NUR 211 FINAL TEST BANK
QUESTIONS WITH CORRECT
ANSWERS
The nurse is caring for a postoperative client on the medical-surgical unit following a
total left hip replacement the previous day. During the assessment, the nurse notes that
the client's left leg is cool, with weak pedal pulses. What is the nurse's first action?
a.
Assess circulatory status of the right leg.
b.
Notify the surgeon immediately.
c.
Measure leg circumference at the calf.
d.
Check for bilateral Homans signs. - Answer- a.
Assess circulatory status of the right leg.
The symptoms may represent impaired circulation or may be normal for this client.
Before the surgeon is notified, the status of the nonoperative leg should be assessed
and assessment findings on both legs compared with the client's baseline. Homans sign
(pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein
thrombosis and should not be evaluated until other assessments are made. Measuring
calf circumference would provide additional data related to deep vein thrombosis.
A client is admitted for a total hip replacement. Past medical history includes diabetes
mellitus type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client
currently takes insulin on a sliding scale and celecoxib (Celebrex). Before administering
the client's medications, which action by the nurse is most appropriate?
a.
Take the client's blood pressure in both arms.
b.
Call the physician to clarify the orders.
c.
Schedule a preoperative electrocardiogram.
d.
Review the client's laboratory values. - Answer- b.
Call the physician to clarify the orders.
Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause
serious adverse reactions such as myocardial infarction and renal problems. This client
already has coronary artery disease and a past myocardial infarction, so the nurse
,should discuss the order with the physician before giving the medication. Reviewing
laboratory results could indicate renal impairment, but taking the client's blood pressure
and scheduling an electrocardiogram (ECG) would not take priority over discussion with
the physician.
A client is receiving warfarin (Coumadin) daily following total hip replacement surgery.
Which laboratory value requires intervention by the nurse?
a.
Potassium (K+), 4.2 mEq/L
b.
International normalized ratio (INR), 5.1
c.
Prothrombin time (PT), 13.4 seconds
d.
Hemoglobin (Hg), 16 g/dL - Answer- b.
International normalized ratio (INR), 5.1
Blood levels of Coumadin will be monitored by checking daily PT and INR (in some
places, only INR). The INR is critically high. The K+ is normal and is not monitored for
Coumadin therapy. The PT is used in some facilities to monitor Coumadin therapy.
Hemoglobin would be important to assess because a side effect of Coumadin is
bleeding, and a dropping hemoglobin level would indicate that bleeding was occurring.
PT and hemoglobin are within the normal range.
The nurse is caring for a client who is 1 day post total hip replacement. The nurse is
instructing the client about how to perform quadriceps-setting exercises correctly. Which
direction does the nurse provide to the client?
a.
Straighten your legs and push the back of your knees into the mattress.
b.
Straighten your legs and bring each leg separately off the mattress 6 inches.
c.
Raise each leg 10 inches off the bed, keep it straight, and make ankle circles.
d.
Bend each knee, and rapidly point your toes downward and then upward. - Answer- a.
Straighten your legs and push the back of your knees into the mattress.
Quadriceps-setting exercises are done by straightening the leg as much as possible by
attempting to push the back of the knees into the mattress. The other exercises may be
performed by the client as tolerated, but these items do not describe quadriceps-setting
exercises.
The home care nurse is making a follow-up visit to a client who had total hip
replacement surgery 2 weeks ago. Which client statement indicates a need for
clarification regarding postoperative routine?
a.
,My daughter helps me put on my elastic TED (thromboembolic deterrent) hose every
day.
b.
I take 200 mg of Motrin (ibuprofen) at bedtime so that I can sleep.
c.
Now that my hip doesn't hurt, I can cross my legs like a lady again.
d.
Each day, I try to increase my walking time by at least 10 minutes. - Answer- c.
Now that my hip doesn't hurt, I can cross my legs like a lady again.
Crossing the legs beyond midline can dislocate the new hip joint and should be avoided
at all times. The other statements demonstrate correct behavior and understanding.
A client who has had total hip replacement surgery asks the nurse when she will be able
to use a regular-height toilet seat again. What is the nurse's best response?
a.
As soon as you are able to walk without a limp.
b.
As soon as the staples are removed from the incision.
c.
When you are off pain medication and warfarin (Coumadin).
d.
When you can hold your leg 6 inches off the bed for 5 full minutes. - Answer- a.
As soon as you are able to walk without a limp.
When the client is able to walk without a limp, the artificial joint is seated sturdily enough
in place that it will not be dislocated or dislodged by overflexing it. At that time, the client
will no longer need assistive devices or ambulatory aids. With staples removed, holding
the leg off the bed and taking Coumadin do not affect readiness to bend the hip enough
to use a regular toilet seat.
