NUR 2214:NUR 2214 Care Of Older Adult: NUR 2214
Package Deal: Questions & Answers
Which nursing action will the nurse on the orthopedic unit plan to delegate to unlicensed assistive
personnel (UAP)?
A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago.
B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis.
C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating.
D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. -
ANSWER:D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours
ago.
Rationale
A. Removing a drain requires broader education and is within the scope of practice of licensed nursing
staff.
B. Assessment requires broader education and is within the scope of practice of a licensed nurse.
C. Client teaching requires broader education and is within the scope of practice of a licensed nurse.
D. Vital sign assessment is a skill that is within the role of the UAP.
The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right
hand with which health care team members? Select all that apply.
A. Occupational therapist
B. Physical therapist
C. Psychologist
D. Respiratory therapist
E. Speech therapist - ANSWER:A. Occupational therapist
B. Physical therapist
C. Psychologist
Rationale
,The client has an amputation and does not have a respiratory condition that warrants collaborative care
with a respiratory therapist.
The nurse plans to refer a client with an amputation and the client's family to which community
resource?
A. American Amputee Society (AAS)
B. Amputee Coalition of America (ACA)
C. Community Workers for Amputees (CWA)
D. National Amputee of America Society (NAAS) - ANSWER:B. Amputee Coalition of America (ACA)
Rationale
A. The AAS is not an organization that actually exists.
B. The ACA is an available resource for clients with amputations and supports them and their families.
C. The CWA is not an organization that actually exists.
D. The NAAS is not an organization that actually exists.
The client is brought to the emergency department (ED) via ambulance after a motor vehicle accident.
What condition will the nurse assess for first?
A. Bleeding
B. Head injury
C. Pain
D. Respiratory distress - ANSWER:D. Respiratory distress
Rationale
A. Bleeding is the second assessment priority in this case.
B. Head injury is the third assessment priority in this case.
C. Pain is the fourth assessment priority in this case.
D. The client is first assessed for respiratory distress, and any oxygen interventions are instituted
accordingly.
The client has a grade III compound fracture of the right tibia. To prevent infection, which intervention
will the nurse implement?
,A. Applying Neosporin (bacitracin, neomycin, and polymyxin B) ointment to the site daily with a sterile
cotton-tipped swab
B. Using strict aseptic technique when cleaning the site
C. Leaving the site open to the air to keep it dry
D. Assisting the client to shower daily and pat the wound site dry - ANSWER:B. Using strict aseptic
technique when cleaning the site
Rationale
A. Chlorhexidine (Hexicleans), 2 mg/mL solution, is the better cleansing solution for pin site care, not
Neosporin ointment.
B. Using aseptic technique is the best way to prevent infection.
C. A wound of this type should be kept covered.
D. The wound site of a compound fracture must not be exposed to a shower. This practice violates
maintaining aseptic technique.
The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal
injury. What information will the nurse include in the teaching plan?
A. Avoid contact sports.
B. Avoid rigorous exercise.
C. Wear helmets when riding a motorcycle.
D. Avoid driving in inclement weather. - ANSWER:C. Wear helmets when riding a motorcycle.
Rationale
A. Telling the general public to avoid contact sports is not realistic.
B. Telling the general public to avoid rigorous exercise is not only unrealistic, it is also opposed to what
many health care professionals recommend to maintain health.
C. Those who ride motorcycles or bicycles should wear helmets to prevent head injury.
D. Telling the general public to avoid driving in inclement weather is not realistic.
The older adult client has had a right open reduction internal fixation (ORIF) of a fractured hip. Which
intervention will the nurse implement for this client?
A. Keep the client's heels off the bed at all times.
B. Reposition the client every 3 to 4 hours.
, C. Administer preventive pain medication during deep-breathing exercises.
D. Prohibit the use of antiembolic stockings. - ANSWER:A. Keep the client's heels off the bed at all times.
Rationale
A. Because the client is an older adult and is more at risk for skin breakdown because of impaired
circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant
pressure on this sensitive area.
B. Repositioning the older adult client must be done every 2 hours to prevent skin breakdown and to
inspect the skin for any signs of breakdown.
C. Pain medication would not be administered for deep-breathing exercises because this client typically
would not experience pain on breathing.
D. Antiembolic stockings are not contraindicated for older adults. They help prevent deep vein
thrombosis.
The client is recovering from an above-knee amputation resulting from peripheral vascular disease.
Which statement indicates that the client is coping well after the procedure?
A. "My spouse will be the only person to change my dressing."
B. "I can't believe that this has happened to me. I can't stand to look at it."
C. "I do not want any visitors while I'm in the hospital!"
D. "It will take me some time to get used to this." - ANSWER:D. "It will take me some time to get used to
this."
Rationale
A. The client is not coping effectively because he or she does not want to participate in self-care.
B. The client is not coping effectively because he or she is unwilling to address what has happened.
C. The client who does not want to receive visitors is having difficulty coping with the change in body
image.
D. This statement indicates that the client is expressing acceptance and effective coping.
Which intervention will the nurse suggest to a client with a leg amputation to help cope with loss of the
limb?
A. Talking with an amputee close to the client's age who has had the same type of amputation
B. Drawing a picture of how the client sees himself or herself
C. Talking with a psychiatrist about the amputation
Package Deal: Questions & Answers
Which nursing action will the nurse on the orthopedic unit plan to delegate to unlicensed assistive
personnel (UAP)?
