Nokea
Which diagnostic test result should the nurse monitor when assessing for evidence of metastasis?
- A. Lung scan
- B. Urinalysis
- C. Spinal tap
- D. Blood glucose
Correct Answer: A
Rationale: A lung scan detects metastasis, as skeletal tumors often spread to the lungs.
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Of the following emergency measures, which one should the nurse perform first?
- A. Check the victim's breathing.
- B. Cover the victim with a blanket.
- C. Move the victim to the curb.
- D. Assess the victim for injuries.
Correct Answer: A
Rationale: In an emergency, the nurse must first assess the victim's breathing to ensure airway patency and adequate oxygenation, following the ABCs (Airway, Breathing, Circulation) of basic life support. Other actions are secondary.
The nurse is working on an orthopedic floor. Which client should the nurse assess first after the change-of-shift report?
- A. The 84-year-old female with a fractured right femoral neck in Buck’s traction.
- B. The 64-year-old female with a left total knee replacement who has confusion.
- C. The 88-year-old male post-right total hip replacement with an abduction pillow.
- D. The 50-year-old postop client with a continuous passive motion (CPM) device.
Correct Answer: B
Rationale: Confusion post-TKR may indicate neurological or metabolic complications, requiring urgent assessment. Fractures, THR, and CPM use are stable.
Which question best helps the nurse determine whether the client is experiencing an adverse effect from taking nonsteroidal anti-inflammatory drugs (NSAIDs)?
- A. Do you have any stomach pain or black stools?
- B. Are you experiencing any joint swelling?
- C. Have you noticed any changes in your vision?
- D. Are you feeling more tired than usual?
Correct Answer: A
Rationale: Stomach pain or black stools indicate gastrointestinal bleeding, a serious NSAID side effect.
The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests should the nurse expect the health-care provider to order to R/O osteoarthritis?
- A. Full-body magnetic resonance imaging scan.
- B. Serum studies for synovial fluid amount.
- C. X-ray of the affected joints.
- D. Serum erythrocyte sedimentation rate (ESR).
Correct Answer: C
Rationale: X-rays reveal OA characteristic joint space narrowing and osteophytes. MRI is excessive, synovial fluid studies are not routine, and ESR is for inflammatory conditions, not OA.
The 27-year-old client has a right above-the-elbow amputation secondary to a boating accident. Which statement to the rehabilitation nurse indicates the client has accepted the amputation?
- A. I am going to sue the guy who hit my boat.'
- B. The therapist is going to help me get retrained for another job.'
- C. I decided not to get a prosthesis. I don't think I need it.'
- D. My wife is so worried about me and I wish she weren't.'
Correct Answer: B
Rationale: Planning job retraining indicates acceptance and adaptation to amputation. Lawsuits, prosthesis refusal, and concern for others suggest denial or unresolved grief.