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Example Nursing Exam for Register Nurse 21th Edition (Adult Health)
1. A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. The nurse should:
A. Put the client’s knee through full passive range of motion
B. Immobilize the knee temporarily
C. Administer an analgesic
D. Notify the physician immediately
Answer: C. Administer an analgesic
Rationale: Pain with knee extension is a common complaint of clients after knee replacement surgery. This is because preoperatively the client placed the knee in flexion to reduce pain, and flexion contracture has resulted. The nurse should encourage the client to keep the knee extended, and administer analgesics as needed.
Test-Taking Strategy: Use the process of elimination. The question states that there is pain with extension only. Immobilizing the knee will not help, so this option may be eliminated first. Putting the joint through full range of motion may be more than the client can tolerate. From the remaining options, you need to know that flexion contracture can occur, which would lead you to choose medicating the client rather than notifying the physician. Review the expected findings following a total knee replacement if you had difficulty with this question.
Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 126.
2. A nurse is caring for a client who had an above the knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage and has fallen off. The nurse immediately:
A. Calls the physician
B. Rewraps the stump with an elastic compression bandage
C. Applies ice to the site
D. Applies a dry sterile dressing and elevates it on one pillow
Answer: B. Rewraps the stump with an elastic compression bandage
Rationale: If the client with amputation has a cast or elastic compression bandage that falls off, the nurse must immediately wrap the stump with another elastic compression bandage. Otherwise, excessive edema will rapidly form, which could cause a significant delay in rehabilitation.
Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first. Elevation on one pillow is not going to greatly impede the development of edema once compression is released. For the same reason, option 3 is eliminated. Ice would be of limited value in controlling edema from this cause. From the remaining options, the better option is to reapply the compression bandage. If the physician were called, the order would likely be to reapply the compression dressing anyway. Review care to the client following an amputation if you had difficulty with this question.
Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 845.
3. A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of:
A. Muscle spasm in the area of the herniated disk
B. Pressure on the spinal cord
C. Pressure on the spinal nerve root
D. Excess cerebrospinal fluid production in the area
Answer: A. Muscle spasm in the area of the herniated disk
Rationale: Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knifelike, and localized in the affected area. Options 2, 3, and 4 are incorrect.
Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because this is unlikely to occur. Pressure on a spinal nerve root causes the symptoms of sciatica, so option 3 can be eliminated next. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. The pain of muscle spasm has the characteristics described in the question, which helps you choose option 1 over option B. Additionally, the words “herniated disk” are stated in the question and again in option A. Review the characteristics of a muscle spasm if you had difficulty with this question.
Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1656.
4. A nurse has an order to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed:
A. In high-Fowler’s position with the foot of the bed flat
B. In semi-Fowler’s position with the knee gatch slightly raised
C. In semi-Fowler’s position with the foot of the bed flat
D. Flat with the knee gatch raised
Answer: B. In semi-Fowler’s position with the knee gatch slightly raised
Rationale: Clients with low back pain are often more comfortable when placed in semi-Fowler’s position with the knee gatch slightly raised or with pillows under the knees. The bed is placed in semi-Fowler’s position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root.
Test-Taking Strategy: Knowledge of this specific position helps you to answer this question. If you are not familiar with it, however, look at the information in the question. The client has back pain with a ruptured intervertebral disk. Positions that relieve this discomfort include those that provide slight flexion of lower back muscles, which relieves pressure and avoids extension of the spine. Keeping the foot of the bed flat will enhance extension of the spine, so options 1 and 3 should be eliminated first. Option 4 would excessively stretch the lower back and would also put the client at risk for thrombophlebitis. By the process of elimination, the correct answer is option B. Review care to a client with a herniated lumbar intervertebral disk if you had difficulty with this question.
Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, p. 2143.
5. A nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse would be especially concerned with which of the following findings?
A. Complaints of discomfort during repositioning
B. An oral temperature of 101° F
C. Old, bloody drainage outlined on the surgical dressing
D. Discomfort during coughing and deep breathing exercises
Answer: B. An oral temperature of 101° F
Rationale: For this specific type of surgery, the nurse monitors the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear, tests positive for glucose). A mild fever is expected after insertion of hardware, but a temperature over 101° F should be reported, because it might possibly require that the hardware be removed.
Test-Taking Strategy: Each of the options contains at least a slight deviation from normal, but the question asks which option would cause the nurse to be “especially concerned.” Thus you are looking for the option that has the greatest deviation from normal. Options 1 and 4 are expected after surgery, and although the nurse tries to minimize discomfort, the client is likely to have some discomfort even with proper analgesic use. The words “old” and “outlined” in option 3 indicate that this is not a new occurrence. This leaves the temperature of 101° F, which is excessive, and should be reported. Review the complications associated with this surgical procedure if you had difficulty with this question.
Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, p. 2144.
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