A client had a total knee replacement this morning and has a continuous passive motion
(CPM) machine. What activity related to the CPM does the RN delegate to the
unlicensed assistive personnel?
a.
Placing controls out of the reach of confused clients
b.
Assessing the client's response to the CPM
c.
Teaching the clients family the rationale for the CPM
d.
Assessing neurovascular status of the leg in the CPM - Answer- a.
Placing controls out of the reach of confused clients
, All activities are appropriate for the client with a CPM, but the nurse can delegate only
the task of keeping controls out of reach of the confused client. All other activities would
need to be performed by the RN.
The nurse is caring for an older adult client who will be discharged after being
hospitalized for a total hip replacement. Which statement indicates that arrangements
may have to be made to have the client's medications supervised at home?
a.
I will take my Coumadin pill every day just before the evening news.
b.
My wife takes iron too, so we will take our pills together every morning.
c.
I prepare all my pills for the week and will place them in a labeled medi-set.
d.
If my legs get swollen, I will take an extra Coumadin pill that day. - Answer- d.
If my legs get swollen, I will take an extra Coumadin pill that day.
Warfarin (Coumadin) is an anticoagulant prescribed to prevent venous
thromboembolism after joint replacement surgery. It is not used for edema. The other
statements show that the client has an appropriate plan for self-administration of his
medications.
The nurse is caring for an older adult client who has fallen and fractured her hip. The
client will have hip replacement surgery followed by extensive rehabilitation. The client
confides in the nurse, I feel like I don't have any control over anything anymore now that
I am old. What is the nurse's best response?
a.
I'll make sure that the physical and occupational therapists see you after surgery to help
get your strength back.
b.
Its normal to feel this way, but hopefully you will be back on your feet after a stay in
rehab.
c.
It's important to control what you can right now, like making out your menu every day
and working with the therapists.
d.
I sense that you are feeling depressed about the situation. I will ask the doctor to
prescribe an antidepressant for you. - Answer- c.
It's important to control what you can right now, like making out your menu every day
and working with the therapists.
The nurse should support the clients self-esteem and increase feelings of competency
by encouraging activities that assist in maintaining some degree of control, such as
participation in decision making and performance of tasks that he or she can manage.
The nurse should provide immediate control options for the client, rather than waiting
until after rehabilitation. The clients desire for control does not indicate depression, so
QUESTIONS WITH CORRECT
ANSWERS
The nurse is caring for a postoperative client on the medical-surgical unit following a
total left hip replacement the previous day. During the assessment, the nurse notes that
the client's left leg is cool, with weak pedal pulses. What is the nurse's first action?
a.
Assess circulatory status of the right leg.
b.
Notify the surgeon immediately.
c.
Measure leg circumference at the calf.
d.
Check for bilateral Homans signs. - Answer- a.
Assess circulatory status of the right leg.
The symptoms may represent impaired circulation or may be normal for this client.
Before the surgeon is notified, the status of the nonoperative leg should be assessed
and assessment findings on both legs compared with the client's baseline. Homans sign
(pain in the calf on dorsiflexion of the foot) is not always indicative of a deep vein
thrombosis and should not be evaluated until other assessments are made. Measuring
calf circumference would provide additional data related to deep vein thrombosis.
A client is admitted for a total hip replacement. Past medical history includes diabetes
mellitus type 2, a heart attack 5 years ago, and allergies to sulfa drugs. The client
currently takes insulin on a sliding scale and celecoxib (Celebrex). Before administering
the client's medications, which action by the nurse is most appropriate?
a.
Take the client's blood pressure in both arms.
b.
Call the physician to clarify the orders.
c.
Schedule a preoperative electrocardiogram.
d.
Review the client's laboratory values. - Answer- b.
Call the physician to clarify the orders.
Celebrex is a cyclooxygenase (COX)-2 inhibitor. These drugs are thought to cause
serious adverse reactions such as myocardial infarction and renal problems. This client
already has coronary artery disease and a past myocardial infarction, so the nurse
,should discuss the order with the physician before giving the medication. Reviewing
laboratory results could indicate renal impairment, but taking the client's blood pressure
and scheduling an electrocardiogram (ECG) would not take priority over discussion with
the physician.
A client is receiving warfarin (Coumadin) daily following total hip replacement surgery.
Which laboratory value requires intervention by the nurse?
a.
Potassium (K+), 4.2 mEq/L
b.
International normalized ratio (INR), 5.1
c.
Prothrombin time (PT), 13.4 seconds
d.
Hemoglobin (Hg), 16 g/dL - Answer- b.
International normalized ratio (INR), 5.1
Blood levels of Coumadin will be monitored by checking daily PT and INR (in some
places, only INR). The INR is critically high. The K+ is normal and is not monitored for
Coumadin therapy. The PT is used in some facilities to monitor Coumadin therapy.
