgiagivarietygiofgisources,giandgithegiclientgiwillgineedgiantibioticgiprophylaxisgiforgiinvasivegiprocedures.
Theginursegiisgicaringgiforgiagiclientgiaftergithegiapplicationgiofgiagiplastergicastgiforgiagifracturedgileftgiradius.giThe
ursegishouldgisuspectgiimpairmentgiwithgithegineurovasculargistatusgiofgithegiclient'sgicastedgiextremitygiifgiwhic
ifindingsgiareginoted?giSelectgiallgithatgiapply.
gi1.Capillarygirefillgiisgilessgithangi3gisecondsgi2.Pulsesgipresentgiandgiwithgiswollen,gipinkgifingersgi
3.Clientgireportgiofgisevere,gideep,giunrelentinggipaingi
4.Clientgireportgiofgipaingiasginursegiassessesgifingergimovementgi
5.Clientgireportgiofginumbnessgiandgitinglinggisensationgiingithegifingersgi-gianswer--3,gi4,gi5gi
Thegipressuregiingicompartmentgisyndrome,giifgiunrelieved,giwillgicausegipermanentgidamagegitoginervegiandgi
usclegitissuegidistalgitogithegipressure.giCirculatorygidamagegimaygiresultgiinginecrosis.giNervegiandgimusclegida
agegimaygiresultgiingipermanentgicontractures,gideformitygiofgithegiextremity,giandgifunctionalgiimpairment.giNo
malgicapillarygirefillgitimegiisgi3gisecondsgiorgiless.giPinkgiappearancegiandgiagipulsegiindicategiadequategibloodg
ow;giswellinggiisgiexpectedgiaftergiagifracture.giClientgireportgiofgisevere,gideep,giunrelentinggipain;giclientgirepo
ofginumbnessgiandgitinglinggisensation;giandgiclientgireportgiofgipaingiasgitheginursegiassessesgifingergimoveme
giaregiindicativegiofgidevelopment giofgicompartmentgisyndrome.
Agiclientgiwithgiagi4-day-
oldgilumbargivertebralgifracturegiisgiexperiencinggimusclegispasms.giWhichgiaregiinterventionsgitogiaidgithegiclie
iingirelievinggithegispasm?giSelectgiallgithatgiapply.
gi1.Icegi
2.Heatgi
3.Analgesicsgi
4.Musclegirelaxersgi
5.Intermittentgitractiongi-gianswer--2,gi3,gi4,gi5gi
Heat,gianalgesics,gimusclegirelaxers,giandgitractiongiallgimaygibegiusedgitogirelievegithegipaingiofgimusclegispasm
ngithegiclientgiwithgiagivertebralgifracture.giIcegiisgiappliedgitogiagipainfulgisitegionlygiforgithegifirstgi48gitogi72gihoursg
ependinggiongithegihealthgicaregiprovider'sgipreference)giaftergiangiinjury.giApplicationgiofgiicegitogithegispinegiof
clientgicouldgibegiuncomfortablegiandgicouldgiresultgiingifeelingsgiofgibeinggichilled.
,Theginursegiisgicaringgiforgiagiclientgiwhogihadgisurgerygitogirepairgiagifracturedgileft-
sidedgihipgiusinggiagiposteriorgiapproach.giIngiimplementinggihipgiprecautions,giwhichgiactiongishouldgitheginurs
teachgithegiclientgitogiavoid?
gi1.Crossinggilegsgiatgithegianklegi
2.Usinggiangielevatedgitoiletgiseatgi3.Placinggiagipillowgibetweengithegilegsgi4.Keepinggithegilegsgiabductedgifro
ithegimidlinegi-gianswer--1gi
Followinggisurgerygitogirepairgiagifracturedgihipgiusinggiagiposteriorgiapproach,giclientgieducationgishouldgiinclu
githegifollowing:giavoidinggicrossinggithegilegsgiatgithegianklegiorgithegiknee,giusinggiangielevatedgitoiletgiseat,gipla
nggiagipillowgibetweengithegilegsgiwhilegilyinggidowngiforgithegifirstgi6giweeks,gikeepinggithegilegsgiabductedgifrom
hegimidline,giandgikeepinggithegihipgiingiagineutralgipositiongiatgiallgitimes.
