MSK, Immobility, Neuro, Renal, GI, Integ

A nurse is assessing a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

• Needs assistance raising her legs to put on socks

• Demonstrates mild dyspnea when eating breakfast

• Performs active range-of-motion (ROM) exercises of all extremities

• Develops fatigue when assisting with morning hygiene care

Answer explanation

During periods of immobility, it is important to have the client perform ROM exercises to reduce the hazards of immobility (contractures, loss of muscle mass, thrombosis). A client who is weak might need the nurse to support her extremities during movement (passive ROM). During active ROM, the client is doing the movement with little to no assistance.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

• An upper respiratory infection

• Pulmonary edema

• Atelectasis

• Delayed gastric emptying

Answer explanation

Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

• An adolescent who has a cervical fracture and is in a halo brace

• A young adult who has a femur fracture and is in skeletal balanced suspension traction

• A middle adult who has a fractured radius and an arm cast

• An older adult who has a hip fracture and is in Buck's traction

Answer explanation

According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

• A reddened area over the sacrum

• Stiffness in the lower extremities

• Difficulty moving the upper extremities

• Difficulty hearing some types of sounds

Answer explanation

A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?

• Restrict calcium intake to one serving per day.

• Drink 3 L of fluid every day.

• Take 3,000 mg of vitamin C daily.

• Eat 12 oz of animal protein daily.

Answer explanation

The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

• Obesity

• Protein in the urine

• Iron deficiency

• Dehydration

Answer explanation

Dehydration can cause hypercalcemia which increases the risk for renal stone formation. Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.

A nurse is caring for a client who is postoperative following a total hip arthroplasty. The nurse assists the client into a supine position. Which of the following actions is appropriate to prevent dislocation of the hip?

• Place a wedge pillow between the legs.

• Elevate the head of the bed to a Fowler’s position.

• Position the legs in alignment with the spine.

• Place a footboard on the bed.

Answer explanation

The nurse places a wedge pillow or other abduction device between the legs to prevent adduction which can lead to possible dislocation.

A nurse is developing a plan of care for a client who has a fracture to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority?

• Provide relief from pain and discomfort.

• Promote independence in activities of daily living

• Provide optimal nutrition and hydration.

• Maintain immobilization and alignment.

Answer explanation

Maintaining the prescribed immobilization and body alignment will keep the fracture fragments in close anatomical proximity, thereby promoting functional fracture healing. According to the safety and risk reduction priority setting framework, this goal should receive the highest priority.

A nurse is assessing a client who has a left lower arm fracture. Which of the following findings indicates impaired venous return in the client's affected arm?

• A bounding distal pulse

• Increasing edema

• Ecchymosis of the surrounding skin

• Acute pain

Answer explanation

Increasing edema is a sign of impaired circulation. It is important for client who has a limb fracture to keep the limb elevated to reduce edema.

A nurse is writing a care plan for a patient admitted to the emer-

gency department (ED) with an open fracture. The nurse will

assign priority to what nursing diagnosis for a patient with an open

fracture of the radius?

• Risk for Infection

• Risk for Ineffective Role Performance

• Risk for Perioperative Positioning Injury

• Risk for Powerlessness

Answer explanation

The patient has a significant risk for osteomyelitis and tetanus

due to the fact that the fracture is open. Powerlessness and

ineffective role performance are psychosocial diagnoses that may

or may not apply, and which would be superseded by immediate

physiologic threats such as infection. Surgical positioning injury is

not plausible, since surgery is not likely indicated.