A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago.
B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis.
C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating.
D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. -
ANSWER:D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours
ago.
Rationale
A. Removing a drain requires broader education and is within the scope of practice of licensed nursing
staff.
B. Assessment requires broader education and is within the scope of practice of a licensed nurse.
C. Client teaching requires broader education and is within the scope of practice of a licensed nurse.
D. Vital sign assessment is a skill that is within the role of the UAP.
The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right
hand with which health care team members? Select all that apply.
A. Occupational therapist
B. Physical therapist
C. Psychologist
D. Respiratory therapist
E. Speech therapist - ANSWER:A. Occupational therapist
B. Physical therapist
C. Psychologist
Rationale
,The client has an amputation and does not have a respiratory condition that warrants collaborative care
with a respiratory therapist.
The nurse plans to refer a client with an amputation and the client's family to which community
resource?
A. American Amputee Society (AAS)
B. Amputee Coalition of America (ACA)
C. Community Workers for Amputees (CWA)
D. National Amputee of America Society (NAAS) - ANSWER:B. Amputee Coalition of America (ACA)
Rationale
A. The AAS is not an organization that actually exists.
B. The ACA is an available resource for clients with amputations and supports them and their families.
C. The CWA is not an organization that actually exists.
D. The NAAS is not an organization that actually exists.
The client is brought to the emergency department (ED) via ambulance after a motor vehicle accident.
What condition will the nurse assess for first?
A. Bleeding
B. Head injury
C. Pain
D. Respiratory distress - ANSWER:D. Respiratory distress
Rationale
A. Bleeding is the second assessment priority in this case.
B. Head injury is the third assessment priority in this case.
C. Pain is the fourth assessment priority in this case.
D. The client is first assessed for respiratory distress, and any oxygen interventions are instituted
accordingly.
The client has a grade III compound fracture of the right tibia. To prevent infection, which intervention
will the nurse implement?
,A. Applying Neosporin (bacitracin, neomycin, and polymyxin B) ointment to the site daily with a sterile
cotton-tipped swab
B. Using strict aseptic technique when cleaning the site
C. Leaving the site open to the air to keep it dry
D. Assisting the client to shower daily and pat the wound site dry - ANSWER:B. Using strict aseptic
technique when cleaning the site
Rationale
A. Chlorhexidine (Hexicleans), 2 mg/mL solution, is the better cleansing solution for pin site care, not
Neosporin ointment.
B. Using aseptic technique is the best way to prevent infection.
C. A wound of this type should be kept covered.
D. The wound site of a compound fracture must not be exposed to a shower. This practice violates
maintaining aseptic technique.
The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal
injury. What information will the nurse include in the teaching plan?
A. Avoid contact sports.
B. Avoid rigorous exercise.
C. Wear helmets when riding a motorcycle.
D. Avoid driving in inclement weather. - ANSWER:C. Wear helmets when riding a motorcycle.
Rationale
A. Telling the general public to avoid contact sports is not realistic.
B. Telling the general public to avoid rigorous exercise is not only unrealistic, it is also opposed to what
many health care professionals recommend to maintain health.
C. Those who ride motorcycles or bicycles should wear helmets to prevent head injury.
D. Telling the general public to avoid driving in inclement weather is not realistic.
The older adult client has had a right open reduction internal fixation (ORIF) of a fractured hip. Which
intervention will the nurse implement for this client?
A. Keep the client's heels off the bed at all times.
B. Reposition the client every 3 to 4 hours.
, C. Administer preventive pain medication during deep-breathing exercises.
D. Prohibit the use of antiembolic stockings. - ANSWER:A. Keep the client's heels off the bed at all times.
Rationale
A. Because the client is an older adult and is more at risk for skin breakdown because of impaired
circulation and sensation, the client's heels must be kept off the bed at all times to avoid constant
pressure on this sensitive area.
B. Repositioning the older adult client must be done every 2 hours to prevent skin breakdown and to
inspect the skin for any signs of breakdown.
C. Pain medication would not be administered for deep-breathing exercises because this client typically
would not experience pain on breathing.
D. Antiembolic stockings are not contraindicated for older adults. They help prevent deep vein
thrombosis.
The client is recovering from an above-knee amputation resulting from peripheral vascular disease.
Which statement indicates that the client is coping well after the procedure?
A. "My spouse will be the only person to change my dressing."
B. "I can't believe that this has happened to me. I can't stand to look at it."
C. "I do not want any visitors while I'm in the hospital!"
D. "It will take me some time to get used to this." - ANSWER:D. "It will take me some time to get used to
this."
Rationale
A. The client is not coping effectively because he or she does not want to participate in self-care.
B. The client is not coping effectively because he or she is unwilling to address what has happened.
C. The client who does not want to receive visitors is having difficulty coping with the change in body
image.
D. This statement indicates that the client is expressing acceptance and effective coping.
Which intervention will the nurse suggest to a client with a leg amputation to help cope with loss of the
limb?
A. Talking with an amputee close to the client's age who has had the same type of amputation
B. Drawing a picture of how the client sees himself or herself
C. Talking with a psychiatrist about the amputation
