ACC Level 2 - RNSG 1443 Exam 4 exam
with complete solutions
The nurse is preparing a client who sustained a hip fracture for discharge. The nurse
should teach the client to avoid which of the following groups of activities to prevent
dislocation of the hip?
A. crossing legs, bending at hips, and sitting on low toilet seats
B. taking leisurely walks, low chair seats, and bending at hips
C. using reachers for applying shoes and socks, and sitting in chairs with arms
D. all exercises, bedrest, and using raised toilet seats - ANSA.crossing legs, bending at
hips, and sitting on low toilet seats
A client in traction slides down in the bed so that the feet touch the foot of the bed. What
should the nurse do to ensure that the pull of traction remains uninterrupted?
A. release the weights, pull the client up in bed, and then reapply weights
B. ask the physician for a change in the amount of weight ordered
C. move the client up in bed without releasing the pull of traction on the extremity
D. elevate the client's feet on a pillow - ANSC.move the client up in bed without
releasing the pull of traction on the extremity
The nurse is assessing a casted extremity of a patient. Which sign is indicative of
infection?
A. Dependent edema
B. Diminished distal pulse
C. Presence of a "hot spot" on the cast
D. Coolness and pallor of the extremity - ANSC. Presence of a "hot spot" on the cast
Signs and symptoms of infection under a casted area include odor or purulent drainage
from the cast or the presence of "hot spots," which are areas of the cast that are warmer
than others. The health care provider should be notified if any of these occur.
Signs of impaired circulation in the distal limb include coolness and pallor of the skin,
diminished distal pulse, and edema.
A patient being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse responds that knowing that which
would most likely result from this improper measurement?
A. A fall and further injury
,B. Injury to the brachial plexus nerves
C. Skin breakdown in the area of the axilla
D. Impaired range of motion while the patient ambulates - ANSB. Injury to the brachial
plexus nerves
Crutches are measured so that the tops are two to three fingerwidths from the axillae.
This ensures that the client's axillae are not resting on the crutch or bearing the weight
of the crutch, which could result in injury to the nerves of the brachial plexus.
Although the conditions in options 1, 3, and 4 can occur, they are not the most likely
result from resting the axilla directly on the crutches.
The nurse has conducted teaching with a patient in an arm cast about the s/s of
compartment syndrome. The nurse determines that the client understands the
information if the client states that he or she should report which of the early symptom of
compartment syndrome?
A. Cold, bluish-colored fingers
B. Numbness and tingling of the fingers
C. Pain that increases when the arm is dependent
D. Pain that is out of proportion to the severity of the fracture - ANSB. Numbness and
tingling of the fingers
The earliest symptom of compartment syndrome is paresthesia (numbness and tingling
in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases
with limb elevation, and pallor and coolness to the distal limb.
Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along
with other symptoms associated with the pain, is not an early manifestation.
The nurse is caring for a client being treated for fat embolus after multiple fractures.
Which data would the nurse evaluate as the most favorable indication of resolution of
the fat embolus?
a. clear mentation
b. minimal dyspnea
c. oxygen saturation of 85%
d. arterial oxygen level of 78 mmHg - ANSa. clear mentation
The nurse will plan to teach a 27-year-old female who smokes 2 packs of cigarettes
daily about the increased risk for
a. kidney stones.
b. bladder cancer.
c. bladder infection.
d. interstitial cystitis. - ANSB
Cigarette smoking is a risk factor for bladder cancer.
, The patients risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney
stones will not be reduced by quitting smoking.
A 68-year-old male patient who has bladder cancer had a cystectomy with creation of
an Indiana pouch. Which topic will be included in patient teaching?
a. Application of ostomy appliances
b. Barrier products for skin protection
c. Catheterization technique and schedule
d. Analgesic use before emptying the pouch - ANSC
The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours.
There is no need for an ostomy device or barrier products. Catheterization of the pouch
is not painful.
A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the
stoma and requests that only the ostomy nurse specialist does the stoma care. The
nurse identifies a nursing diagnosis of
a. anxiety related to effects of procedure on lifestyle.
b. disturbed body image related to change in function.
c. readiness for enhanced coping related to need for information.
d. self-care deficit, toileting, related to denial of altered body function. - ANSB
The patients unwillingness to look at the stoma or participate in care indicates that
disturbed body image is the best diagnosis.
No data suggest that the impact on lifestyle is a concern for the patient. The patient
does not appear to be ready for enhanced coping. The patients insistence that only the
ostomy nurse care for the stoma indicates that denial is not present.
Which information from a patient who had a transurethral resection with fulguration for
bladder cancer 3 days ago is most important to report to the health care provider?
a. The patient is voiding every 4 hours.
b. The patient is using opioids for pain.
c. The patient has seen clots in the urine.
d. The patient is anxious about the cancer. - ANSC
Clots in the urine are not expected and require further follow-up.Voiding every 4 hours,
use of opioids for pain, and anxiety are typical after this procedure.
When preparing a female patient with bladder cancer for intravesical chemotherapy, the
nurse will teach about
a. premedicating to prevent nausea.
b. obtaining wigs and scarves to wear.
c. emptying the bladder before the medication.
d. maintaining oral care during the treatments. - ANSC
with complete solutions
The nurse is preparing a client who sustained a hip fracture for discharge. The nurse
should teach the client to avoid which of the following groups of activities to prevent
dislocation of the hip?