Angioldergiclientgiisgidiagnosedgiwithgiosteoporosis.giTheginursegiteachesgithegiclientgiaboutgiself-
caregimeasures,giknowinggithatgithegiclientgiisgimostgiatgiriskgiforgiwhichgiproblemgiasgiagiresultgiofgithisgidisorder
fgithegibones?
gi1.Anemiagi
2.Fracturesgi
3.Infectiongi
4.Musclegisprainsgi-gianswer--2
Thegiclientgiisgimostgiatgiriskgiforgifracturesgiasgiagiresultgiofgiosteoporosis.giAlthoughgiothergicomplicationsgican
ccur,gifracturegiisgithegigreatestgiconcern.giAnemiagiandgiinfectiongicangioccurgiwithgibonegimarrowgidisorders,
ndgimusclegisprainsgiaregiunrelatedgitogiosteoporosis.
Agiclientgiwithgiaginewgimedicationgiprescriptiongiforgiallopurinolgiasksgitheginurse,gi"Igiknowgithisgiisgiforgigout,gib
ihowgidoesgiitgiwork?"giTheginursegiplansgitogireplygibasedgiongiwhichgimedicationgiaction?
gi1.Allopurinolgidecreasesgiuricgiacidgiproduction.gi
2.Allopurinolgireducesgithegiproductiongiofgifibrinogen.gi
3.Allopurinolgidecreasesgithegiriskgiofgisulfagicrystalgiformationgiingithegiurine.gi4.Allopurinolgipreventsgiinfluxgio
calciumgiionsgiduringgicellgidepolarization.gi-gianswer--1
Allopurinolgiisgiclassifiedgiasgiangiantigoutgimedication.giItgidecreasesgiuricgiacidgiproductiongibygiinhibitinggithe
anthinegioxidasegienzyme,giandgiitgireducesgiuricgiacidgiconcentrationsgiingibothgiserumgiandgiurine.giThegiothe
optionsgiaregiincorrect.
Theginursegiisgicaringgiforgiagiclientgidiagnosedgiwithgiosteitisgideformansgi(Paget'sgidisease).giWhichgidoesgith
nursegiidentifygiasgithegicausegiofgithegiclient'sgistoopedgiposturegiandgibowinggiofgilowergiextremities?
gi1.Musclegimetabolismgiandgigrowthgi2.Bonegiresorptiongiandgiregenerationgi3.Nervousgisystemgiimpulsegitr
smissiongi4.Jointgiintegritygiandgisynovialgifluidgiproductiongi-gianswer--2
Paget'sgidiseasegiisgicharacterizedgibygiskeletalgideformitiesgiresultinggifromgiabnormalgibonegiresorptiongifol
wedgibygiabnormalgiregeneration.giItgiisginotgicausedgibygiproblemsgiwithgimuscle,ginervousgisystem,giorgijointgi
nctioning.
Agiclientgihasgibeengidiagnosedgiwithgigout,giandgitheginursegiprovidesgidietarygiinstructions.giTheginursegidete
inesgithatgithegiclientgineedsgiadditionalgiteachinggiifgithegiclientgistatesgithatgiitgiisgiacceptablegitogieatgiwhichgifo
?
gi1.Carrotsgi
2.Tapiocagi
3.Chocolategi
4.Chickengilivergi-gianswer--4gi
Livergiandgiothergiorgangimeatsgishouldgibegiomittedgifromgithegidietgiofgiagiclientgiwhogihasgigoutgibecausegiofgit
rgihighgipurinegicontent.giPurinesgiaregiagiformgiofgiprotein.giThegifoodgiitemsgiidentifiedgiingithegiothergioptionsgic
tainginegligiblegiamountsgiofgipurinesgiandgimaygibegiconsumedgifreelygibygithegiclientgiwithgigout.
