CH 57

[Osborn] chapter 57
Learning Outcomes [Number and Title ]

Learning Outcome 1
List components of the neurovascular assessment appropriate
for a patient who has had orthopedic surgery.
Learning Outcome 2
Discuss the types of precautions required to prevent hip
dislocation in the postoperative hip replacement patient.
Learning Outcome 3
Describe the nursing actions appropriate for a patient with
symptoms of complications, including compartment syndrome.
Learning Outcome 4
Describe the appropriate use of assistive devices utilized for
orthopedic patients.
Learning Outcome 5
Discuss the importance of optimal pain control in the
postoperative orthopedic patient.
Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
1. Which findings would indicate a change in the clients condition that would relate to a
compromised ulnar nerve integrity following a surgical repair of the elbow?
1. Inability to make the ok sign by bringing the thumb to the fourth or fifth
finger
2. Pain radiating down from the wrist to the middle finger
3. Edema in the forearm that is ranked 3+
4. Notation of slight flexion limitation (less than 15 degrees) during passive
ROM
Correct Answer: Inability to make the ok sign by bringing the thumb to the fourth or
fifth finger
Rationale: Compression from bleeding or severe swelling at the ulnar nerve will not
allow the finger and thumb to be brought together without severe pain. Numbness in the
ring and pinkie fingers is a symptom of compartment syndrome, not a radiating pain from
the wrist to the middle finger. A 3+ edema postoperatively in the forearm is a symptom of
impaired circulation above the site of the edema, either from a tight dressing or cast; this
is not a symptom of a compromised ulnar integrity. Slight flexion limitations are a
symptom of musculoskeletal shortening that comes with disuse and are not a symptom
related to ulnar integrity changes.
Cognitive Level: Synthesis
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 1

Inc.
2. The nurse would include which assessments to evaluate the neurovascular status of a
client with a short-arm cast and arm sling?
Select all that apply.
1.
2.
3.
4.
5.
Pain in or around the casted area

Paresthesia of the hand and/or some of the fingers
Paraplegia
Passive ROM limitations at the elbow
Peripheral muscle tone loss
Correct Answer:
1. Pain in or around the casted area
2. Paresthesia of the hand and/or some of the fingers
Rationale: Pain in or around the casted area. Pain is related to nerve and blood vessel
compression that would indicate a compromised neurovascular integrity. Additional Ps
that are noted include: paresthesia, paralysis, pallor, pulse changes. Paresthesia of the
hand and/or some of the fingers. Paresthesia is related to nerve and blood vessel
compression that would indicate a compromised neurovascular integrity. Additional Ps
that are noted include: pain, paralysis, pallor, pulse changes. Paraplegia. Paraplegia is
defined as the motor and sensory loss of the lower extremities and does not relate to
upper extremity assessments. Passive ROM limitations at the elbow. Passive ROM
limitations at the elbow relate to muscle, tendon, and ligament limitations and not to the
nerves or vascular supply. Peripheral muscle tone loss. Peripheral muscle tone losses
are related to wasting of muscle tissue from disuse, misuse, or the absence of use over a
period of time. Muscle tone loss does not relate to the neurovascular integrity assessment
of the arm.
Cognitive Level: Application
Nursing Process: Assessment
LO: 1

Inc.
3. Which action by the nurse would best assess a 30-year-old client for symptoms of
dehydration?
1. Pinching skin on distal extremity between thumb and index finger
2. Comparing daily weights on chart over several days
3. Comparing intake and output over several days
4. Asking the client about the degree of thirst present
Correct Answer: Pinching skin on distal extremity between thumb and index finger
Rationale: Pinching the skin on the distal extremity between thumb and index finger will
evaluate the degree of tent-like projection; observe the timing it requires to return to
normal. Prolonged return time will indicate a decreased hydration status or dehydration.
Daily weight comparison can give some indication of overall fluid gain or loss, but
additional causes may be present that do not directly focus on the process of evaluation
for dehydration. Comparing intake and output will help evaluate the overall fluid status
but does not tell if the client is dehydrated, since fluids may be retained at the kidneys
and may balance intake but still leave the cells of the body dehydrated. The degree of
thirst declines with the aging process and other disease processes and is not a good
indicator of dehydration.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 1

Inc.
4. The nurse would immediately report to the surgeon which findings in a client who had
a total knee replacement within the last 24 hours?
1. Capillary refill time of 5 seconds in the toes of the surgical leg
2. Slight pallor and skin coolness bilaterally
3. Diminished sensations in both legs and feet
4. Motor strength of 4 in the unaffected leg
Correct Answer: Capillary refill time of 5 seconds in the toes of the surgical leg
Rationale: Capillary refill times of less than 3 seconds are considered normal; it is
prolonged in this client, which might indicate compromised arterial flow in the surgical
leg, and notification is necessary. Pallor and cool skin temperature can reflect arterial
flow decreases, but in this client, it is bilateral in nature; it needs further investigation but
it is not urgent and probably not related to the surgery itself and does not require
immediate notification. Diminished sensations in both legs are a reflection of prolonged
neurovascular changes and should be compared to the presurgical status; it is probably
not related to the surgery itself and immediate notification is not required. Motor strength
in the unaffected leg of 4 does not require immediate notification to the health care
provider, and it is probably not related to the surgery.
Client Need: Safe, Effective Care Environment
LO: 2

Inc.
5. The nurse would recognize the need for additional teaching in a postoperative posterior
hip replacement client when which of the following activities was observed. The client:
1. Used a regular-height toilet seat.
2. Used the abductor pillow while in bed.
3. Kept the affected leg and foot turned upright while in bed.
4. Kept the operative leg straight when getting out of bed, while using the
arms to push up.
Correct Answer: Used a regular-height toilet seat.
Rationale: The toilet seat height needs to be raised to prevent overextension of the hip
joint; therefore, additional teaching is needed to prevent complications from the posterior
hip replacement. An abductor pillow is required to keep the hip in proper alignment and
to prevent it from popping out of place. An upright position will keep the leg and hip in
proper alignment to prevent displacement; the leg is not turned inward for the same
reason. Keeping the leg straight and using the arms will prevent displacement from
twisting the hip when attempting to get out of bed.
Client Need: Psychosocial Integrity
LO: 2

Inc.
6. The nurse would understand the need for additional teaching for home management for
a client who had hip replacement when the client states, I will:
1. Sit down in a chair to reach items below the waist height.
2. Use a shower chair and raised toilet seat when performing hygiene.
3. Have a reacher to access things on the floor.
4. Remove loose carpets or objects in walkways.
Correct Answer: Sit down in a chair to reach items below the waist height. Rationale:
Sitting down in a chair and then trying to reach below the waist height is still
placing the hip at risk of displacement due to an angle that is less than 90 degrees.
Additional teaching is required. Suggestions should include placing objects at the
waist height or using a reacher to assist without additional bending or twisting of
the hips.
A shower chair and raised toilet seat are keeping the hips at the correct angle to
prevent displacement.
Using a reacher will prevent bending or stooping that might cause hip
displacement.
Loose carpets and objects in walkways may cause unnecessary falls and further
injure the client and/or hip replacement itself.
LO: 2

Inc.
7. What would be the first action by the nurse for a client with a hip arthroplasty when the
affected leg was noted to be rotated outward, pale in coloring, diminishing pulses
palpated, skin temperature cool to touch, and shortening in length noted?
1. Ask about changes in pain levels.
2. Call the health care provider.
3. Replace the leg and foot to proper alignment with toes upward.
4. Reinforce proper positioning by putting the abductor pillow in place.
Correct Answer: Ask about changes in pain levels.
Rationale: Asking about changes in pain levels will indicate the compromise of bone and
tissue alignment. Increased pain and the absence of pain are both caused by pressure on
nerves and blood vessels when the hip is misaligned. Assessment is the first action prior
to calling the health care provider. Gathering all information prior to notifying the health
care provider will allow faster a decision-making process and better communication
about the clients current status. Replacing the leg and foot to proper alignment, prior to
understanding what mechanism is present in the misalignment, would increase risk for
additional damage to the hip. This is not a nursing role and should be performed by health
care providers trained to do so. Placing the abductor pillow can also increase harm or risk
of potential damage once the leg is misaligned. The shortening of the hip shows that the
hip is out of the socket and needs professional replacement by a trained health care
provider. Moving the leg should not be done until the health care provider is present.
LO: 2

Inc.
8. Which activity would be inappropriate to include in the plan of care for the first few
hours after a hip arthroplasty?
1. Ambulation with assistance using a walker
2. Incentive spirometry every 2 hours while awake
3. Lab comparison of hemoglobin and hematocrit to presurgery levels
4. Application of bilateral sequential compressive devices
Correct Answer: Ambulation with assistance using a walker
Rationale: Ambulation with a walker and assistance is begun the first day postoperatively.
During the first few hours after surgery, fluid volumes, respiratory functions, pain
management, bed positioning (abductor pillow), and bleeding are the priority of care.
Getting out of bed to a chair begins the first day postop. Incentive spirometry is begun in
the immediate postoperative period to prevent pulmonary complications. Hemoglobin
and hematocrit levels need to be closely assessed for internal bleeding and blood losses
that might have occurred in surgery and immediately postoperatively. Replacement
therapy may be required if severe. Hypoxia from low RBC will delay healing and tissue
repairs and increase risk of complications. Bilateral sequential compression devices
(SCDs) are applied to prevent deep vein thrombosis, which is a common complication of
postoperative orthopedic clients. Prevention is the best treatment; therefore, low-weight
molecular heparin and SCDs are used prophylactically.
Nursing Process: Planning
LO: 2

Inc.
9. If the 5 Ps of assessments for neurovascular status are present in a long-leg casted

client, the nurse would plan for what action to improve the neurovascular status?
1. Bi-valving the cast
2. Complete removal of the cast and replacement by skeletal traction
3. Elevation of the head of the bed (HOB)
4. Reassessment after the application of ice packs over the intact cast
Correct Answer: Bi-valving the cast
Rationale: Bi-valving the cast will allow for expansion of tissue that is swollen and direct
assessment of the extremity while maintaining bone alignment. The cast may be the
source of a compartment syndrome by limiting the potential swelling and compressing
blood vessels that diminish the blood supply to the distal portion of the extremity.
Removal of the cast will decrease the risk for the restriction of tissue swelling but does
not maintain bone alignment. Skeletal traction would keep the bones aligned but requires
additional surgical placement and increases risk of infection that is unrelated to the
swelling causing the neurovascular compromise. Elevating the HOB will increase
dependent edema in the lower extremities and will not reduce the neurovascular
compression that is caused by the swelling in the casted leg. Application of ice will
reduce swelling in the leg but will not increase the blood flow to the lower extremity fast
enough to prevent potentially permanent damage to the leg. Relief of the pressure inside
the cast is needed immediately to prevent additional or permanent damage from
compromised blood flow to the distal portion of the lower extremity.
Cognitive Level: Evaluation
LO: 3

Inc.
10. One of the nursing actions includes turning, coughing, and deep breathing the client
every 2 hours; what assessment is needed to validate the effectiveness of these actions?
1. Assessment of bilateral lung sounds
2. Documenting the blood pressure to compare the trends
3. Monitoring intake and output
4. Assess carotid pulses for bruits
Correct Answer: Assessment of bilateral lung sounds
Rationale: Assessment of bilateral lung sounds will evaluate the effectiveness of
pulmonary exchanges of air and the possible fluid buildup that would diminish or prevent
air flow in the bases of the lungs from atelectasis. Trending the blood pressures will show
hemodynamic status but does not address the atelectasis and pulmonary functions that are
directly related to the actions of turning, coughing, and deep breathing. Monitoring intake
and output will show fluid status that increases the risk of fluids in the lungs but will not
be improved by the actions of turning, coughing, and deep breathing. Assessment of the
carotid pulses for bruits is used to show vascular status and is not impacted by pulmonary
status that is related to turning, coughing, and deep breathing.
Nursing Process: Assessment
LO: 3

Inc.
11. What would be the nurses next action with the following findings noted upon
assessment of a client postarthroplasty: tachypnea, air hunger, hypoxia, O2 sat of 86%,
decreasing mental status, and petechiae?
1. Prepare the client for immediate intubation and mechanical ventilation
with PEEP.
2. Raise the head of the bed (HOB) and encourage coughing every hour.
3. Call a code for potential cardiac arrest situation.
4. Apply oxygen at 3 to 4 liters /minute and then call the health care
provider.
Correct Answer: Prepare the client for immediate intubation and mechanical ventilation
with PEEP.
Rationale: The symptoms are related to severely compromised pulmonary status,
probably acute respiratory distress syndrome (ARDS), which is related to a fat emboli
blocking the pulmonary vessel and inactivating surfactant. Intubation and mechanical
ventilation with PEEP (positive end-expiratory pressure) are needed to maximize air
exchange and treat symptoms until the condition resolves. Raising the HOB will improve
gas exchange slightly by allowing the diaphragm to assist by gravitational pull to expand
the chest, but since the problem is not expansion of the chest but obstruction of the
pulmonary vessels by fat emboli, the condition will not improve. Calling for a code
related to cardiac arrest is not appropriate at this time since the heart is not the problem;
the pulmonary status is what needs to be addressed first. Application of oxygen will
improve the availability of oxygen within the lungs but does not improve the perfusion of
air exchange; since the pulmonary vessel is obstructed by fat emboli the normal
respiratory effort is not enough pressure to force oxygen to the smaller vessels. Therefore,
PEEP is needed to open up smaller vessels to maximize air exchange while under
pressure.
LO: 3

Inc.
12. Following extensive spinal surgery, which action by the nurse would be prudent to
prevent a common complication related to spinal swelling?
1. Administration of a stool softener and/or laxative with the return of
bowel sounds
2. Immediate removal of a Foley in the PACU to prevent potential
infections
3. Encouragement of the semi-Fowlers position for the first 24 hours
4. Forcing fluids greater than 100 mL/hour once tolerating oral fluids
Correct Answer: Administration of a stool softener and/or laxative with the return of
bowel sounds
Rationale:Swelling in the spine following extensive surgery can cause compression on
the innervations of bowel and bladder functions. Prevention of constipation caused by
narcotics, bed rest, anesthesia, and nerve compression will minimize the risk of straining
to evacuate the bowel by prophylactically giving stool softeners and/or laxatives prior to
actual need. Immediate removal of the Foley in the PACU is not recommended due to the
increased risk of swelling innervations for bladder functions; but within 24 hours after
surgery if the client is getting up the Foley is removed to minimize risk of infections.
Intermittent catherizations are used if the client is unable to void. A semi-Fowlers
position is contraindicated due to the risk of spinal fluid losses that occur in surgical
repairs. A flat position is recommended to minimize the risk of spinal headaches that can
occur with spinal fluid losses during surgery. In addition, a flat position is strongly
recommended to minimize the bone stability or the risk of trauma to the surgical site.
Often the orders are to lie in bed or be up walking and to not twist or turn to avoid malalignment of the surgical repair. Forcing fluids to 100 mL/hour may be contraindicated
for cardiac or renal clients and will not improve the risk for constipation or bowel
dysfunctions from spinal swelling.
LO: 3

Inc.
13. The nurse would expect which action immediately following the treatment of a
cerebral spinal fluid leak in a post-spine-surgery client?
1. Keeping the client flat in bed for 2 hours
2. Raising the head of the bed (HOB) into a Trendelenburg position
3. Administering a bolus of IV fluids
4. Initiating strict isolation policies
Correct Answer: Keeping the client flat in bed for 2 hours
Rationale: Keeping the client flat in bed for 2 hours will allow the blood patch repair for
the cerebral spinal leak to clot and not migrate to other parts of the spine, thus allowing
the seal to be formed to minimize/stop the leaking of cerebral spinal fluids. Raising the
HOB will increase the risk of spinal leaking and increase the risk of spinal headache as
the fluid is pulled by gravity to the lower areas of the spinal column. Administration of
increased fluids is not the issue. It could increase the cerebral spinal pressure and increase
the risk of rupture of the patch if given too much in a short period of time. Therefore, it is
not recommended to give a bolus after a blood patch repair for the spinal leak. Strict
isolation is not needed to prevent potential for meningitis from the open wound in the
spinal column. Sterile techniques and sterile dressings should minimize that risk. It is not
related to the administration of the blood patch for the spinal leak itself.
LO: 3

Inc.
14. Following hip surgery, which assistive device would be most helpful to be included in
the plan of care at all times to prevent fall injuries?
1. Ambulation with a walker
2. Assistance with two staff persons and the use of a safety belt
3. Bed rails X2 up at all times
4. Transportation by a wheelchair
Correct Answer: Ambulation with a walker
Rationale: Ambulation with a walker will give a stable support system to prevent falling
injuries. The ability to bear weight on the surgical leg is variable based upon the type of
surgery performed, but a walker will give a more stable base than a cane or crutch
assistive device. Assistance by two staff may or may not be needed at all times. The use
of a safety belt is strongly recommended no matter what number of assistants is present.
As the client progresses, assistance may be only one staff person. Complete independence
with the use of a walker is the goal prior to discharge. Bedrails up X2 is restrictive and
can be considered illegal restraint. The least restrictive environment is required by law. If
confusion is a problem, bed alarms or sitters may be more effective. Raising side rails for
nursing convenience is not acceptable practice. Use of a wheelchair is not encouraged.
LO: 4

Inc.
15. In planning care for a client who has had a relapse of carpal tunnel syndrome, what
information is needed to prevent complications and allow maximization of healing? The
client needs to:
1. Wear a brace or wrist splint at night and during activities that
aggravate the symptoms.
2. Exercise the wrist for complete rotation and ROM every 4 hours while
awake.
3. Wear a cast for the first 3 weeks, followed by a protective splint for the
next 6 to 8 weeks.
4. Wear an external hinge splint to support the wrist for several months.
Correct Answer: Wear a brace or wrist splint at night and during activities that aggravate
the symptoms.
Rationale: Wearing the brace or splint will keep the wrist in a natural position and prevent
damage to the surgically repaired area during sleep and activities that aggravate the
symptoms. Exercising the wrist will increase strain and cause more swelling that will
delay the healing process. Wearing a cast for several weeks followed by a sprint is related
to wrist arthroplasty. A hinge splint is designed for elbow surgery and not for wrists.
LO: 4

Inc.
16. A client has had extensive ankle reconstruction and required a cast for stabilization.
The nurse would expect which educational topic to be included in the plan of care before
discharge?
1. Home management of the casted extremity
2. Application of heat four times each day
3. Weight-bearing training
4. Log-rolling techniques when getting out of bed
Correct Answer: Home management of the casted extremity
Rationale: Home management of the casted extremity is required to assist in self-care
once discharged. Care of the cast, assessments, limitations, and safety concepts need to be
included in home care. Heat is not applied to a cast due to increased risk of swelling and
bleeding due to its vasodilation effects. Ice can be applied with an on-off process lasting
no longer than 30 minutes several times during the day. The ice will decrease swelling
and pain by vasoconstriction. Weight-bearing is contraindicated in extensive ankle
surgery. Crutches or walkers are needed for getting around safely. Log-rolling is done for
back surgery to stabilize the spinal column, not for ankle surgeries.
LO: 4

Inc.
17. A subcutaneous pain pump is used for a client with a hip replacement surgery. Which
statement by the client during the first 24 hours after the surgery requires additional
assessment by the nurse?
1. I feel numbness all the way down to my ankle.
2. I feel sleepy when I push my PCA (patient control analgesia) button.
3. I cannot believe how good I feel when I get up; I expected more
pain.
4. I will need to use a toe-touch method even if there is no pain
present.
Correct Answer: I feel numbness all the way down to my ankle.
Rationale: Numbness that has extended to the ankle from a hip surgery means some
compression is present on the nerves that supply the foot with sensation. Additional
assessments are required to gather when and under what circumstances the numbness
began and continued. Feeling sleepy with the PCA is common since most of the drugs are
narcotics or opiates that control pain, and the CNS will be depressed also. PCA given
with the SQ pain pump needs close assessments to include the observations for potential
overdosing of narcotics. Feeling sleepy is an acceptable level of comfort. Inability to
awaken the client would require additional assessment for an overdose situation. With
most hip replacements, the cause of the pain has been removed. Bone is not on bone,
infection or inflammation has been cleared out, and mal-alignment is corrected by the
surgical procedure. The SQ pain pump gives direct relief and minimizes the pain
experienced in the immediate postoperative time frame. Toe-touch walking is the correct
method of ambulating until weight bearing is authorized by the health care provider.
Weight bearing is allowed based upon the type of replacement structures that are involved
in the surgery.
Client Need: Psychosocial Integrity, Physiological Integrity
LO: 5

Inc.
18. The nurse would expect to find which of the following orders to be included in pain
management following an above-the-knee amputation on a client?
Select all that apply.
1. Antiseizure medications
2. Nerve blocks
3. Transcutaneous electrical nerve stimulators (TENS)
4. Antidepressants
5. Relaxation exercises
Correct Answer:
1. Antiseizure medications
2. Nerve blocks
3. Transcutaneous electrical nerve stimulators (TENS)
Rationale: Antiseizure medications. Pain is characterized as acute and phantom in nature
when dealing with amputations; therefore, various nerve pathways and atypical
medications have been able to control pain as much or more than the traditional narcotics
used for acute pain. Nerve blocks. Nerve blocks work by blocking the pain pathways
through low-level stimuli and not allowing pain sensation to reach the brain centers of
pain interpretation. Transcutaneous electrical nerve stimulators (TENS). TENS work
by blocking the pain pathways through low-level stimuli and not allowing pain sensation
to reach the brain centers of pain interpretation. Antidepressants. Pain is characterized as
acute and phantom in nature when dealing with amputations; therefore, various nerve
pathways and atypical medications have been able to control pain as much or more than
the traditional narcotics used for acute pain. Relaxation exercises. Relaxation exercises
are used most often with chronic pain management. Normally relaxation will not assist
with a new postoperative client who is in pain.
LO: 5

Inc.
19. When planning care for the orthopedic surgical client, the nurse would include which
approach?
1. Anticipatory pain management prior to therapy
2. Allowing family to assist in pushing the patient-controlled analgesia
(PCA) button
3. Administering pain medications only while awake
4. Assessing vital signs to evaluate the degree of pain
Correct Answer: Anticipatory pain management prior to therapy
Rationale: Anticipatory pain management will improve the efforts during therapy to
speed up the recovery process. Better pain management that is more consistently given
will improve outcomes of recovery and client satisfaction. No one should be allowed to
push the PCA button except the client. Nursing staff and visitors are not the individuals
experiencing the pain; only the client should push the PCA button to regulate the dosage
given based upon his or her perceptions. Pain medications should be given around the
clock for more effective management of pain at all times. Additional dosages may be
needed during increased periods of activity, but by keeping a regulated amount of pain
medication present within the body, the muscles are more relaxed and the client is better
able to tolerate therapy. Vital signs do not always reflect the degree of pain experienced
by the client. Chronic pain management clients with long-term pain issues may not have
the same sympathetic responses that are experienced by those in acute pain. Pain is a
perception of the individual and should not be judged by the nurse.
LO: 5

Inc.

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CH 57

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[Osborn] chapter 57

Learning Outcomes [Number and Title ]

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Pain in or around the casted area

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

9. If the 5 Ps of assessments for neurovascular status are present in a long-leg casted

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

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