A. crossing legs, bending at hips, and sitting on low toilet seats
B. taking leisurely walks, low chair seats, and bending at hips
C. using reachers for applying shoes and socks, and sitting in chairs with arms
D. all exercises, bedrest, and using raised toilet seats - ANSA.crossing legs, bending at
hips, and sitting on low toilet seats
A client in traction slides down in the bed so that the feet touch the foot of the bed. What
should the nurse do to ensure that the pull of traction remains uninterrupted?
A. release the weights, pull the client up in bed, and then reapply weights
B. ask the physician for a change in the amount of weight ordered
C. move the client up in bed without releasing the pull of traction on the extremity
D. elevate the client's feet on a pillow - ANSC.move the client up in bed without
releasing the pull of traction on the extremity
The nurse is assessing a casted extremity of a patient. Which sign is indicative of
infection?
A. Dependent edema
B. Diminished distal pulse
C. Presence of a "hot spot" on the cast
D. Coolness and pallor of the extremity - ANSC. Presence of a "hot spot" on the cast
Signs and symptoms of infection under a casted area include odor or purulent drainage
from the cast or the presence of "hot spots," which are areas of the cast that are warmer
than others. The health care provider should be notified if any of these occur.
Signs of impaired circulation in the distal limb include coolness and pallor of the skin,
diminished distal pulse, and edema.
A patient being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse responds that knowing that which
would most likely result from this improper measurement?
A. A fall and further injury
,B. Injury to the brachial plexus nerves
C. Skin breakdown in the area of the axilla
D. Impaired range of motion while the patient ambulates - ANSB. Injury to the brachial
plexus nerves
Crutches are measured so that the tops are two to three fingerwidths from the axillae.
This ensures that the client's axillae are not resting on the crutch or bearing the weight
of the crutch, which could result in injury to the nerves of the brachial plexus.
Although the conditions in options 1, 3, and 4 can occur, they are not the most likely
result from resting the axilla directly on the crutches.
The nurse has conducted teaching with a patient in an arm cast about the s/s of
compartment syndrome. The nurse determines that the client understands the
information if the client states that he or she should report which of the early symptom of
compartment syndrome?
A. Cold, bluish-colored fingers
B. Numbness and tingling of the fingers
C. Pain that increases when the arm is dependent
D. Pain that is out of proportion to the severity of the fracture - ANSB. Numbness and
tingling of the fingers
The earliest symptom of compartment syndrome is paresthesia (numbness and tingling
in the fingers). Other symptoms include pain unrelieved by opioids, pain that increases
with limb elevation, and pallor and coolness to the distal limb.
Cyanosis is a late sign. Pain that is out of proportion to the severity of the fracture, along
with other symptoms associated with the pain, is not an early manifestation.
The nurse is caring for a client being treated for fat embolus after multiple fractures.
Which data would the nurse evaluate as the most favorable indication of resolution of
the fat embolus?
a. clear mentation
b. minimal dyspnea
c. oxygen saturation of 85%
d. arterial oxygen level of 78 mmHg - ANSa. clear mentation
The nurse will plan to teach a 27-year-old female who smokes 2 packs of cigarettes
daily about the increased risk for
a. kidney stones.
b. bladder cancer.
c. bladder infection.
d. interstitial cystitis. - ANSB
Cigarette smoking is a risk factor for bladder cancer.
, The patients risk for developing interstitial cystitis, urinary tract infection (UTI), or kidney
stones will not be reduced by quitting smoking.
A 68-year-old male patient who has bladder cancer had a cystectomy with creation of
an Indiana pouch. Which topic will be included in patient teaching?
a. Application of ostomy appliances
b. Barrier products for skin protection
c. Catheterization technique and schedule
d. Analgesic use before emptying the pouch - ANSC
The Indiana pouch enables the patient to self-catheterize every 4 to 6 hours.
There is no need for an ostomy device or barrier products. Catheterization of the pouch
is not painful.
A patient who had surgery for creation of an ileal conduit 3 days ago will not look at the
stoma and requests that only the ostomy nurse specialist does the stoma care. The
nurse identifies a nursing diagnosis of
a. anxiety related to effects of procedure on lifestyle.
b. disturbed body image related to change in function.
c. readiness for enhanced coping related to need for information.
d. self-care deficit, toileting, related to denial of altered body function. - ANSB
The patients unwillingness to look at the stoma or participate in care indicates that
disturbed body image is the best diagnosis.
No data suggest that the impact on lifestyle is a concern for the patient. The patient
does not appear to be ready for enhanced coping. The patients insistence that only the
ostomy nurse care for the stoma indicates that denial is not present.
Which information from a patient who had a transurethral resection with fulguration for
bladder cancer 3 days ago is most important to report to the health care provider?
a. The patient is voiding every 4 hours.
b. The patient is using opioids for pain.
c. The patient has seen clots in the urine.
d. The patient is anxious about the cancer. - ANSC
Clots in the urine are not expected and require further follow-up.Voiding every 4 hours,
use of opioids for pain, and anxiety are typical after this procedure.
When preparing a female patient with bladder cancer for intravesical chemotherapy, the
nurse will teach about
a. premedicating to prevent nausea.
b. obtaining wigs and scarves to wear.
c. emptying the bladder before the medication.
d. maintaining oral care during the treatments. - ANSC