,DiagnosticgistudiesgiaregiprescribedgiforgiagiclientgiwithgisuspectedgiPaget'sgidisease.giIngireviewinggithegiclien
girecord,githeginursegiwouldgiexpectgitoginotegithatgithegihealthgicaregiprovidergihasgiprescribedgiwhichgilaborato
istudy?
gi1.Plateletgicountgi
2.Alkalinegiphosphatasegi
3.Whitegibloodgicellgicountgi
4.Completegibloodgicellgicountgi-gianswer--2
Paget'sgidiseasegiisgiagichronicgimetabolicgidisordergiingiwhichgibonegiisgiexcessivelygibrokengidowngiandgirefo
ed.giThegiresultgiisgibonegithatgiisgistructurallygidisorganized,gicausinggibonegitogibegiweakgiwithgiincreasedgirisk
orgibowinggiofgilonggibonesgiandgifractures.giDiagnosticgilaboratorygifindingsgiforgiPaget'sgidiseasegiincludegian
levatedgiserumgialkalinegiphosphatasegilevelgiandgielevatedgiurinarygihydroxyprolinegiexcretion.giThegiremain
ggioptionsgiaregiunrelatedgitogidiagnosticgievaluationgiofgithisgidisease.
Agiclientgiisgitogireceivegiagiprescriptiongiforgimethocarbamol.giTheginursegiprovidesgiinstructionsgitogithegiclient
boutgithegimedication.giWhichgiclientgistatementgiwouldgiindicategiagineedgiforgifurthergieducation?
gi1."Mygiurinegimaygiturngibrowngiorgigreen."gi2."Igimightgigetgisomeginasalgicongestiongifromgithisgimedication."
3."Thisgimedicationgiisgiprescribedgitogihelpgirelievegimygimusclegispasms."gi
4."Ifgimygivisiongibecomesgiblurred,giIgidon'tgineedgitogibegiconcernedgiaboutgiit."gi-gianswer--4gi
Methocarbamolgiisgiagimusclegirelaxantgithatgiworksgibygiblockingginervegiimpulsesgi(orgipaingisensations)githa
aregisentgitogithegibrain.giThegiclientgineedsgitogibegitoldgithatgithegiurinegimaygiturngibrown,giblack,giorgigreen.giO
ergiadversegieffectsgiincludegiblurredgivision,ginasalgicongestion,giurticaria,giandgirash.giThegiclientgineedsgitogi
giinstructedgitoginotifygithegihealthgicaregiprovidergiifgithesegiside/adversegieffectsgioccur.
Theginursegiisgiplanninggimeasuresgitogiincreasegibedgimobilitygiforgiagiclientgiingiskeletalgileggitraction.giWhichg
mgishouldgitheginursegiconsidergitogibegimostgihelpfulgiforgithisgiclient?
gi1.Televisiongi
2.Fracturegibedpangi
3.Overheadgitrapezegi
4.Readinggimaterialsgi-gianswer--3gi
Thegiusegiofgiangioverheadgitrapezegiisgiextremelygihelpfulgiforgiagiclientgitogimovegiaboutgiingibedgiandgitogigetgio
andgioffgithegibedpan.giThisgidevicegihasgithegigreatestgivaluegiingiincreasinggioverallgibedgimobility.giTelevision
ndgireadinggimaterials,gialthoughgihelpfulgiingireducinggiboredomgiandgiprovidinggidistraction,gidoginotgiincreas
bedgimobility.giAgifracturegibedpangiisgiusefulgiingireducinggidiscomfortgiwithgielimination.
Theginursegiisgicaringgiforgiagiclientgiwhogisustainedgiangiopengifracturegiandgiisgidiagnosedgiwithgiacutegiosteom
elitisgiofgithegirightgilowergiextremity.giWhichgiinterventiongishouldgitheginursegiplangitogiperform?
gi1.Applygiicegitogithegiaffectedgiarea.gi2.Performgisterilegidressinggichanges.gi3.Instructgithegiclientgiongileggiex
cises.gi4.Measuregithegileggicircumferencegidaily.gi-gianswer--2
Osteomyelitisgiisgiagiseveregiinfectiongiofgithegibone,gibonegimarrow,giandgisurroundinggisoftgitissue.giClinicalgim
nifestationsgiincludegiconstantgibonegipaingiunrelievedgibygirestgithatgiworsensgiwithgiactivity;giswelling,gitende
ess,giandgiwarmthgiatgithegiinfectiongisite;girestrictedgimovementgiofgithegiaffectedgipart;gifever,ginightgisweats,g
ills,girestlessness,ginausea,giandgimalaise.giOptiongi2giisgithegicorrectgioption,giasgitreatmentgiofgiosteomyelitis
tengiincludesgisurgicalgidebridementgiandgirequiresgisterilegidressinggichanges.giOptiongi1giisgiincorrect,giasgio
eomyelitisgiisgiangiinfectiongiandgiapplyinggiicegitogithegiareagiwillginotgihelpgianygiswellinggiandgimaygicausegivas
constriction.giOptiongi3giisgiincorrect,giasgimovementgiworsensgithegipaingiandgisomegiimmobilizationgiofgithegia
ectedgilimbgi(e.g.,gisplint,gitraction)giisgiusuallygiindicated.giOptiongi4,gimeasuringgileggicircumferencegidaily,giis
otginecessary.
Thegihealthgicaregiprovidergihasgiprescribedgiagilidocainegi5%gipatchgiforgiagiclientgiwithgiagidiagnosisgiofgineckg
ingiduegitogiosteoarthritis.giWhichgishouldgitheginursegitellgithegiclientgiregardinggithisgimedication?
gi1.Thegimedicationgipatchgiwillgiactgiasgiagilocalgianesthetic.gi
2.Thegimedicationgipatchgiactsgibygidecreasinggimusclegispasms.gi
3.Thegimedicationgiisgiprescribedgitogicausegithegiskingitogipeelgibelowgithegipatch.gi
, 4.Applygiagiheatinggipadgitogithegiareagiaftergiapplyinggithegimedicationgipatchgitogiincreasegithegieffectiveness
gianswer--1
Agilidocainegipatchgiprovidesgiagilocalgianestheticgieffectgitogithegisitegiofgiapplication.giThegimedicationgidoesgin
giactgiingiagisystemicgimanner.giItgiisginotgiprescribedgitogicausegithegiskingitogipeel,gisogiifgithisgireactiongioccurs,g
egihealthgicaregiprovidergishouldgibeginotified.giAgiheatinggipadgishouldginotgibegiappliedgibecausegiirritationgior
urninggiofgithegiskingimaygioccur.
Theginursegiwitnessedgiagivehiclegihitgiagipedestrian.giThegivictimgiisgidazedgiandgitriesgitogigetgiup.giAgileggiappe
sgifractured.giWhichgiinterventiongishouldgitheginursegitake?
gi1.Trygitogireducegithegifracturegimanually.gi2.Assistgithegivictimgitogigetgiupgiandgiwalkgitogithegisidewalk.gi
3.Leavegithegivictimgiforgiagifewgimomentsgitogicallgiangiambulance.gi
4.Staygiwithgithegivictimgiandgiencouragegihimgiorgihergitogiremaingistill.gi-gianswer--4gi
Withgiagisuspectedgifracture,githegivictimgiisginotgimovedgiunlessgiitgiisgidangerousgitogiremaingiingithatgispot.giTh
nursegishouldgiremaingiwithgithegivictimgiandgihavegisomeonegielsegicallgiforgiemergencygihelp.giAgifracturegiisgi
tgireducedgiatgithegiscene.giBeforegithegivictimgiisgimoved,githegisitegiofgifracturegiisgiimmobilizedgitogipreventgifu
ergiinjury.
