Question

A client is brought to the emergency department by ambulance after stepping in a hole and falling. During the assessment, the nurse notes that the right leg is shorter than the left leg, the right hip is noticeably deformed, and acute pain is noted. Imaging does not reveal a fracture. What is the most likely explanation for this client's signs and symptoms?

Answer 1

Correct Answers:

Right hip dislocation

Rationale :

✍️ The client's right leg is shorter than the left, and the hip is noticeably deformed, which are classic signs of hip dislocation.

✍️ A dislocated hip causes severe pain and deformity, but imaging can sometimes fail to reveal fractures because the joint is not properly aligned.

✍️ Immediate reduction and immobilization of the joint are required to prevent neurovascular damage.

✍️ The lack of a fracture on imaging helps confirm that this is a dislocation rather than a contusion, strain, or osteoarthritis.

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Answer 2

Correct Answers:

Arterial insufficiency

Rationale :

♦️ Pale, cool skin and ulcers on the soles of the feet are signs of arterial insufficiency, which occurs when blood flow to the lower extremities is inadequate.

♦️ These ulcers, especially circular in shape, are often associated with poor perfusion due to atherosclerosis or peripheral artery disease.

♦️ Arterial insufficiency ulcers are often painful and slow to heal due to insufficient oxygenated blood reaching the tissues.

♦️ Proper assessment and intervention, such as enhancing circulation and possibly revascularization, are essential.

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Answer 3

Correct Answers:

Braden Scale

Rationale :

✅ The Braden Scale is the standardized tool used to assess the risk of pressure ulcers based on factors like mobility, nutrition, moisture, and friction.

✅ This scale helps in identifying clients at high risk for developing pressure ulcers and in planning appropriate interventions.

✅ The Morse Scale is used for fall risk, the Bristol Scale assesses bowel movements, and the Hendrich II scale evaluates fall risk.

✅ The Braden Scale is comprehensive, evaluating all relevant factors affecting skin integrity.

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Answer 4

Correct Answers:

Walking briskly

Rationale :

⬛ For clients with osteoporosis, low-impact weight-bearing activities like brisk walking help to strengthen bones without causing excessive strain.

⬛ Walking improves bone density by promoting osteoblast activity and also enhances balance and coordination, reducing fall risks.

⬛ Stretching exercises are helpful for flexibility but do not directly stimulate bone formation.

⬛ High-impact aerobics may increase fracture risk, especially for clients with osteoporosis.

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Answer 5

Correct Answers:

"UTI's can be caused by urethrovesical reflux which is the backward flow of urine from the urethra to the bladder after coughing, sneezing or straining-
Glycosaminoglycan (GAG) is a protein in the urinary tract that exerts a nonadherent protective effect against various bacteria."
The normal urinary tract is sterile above the urethra.

Rationale :

🔵 UTIs can be caused by urethrovesical reflux, which is the backward flow of urine from the urethra to the bladder after coughing, sneezing, or straining.

⋙ Urethrovesical reflux occurs when increased intra-abdominal pressure leads to urine flowing backward, increasing the risk of bladder infections.

⋙ Preventive measures should focus on reducing bladder reflux through good hygiene and avoiding bladder overdistention.

🔵 Glycosaminoglycan (GAG) is a protein in the urinary tract that exerts a nonadherent protective effect against various bacteria.

⋙ GAGs form a protective glycocalyx that prevents bacteria from adhering to the bladder wall, thereby reducing UTI risk.

⋙ Maintaining GAG levels can be essential in preventing recurrent UTIs, particularly in vulnerable populations like the elderly.

🔵 The normal urinary tract is sterile above the urethra.

⋙ The urinary tract is typically sterile above the urethra, preventing bacterial growth from ascending into the kidneys.

⋙ This is why infections are most often confined to the lower urinary tract (bladder and urethra) unless a significant ascending infection occurs.

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Answer 6

Correct Answers:

200

Rationale :

✍️ Use the formula

Dosage = Weight in kg × Prescribed dose

➤ Convert the client's weight from pounds (lb) to kilograms (kg).

1kg = 2.2lb

↠ 88 ÷ 2.2 = 40 kg

◎ Prescribed dosage = 5 mg/kg

◎ Weight in kg = 40 kg

↠ 5 mg × 40 kg

👉= 200 mg

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Answer 7

Correct Answers:

Kyphosis

Rationale :

⬧ Kyphosis is the forward curvature of the spine, often seen in clients with osteoporosis, which weakens bones and causes vertebral compression fractures.

