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A client is admitted with a large draining wound on the leg. What action does the nurse take first?
- A. Administer ordered antibiotics
- B. Insert an intravenous line
- C. Give pain medications if needed
- D. Obtain cultures of the leg wound
Correct Answer: D
Rationale: Obtaining wound cultures is the priority to identify the causative organism before administering antibiotics, which could alter culture results. IV insertion and pain management follow, as they are secondary to accurate diagnosis.
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A nurse is assessing an older client and discovers back pain with tenderness along L2 and L3. What action by the nurse is best?
- A. Consult the provider about an X-ray
- B. Encourage the client to use ibuprofen (Motrin)
- C. Have the client perform hip range of motion
- D. Apply a cervical collar
Correct Answer: A
Rationale: Back pain with tenderness at L2 and L3 suggests a spinal compression fracture, common in osteoporosis. Consulting the provider for an X-ray is the priority to confirm the diagnosis. Ibuprofen may be considered post-diagnosis, and hip range of motion is unrelated. A cervical collar is inappropriate for lumbar issues.
A client with Paget's disease is hospitalized for an unrelated issue. The client reports pain and it is not yet time for more medication. What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Administering pain medication
- B. Applying a heating pad
- C. Providing a massage
- D. Referring the client to a support group
- E. Using a bed cradle to lift sheets off the feet
Correct Answer: B,C
Rationale: Heat and massage are nonpharmacologic comfort measures for Paget's disease pain that can be delegated to a UAP. Administering medication and referrals are nursing responsibilities, and a bed cradle is unnecessary.
A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.)
- A. Administering the antibiotic regimen
- B. Correct intramuscular injection technique
- C. Eating high-protein and high-carbohydrate foods
- D. Keeping daily follow-up appointments
- E. Proper use of the intravenous equipment
Correct Answer: A,C,E
Rationale: Chronic osteomyelitis requires long-term IV or oral antibiotics, proper IV equipment use, and a high-protein, high-carbohydrate diet to promote healing. IM injections are not typically used, and daily follow-up is unnecessary.
A client has a bone density score of 2.8. What action by the nurse is best?
- A. Asking the client to keep a food diary
- B. Planning to teach about bisphosphonates
- C. Scheduling another scan in 2 years
- D. Scheduling another scan in 2 months
Correct Answer: B
Rationale: A T-score of 2.5 or lower indicates osteoporosis. The nurse should plan to teach about medications used to treat this disease, such as bisphosphonates. A food diary may help assess calcium and vitamin D intake, but dietary changes alone are insufficient at this stage. Scheduling another scan does not address immediate treatment needs.
Which diagnostic tests are used to confirm muscular dystrophy? (Select all that apply.)
- A. Electromyography
- B. Muscle biopsy
- C. Nerve conduction studies
- D. Serum aldolase
- E. Creatinine kinase levels
Correct Answer: A,B,D,E
Rationale: Electromyography, muscle biopsy, serum aldolase, and creatinine kinase levels are used to diagnose muscular dystrophy. Nerve conduction studies are not relevant to this condition.