Question

A nurse is caring for an older adult client who had a femoral head fracture 24 hours ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?

Answer 1

Correct Answers:

Fat embolism

Rationale :

Fat embolism is a common complication after long bone fractures, particularly femoral fractures. It can cause respiratory distress, petechiae, and altered mental status due to obstruction in the pulmonary circulation. Early recognition and supportive care are crucial.

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Answer 2

Correct Answers:

Fresh flowers and potted plants in the room

Rationale :

Neutropenic clients are at high risk for infections, and fresh flowers or plants can harbor fungi and bacteria that could lead to serious infections. It is essential to implement strict infection control measures.

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Answer 3

Correct Answers:

"The manifestations usually go away after menopause."

Rationale :

Fibrocystic breast changes are hormone-related and typically resolve after menopause due to the decline in estrogen and progesterone levels. This provides relief from the cyclical breast pain and lumps.

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Answer 4

Correct Answers:

Malnutrition

Rationale :

Systemic factors such as inadequate nutrition impair wound healing by reducing the availability of proteins, vitamins, and essential nutrients required for tissue repair and immune function.

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Answer 5

Correct Answers:

A chest tube

Rationale :

A chest tube is required after a lobectomy to drain excess air and fluid from the pleural space, prevent pneumothorax, and promote lung expansion. It is a standard postoperative intervention.

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Answer 6

Correct Answers:

Raisins
Bananas

Rationale :

These foods are high in potassium and should be restricted in clients with chronic kidney disease to prevent hyperkalemia, which can cause life-threatening cardiac arrhythmias.

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Answer 7

Correct Answers:

Urine output 75 mL in 1 hr

Rationale :

Dehydration reduces renal perfusion, leading to oliguria (<30 mL/hr). A urine output of 75 mL/hr indicates restored intravascular volume and kidney function. Specific gravity normalization (1.010–1.020) further confirms hydration status.

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Answer 8

Correct Answers:

Refusing to look at the dressing or surgical incision

Rationale :

Mastectomy alters body image, triggering grief or denial. Avoidance behaviors (e.g., not looking at the incision) suggest maladaptive coping. Early psychosocial support helps patients process loss and adapt to changes.

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Answer 9

Correct Answers:

"Female condoms can help prevent transmission of sexually transmitted viruses."

Rationale :

Female condoms (e.g., FC2) create a physical barrier against STIs, including HIV, HPV, and herpes. They are FDA-approved for STI prevention and empower women to control protection. Polyurethane condoms are more effective than natural membrane (latex) for virus prevention.

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Answer 10

Correct Answers:

Swimming

Rationale :

Swimming is non-weight-bearing, reducing spinal compression while strengthening paraspinal muscles. Buoyancy minimizes joint stress, making it ideal for chronic back pain. Italso avoids exacerbating pain.

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RN Medsurg II~2024 Final Assessment

No.

1 : A nurse is caring for an older adult client who had a femoral head fracture 24 hours ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?

2 : A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?

3 : A nurse is caring for a client who has fibrocystic breasts. The client asks the nurse, "What will happen to my fibrocystic breast changes after menopause?" Which of the following statements is an appropriate response by the nurse?

4 : A nurse is caring for a client with a chronic wound. Which of the following is a systemic cause of chronic wounds?

5 : A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure?

6 : A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply)

7 : A nurse is caring for a 68-kg (150-1b) client who has dehydration. Which of the following manifestations is an indication of effective treatment?

8 : A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?

9 : A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching?

10 : A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?

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