Theginursegihasgisuggestedgispecificgileggiexercisesgiforgiagiclientgiimmobilizedgiingirightgiskeletalgilowergileggitr
tion.giTheginursegideterminesgithatgithegiclientgineedsgifurthergiinstructiongiifgitheginursegiobservesgithegiclientgip
forminggiwhichgiaction?
gi1.Pullinggiupgiusinggithegitrapezegi2.Flexinggiandgiextendinggithegifeetgi3.Doinggiquadriceps-
settinggiandgigluteal-settinggiexercisesgi
4.Performinggiactivegirangegiofgimotiongitogithegirightgianklegiandgikneegi-gianswer--4
Activegirangegiofgimotiongitogithegirightgianklegiandgikneegiwouldgidisruptgiskeletalgitractiongiofgithegirightgilowerg
g.giThegiclientgimaygipullgiupgiusinggithegitrapeze,giperformgiactivegirangegiofgimotiongiwithgiuninvolvedgijoints,gia
dgidogiisometricgimuscle-settinggiexercisesgi(suchgiasgiquadriceps-giandgigluteal-
settinggiexercises).giThegiclientgialsogimaygiflexgiandgiextendgithegifeet.giThesegiexercisesgiaregiwithingitherape
cgilimitsgiforgithegiclientgiingiskeletalgitractiongitogimaintaingimusclegistrengthgiandgirangegiofgimotion.
Agiclientgihasgijustgibeengiadmittedgitogithegihospitalgiwithgiagifracturedgifemurgiandgipelvicgifractures.giTheginurs
shouldgiplangitogicarefullygimonitorgithegiclientgiforgiwhichgisigns/symptoms?
1.Fevergiandgibradycardiagi
2.Fevergiandgihypertensiongi3.Tachycardiagiandgihypotensiongi4.Bradycardiagiandgihypertensiongi-gianswer
3gi
Clientsgiwhogiexperiencegifracturesgiofgithegifemur,gipelvis,githorax,giandgispinegiaregiatgiriskgiforgihypovolemicg
hock.giBonegifragmentsgicangidamagegibloodgivessels,gileadinggitogihemorrhagegiintogithegiabdominalgicavity
ndgithegithigh.giThisgicangioccurgiwithgiclosedgifracturesgiasgiwellgiasgiopengifractures.giSignsgiofgihypovolemicgi
ockgiincludegitachycardiagiandgihypotension.
Theginursegiisgicaringgiforgiagiclientgiwithgiacutegibackgipain.giWhichgiaregithegimostgilikelygicausesgiofgithisgiprob
m?giSelectgiallgithatgiapply.
gi1.Twistinggiofgithegispinegi
2.Curvaturegiofgithegispinegi3.Hyperflexiongiofgithegispinegi
4.Sciaticginervegiinflammationgi5.Degenerationgiofgithegifacetgijointsgi6.Herniationgiofgiangiintervertebralgidisk
gianswer--1,gi3,gi6gi
Acutegibackgipaingiisgisuddengiingionsetgiandgiisgiusuallygiprecipitatedgibygiinjurygitogithegilowergiback,gisuchgiasg
thgihyperflexion,gitwisting,giorgidiskgiherniation.giScoliosisgi(curvature),gisciatica,giandgidegenerativegivertebra
changesgiaregimoregilikelygitogicausegichronicgibackgipain,giwhichgicangibegimoregiinsidiousgiingionsetgiandgimay
alsogibegiaccompaniedgibygidegenerationgiofgithegiintervertebralgidisk.
Agiclientgihasgibeengiongitreatmentgiforgirheumatoidgiarthritisgiforgi3giweeks.giDuringgithegiadministrationgiofgieta
ercept,giwhichgiisgimostgiimportantgiforgitheginursegitogiassess?
gi1.Thegiinjectiongisitegiforgiitchinggiandgiedemagi