⬧ Spinal deformities like kyphosis can result in a hunched posture, back pain, and difficulty with balance.

⬧ Lordosis and scoliosis are distinct spinal deformities, with lordosis causing excessive inward curvature and scoliosis causing lateral curvature.

⬧ Kyphosis can be prevented and managed with appropriate exercise, good posture, and bone-strengthening medications.

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Answer 8

Correct Answers:

250

Rationale :

✍️Use the formula

✔ Volume ÷ Time = infusion rate.

➢ Volume = 3000 mL

➢ Time = 12 hours

➨ 3000 mL ÷ 12 hours

👉= 250 mL/hr

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Answer 9

Correct Answers:

Fat embolism syndrome

Rationale :

❖ Fat embolism syndrome occurs when fat globules from long bone fractures enter the bloodstream, leading to respiratory distress and chest pain.

❖ The symptoms develop 24–72 hours post-injury and can result in acute respiratory failure if untreated.

❖ Hypovolemic shock and venous thromboembolism are also possible complications but are less likely to cause shortness of breath and chest pain so acutely after trauma.

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Answer 10

Correct Answers:

Malunion
Fat embolism
Deep vein thrombosis

Rationale :

🔴 Malunion

🔹 A malunion occurs when bones heal in an improper position, often resulting in functional impairment or pain.

🔹 Monitoring for signs of healing and realigning the bone can prevent this complication.

🔴 Fat embolism

🔹 A fat embolism can result from the release of fat droplets into the bloodstream, causing pulmonary distress and mental confusion.

🔹 The fat droplets may lodge in the lungs, causing respiratory compromise and requiring immediate medical intervention.

🔴Deep vein thrombosis (DVT)

🔹 DVT can develop in patients with reduced mobility following fractures.

🔹 Preventing DVT with early ambulation and anticoagulation therapy is essential.

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RN ATI Medsurg Nurs 102

No.

3 :
A nurse is completing a risk assessment on a new admission. Which standardized scale will the nurse use to calculate the client's risk for pressure ulcers?

4 :
A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

5 :
A nurse educator is providing an in-service to nursing staff about urinary tract infections (UTIs). Which statements made by the staff validate they understand the etiology and pathophysiology of UTIs? Select all that apply.

6 :
A nurse is caring for an adolescent client who has pneumonia and a prescription for cefpodoxime 5 mg/kg PO for 5 days. The client weighs 88 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number.)

7 :
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

8 :
A nurse needs to infuse three IL bags over 12 hours. At what rate should the nurse program the pump to run in milliliters per hour? Round to the nearest whole number.

10 :
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply.

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RN ATI Medsurg Nurs 102

No.

3 : A nurse is completing a risk assessment on a new admission. Which standardized scale will the nurse use to calculate the client's risk for pressure ulcers?

4 : A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

5 : A nurse educator is providing an in-service to nursing staff about urinary tract infections (UTIs). Which statements made by the staff validate they understand the etiology and pathophysiology of UTIs? Select all that apply.

6 : A nurse is caring for an adolescent client who has pneumonia and a prescription for cefpodoxime 5 mg/kg PO for 5 days. The client weighs 88 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number.)

7 : A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

8 : A nurse needs to infuse three IL bags over 12 hours. At what rate should the nurse program the pump to run in milliliters per hour? Round to the nearest whole number.

10 : A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply.

3 :
A nurse is completing a risk assessment on a new admission. Which standardized scale will the nurse use to calculate the client's risk for pressure ulcers?

4 :
A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

5 :
A nurse educator is providing an in-service to nursing staff about urinary tract infections (UTIs). Which statements made by the staff validate they understand the etiology and pathophysiology of UTIs? Select all that apply.

6 :
A nurse is caring for an adolescent client who has pneumonia and a prescription for cefpodoxime 5 mg/kg PO for 5 days. The client weighs 88 lb. How many mg should the nurse administer? (Round the answer to the nearest whole number.)

7 :
A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

8 :
A nurse needs to infuse three IL bags over 12 hours. At what rate should the nurse program the pump to run in milliliters per hour? Round to the nearest whole number.

10 :
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply.