Nokea
The nurse is conducting a community health fair. Which of the following clients is at the greatest risk of developing osteoporosis?
- A. 27-year-old woman who jogs three times a week and drinks red wine daily
- B. 60-year-old woman who smokes cigarettes and just recently stopped drinking alcohol
- C. 51-year-old man who suffers from alcoholism and recently stopped smoking
- D. 25-year-old man with asthma who takes inhaled corticosteroids
Correct Answer: B
Rationale: The 60-year-old woman who smokes has the greatest osteoporosis risk due to age, smoking (reduces bone density), and likely post-menopausal status. Jogging, male gender, and younger age lower risk in others.
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The nurse in the medical-surgical unit is caring for a newly admitted client.
Item 5 of 6
History and Physical
1930: Client is a 45-year-old male who has a one-and-a-half-week history of pain, redness, and swelling in his right foot. He reported that the symptoms began after he accidentally cut his foot while walking barefoot in his backyard. Over the next few days, he developed pain and swelling around the cut, accompanied by redness and warmth. He went to urgent care two days later and was diagnosed with cellulitis in his right foot. He was prescribed antibiotics but could not afford the treatment. Three days ago, the pain escalated and was described as throbbing and constant, with a severity rating of 7/10 on the Numerical Pain Rating Scale. He states, "the pain is now in the bone of my foot; I don't know how else to describe it." He also noted occasional fever 101°F (38.3°C), chills, and general malaise. On physical examination, his right foot was erythematous, swollen, and warm to the touch. A 3 cm ulcer was noted on the plantar aspect of the right foot, with moderate purulent discharge present. The ulcer appeared deep, and palpation of the surrounding tissue elicited tenderness. There was limited range of motion in the right ankle due to pain. The distal pulses were palpable 2+, and there were signs of neuropathy in the feet (decreased sensation to light touch and pinprick). He has a medical history of uncontrolled diabetes mellitus (type two), obesity, peripheral neuropathy in all extremities, hypertension, hyperlipidemia, and epilepsy.
Orders
2100:
Magnetic resonance imaging of the right foot without contrast
Insert peripheral vascular access device
Laboratory tests: blood culture and sensitivity (C & S), complete blood count (CBC), complete metabolic panel (CMP), lactic acid
vancomycin 1 g, IV, every 12 hours
Wound culture
fentanyl 50 mcg IV, every 5 hours PRN pain
Consultation
Infectious Disease Consultation
2050: Client was evaluated and I strongly suspect osteomyelitis in his right foot. Labs are pending. Agree with admission and will follow closely.
Nurses' Notes
2110: Orders received and reviewed. Vital signs: T 103° F (39.4° C), P 92, RR 18, BP 141/87, pulse oximetry reading 98% on room air. Client reports pain '8' on the Numerical Pain Scale.
The nurse reviews the physician's orders, client's laboratory data, and makes an entry into the nurses' notes. Which of the following actions should the nurse take?
- A. Withhold administering the prescribed antibiotic and notify the physician.
- B. Place a dressing over the client's wound before transporting the client to MRI.
- C. Notify the physician to hold the ordered MRI because of the client's kidney function.
- D. Instruct the client to remove all metal objects before the MRI.
- E. Administer prescribed pain medication before the MRI.
- F. Irrigate the wound with 0.9% sodium chloride (normal saline) before obtaining wound culture.
- G. Request a prescription for a nonsteroidal anti-inflammatory drug.
Correct Answer: B, D, E, F
Rationale: B: A dressing protects the wound during transport. D: Removing metal prevents MRI interference. E: Pain medication improves comfort for MRI. F: Irrigation ensures a clean sample for culture. A and C require more data, and G is not urgent.
The nurse is caring for a client who is in Buck traction. Which of the following actions should the nurse take?
- A. Ensure that weight is between 15 to 30 lb (6.8 to 13.6 kg)
- B. Turn the client using a foam wedge every two hours
- C. Ensure that a client's heels are supported with a pillow
- D. Elevate the foot of the bed to provide counter traction
Correct Answer: D
Rationale: Elevating the foot of the bed provides counter traction to maintain alignment in Buck traction. Excessive weight risks injury, turning disrupts traction, and heel support is good but not the priority.
A client sustained a right leg fracture after an industrial accident and reports tingling and severe pain inside the newly applied plaster cast. Upon inspection, the nurse noted that the exposed toes were cyanotic. What is the most appropriate nursing intervention?
- A. Apply heat packs on the leg
- B. Elevate the affected extremity
- C. Contact the physician immediately
- D. Instruct the client to move or wiggle their toes
Correct Answer: C
Rationale: Tingling, severe pain, and cyanotic toes suggest compartment syndrome, a medical emergency. Contacting the physician immediately is critical for evaluation and possible intervention like cast removal or fasciotomy. Heat worsens swelling, elevation helps but is not enough, and toe movement doesn't address the urgency.
The nurse is teaching a client scheduled for a dual-energy x-ray absorptiometry (DEXA) scan. Which of the following information should the nurse include?
- A. Do not eat or drink 6-8 hours prior to your test.'
- B. You will feel flushing as you receive the intravenous contrast.'
- C. The scan takes several hours to complete.'
- D. Please remove all metallic objects before this exam.'
Correct Answer: D
Rationale: Removing metallic objects prevents interference with the DEXA scan, which measures bone density. Fasting and contrast are not required, and the scan typically takes 10-30 minutes.
The nurse is teaching a new grad about contractures. The nurse knows which statement about contractures secondary to immobility is accurate?
- A. Contractures cannot be prevented because of muscular spasticity.
- B. Contractures cannot be prevented because of muscular tension.
- C. Flexion contractures are the least commonly occurring contracture.
- D. Flexion contractures are the most commonly occurring contracture.
Correct Answer: D
Rationale: Flexion contractures are the most common due to immobility, as muscles shorten in a flexed position. Contractures can be prevented with range of motion and positioning, despite spasticity or tension.