Hemoglobin would be important to assess because a side effect of Coumadin is
bleeding, and a dropping hemoglobin level would indicate that bleeding was occurring.
PT and hemoglobin are within the normal range.
The nurse is caring for a client who is 1 day post total hip replacement. The nurse is
instructing the client about how to perform quadriceps-setting exercises correctly. Which
direction does the nurse provide to the client?
a.
Straighten your legs and push the back of your knees into the mattress.
b.
Straighten your legs and bring each leg separately off the mattress 6 inches.
c.
Raise each leg 10 inches off the bed, keep it straight, and make ankle circles.
d.
Bend each knee, and rapidly point your toes downward and then upward. - Answer- a.
Straighten your legs and push the back of your knees into the mattress.
Quadriceps-setting exercises are done by straightening the leg as much as possible by
attempting to push the back of the knees into the mattress. The other exercises may be
performed by the client as tolerated, but these items do not describe quadriceps-setting
exercises.
The home care nurse is making a follow-up visit to a client who had total hip
replacement surgery 2 weeks ago. Which client statement indicates a need for
clarification regarding postoperative routine?
a.
,My daughter helps me put on my elastic TED (thromboembolic deterrent) hose every
day.
b.
I take 200 mg of Motrin (ibuprofen) at bedtime so that I can sleep.
c.
Now that my hip doesn't hurt, I can cross my legs like a lady again.
d.
Each day, I try to increase my walking time by at least 10 minutes. - Answer- c.
Now that my hip doesn't hurt, I can cross my legs like a lady again.
Crossing the legs beyond midline can dislocate the new hip joint and should be avoided
at all times. The other statements demonstrate correct behavior and understanding.
A client who has had total hip replacement surgery asks the nurse when she will be able
to use a regular-height toilet seat again. What is the nurse's best response?
a.
As soon as you are able to walk without a limp.
b.
As soon as the staples are removed from the incision.
c.
When you are off pain medication and warfarin (Coumadin).
d.
When you can hold your leg 6 inches off the bed for 5 full minutes. - Answer- a.
As soon as you are able to walk without a limp.
When the client is able to walk without a limp, the artificial joint is seated sturdily enough
in place that it will not be dislocated or dislodged by overflexing it. At that time, the client
will no longer need assistive devices or ambulatory aids. With staples removed, holding
the leg off the bed and taking Coumadin do not affect readiness to bend the hip enough
to use a regular toilet seat.
A client had a total knee replacement this morning and has a continuous passive motion
(CPM) machine. What activity related to the CPM does the RN delegate to the
unlicensed assistive personnel?
a.
Placing controls out of the reach of confused clients
b.
Assessing the client's response to the CPM
c.
Teaching the clients family the rationale for the CPM
d.
Assessing neurovascular status of the leg in the CPM - Answer- a.
Placing controls out of the reach of confused clients
, All activities are appropriate for the client with a CPM, but the nurse can delegate only
the task of keeping controls out of reach of the confused client. All other activities would
need to be performed by the RN.
The nurse is caring for an older adult client who will be discharged after being
hospitalized for a total hip replacement. Which statement indicates that arrangements
may have to be made to have the client's medications supervised at home?
a.
I will take my Coumadin pill every day just before the evening news.
b.
My wife takes iron too, so we will take our pills together every morning.
c.
I prepare all my pills for the week and will place them in a labeled medi-set.
d.
If my legs get swollen, I will take an extra Coumadin pill that day. - Answer- d.
If my legs get swollen, I will take an extra Coumadin pill that day.
Warfarin (Coumadin) is an anticoagulant prescribed to prevent venous
thromboembolism after joint replacement surgery. It is not used for edema. The other
statements show that the client has an appropriate plan for self-administration of his
medications.
The nurse is caring for an older adult client who has fallen and fractured her hip. The
client will have hip replacement surgery followed by extensive rehabilitation. The client
confides in the nurse, I feel like I don't have any control over anything anymore now that
I am old. What is the nurse's best response?
a.
I'll make sure that the physical and occupational therapists see you after surgery to help
get your strength back.
b.
Its normal to feel this way, but hopefully you will be back on your feet after a stay in
rehab.
c.
It's important to control what you can right now, like making out your menu every day
and working with the therapists.
d.
I sense that you are feeling depressed about the situation. I will ask the doctor to
prescribe an antidepressant for you. - Answer- c.
It's important to control what you can right now, like making out your menu every day
and working with the therapists.
The nurse should support the clients self-esteem and increase feelings of competency
by encouraging activities that assist in maintaining some degree of control, such as
participation in decision making and performance of tasks that he or she can manage.
The nurse should provide immediate control options for the client, rather than waiting
until after rehabilitation. The clients desire for control does not indicate depression, so
