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    Exam Review

    1. A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?
      A)
      Determining the client's mobility
      B)
      Explaining the roles of the RN, licensed practical nurse, and assistive personnel
      C)
      Introducing health care team members to the client
      D)
      Understanding the client's routine for his own care at home
    2. Please indicate whether the following statement is true or false. A nurse working on the orthopedic floor understands that a gastrointestinal assessment should be done every three days.
      A)
      False
      B)
      Maybe
      C)
      Perhaps
      D)
      True
      E)
      True
    3. The nurse working in the medical-surgical unit, is caring for a patient that had knee surgery. She notices that the incision on the knee is opening each time the CPM is at its maximum angle. The patient is also complaining of tightness around the sutures. She should
      A)
      reassess the area in 8 hours
      B)
      stop the machine and notify the primary care provider
      C)
      increase the angle of the flexion of the joint to change the pressure on the heel
      D)
      pad the portion of the machine that the heel rests on
    4. A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home education plan information relative to: (Select all that apply.)
      (SATA)
      A)
      using the spreader bar to turn the patient.
      B)
      protecting the cast from soiling.
      C)
      grasping the cast over the leg to help in turning.
      D)
      easing itching under the cast by scratching with a bent coat hanger.
      E)
      turning frequently to the prone position.
    Page 1 of 12

    Exam Review

    1. A nurse is collecting data about a client's range of motion. Which of the following instructions should the nurse give to the client to observe hyperextension of the neck?
      A)
      "Keep your head straight and turn it as far as possible to either side."
      B)
      "Move your head from the upright position back as far as you can."
      C)
      "Move your head so that your chin rests on your chest."
      D)
      "Move your head laterally towards your right and left shoulder."
    2. A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?
      A)
      Abducting the arm to a 90-degree angle from the side of the body
      B)
      Adducting the arm so that is lies next to the client's side
      C)
      Flexing the shoulder by raising the arm from a side position to a 180-degree angle
      D)
      Circumducting the shoulder in a 180-degree half circle
    3. A nurse is applying an elasticized bandage to the leg of a patient. To perform this procedure correctly, the nurse should:
      A)
      use metal clips to secure the wrap.
      B)
      adjust the pressure or tension as needed.
      C)
      overlap turns of the bandage equally.
      D)
      face the patient and wrap from proximal to distal.
    4. A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?
      A)
      Ask the client if she has been out of bed today.
      B)
      Ask the client to push her legs and feet against the nurse's palms.
      C)
      Check the client's pedal pulses and feet for edema.
      D)
      Ask the client how strong she feels today.
    Page 2 of 12

    Exam Review

    1. A patient has just had a leg cast applied with plaster of Paris. The nurse can best reduce the incidence of edema by:
      A)
      speeding the drying with a hair dryer.
      B)
      elevating the leg on one to two pillows.
      C)
      petaling the edges of the cast.
      D)
      placing the patient in high Fowler's position.
    2. An anxious patient in skeletal traction is distressed by the clear fluid drainage that is oozing from the pin sites. The nurse's best intervention would be to:
      A)
      cover the pin with several gauze pads and tape securely.
      B)
      assure the patient that such drainage is expected.
      C)
      notify the charge nurse of possible infection.
      D)
      wipe off drainage with a damp wash cloth.
    3. A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)
      A)
      Elevate the foot.
      B)
      Encourage range-of-motion exercises of the foot.
      C)
      Provide the client with a light snack.
      D)
      Apply a compression bandage.
      E)
      Apply ice to the ankle.
    4. A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?
      A)
      Abduction
      B)
      External rotation
      C)
      Internal rotation
      D)
      Adduction
    Page 3 of 12

    Exam Review

    1. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further reinforcement of teaching?
      A)
      "I have a set of my brother's crutches in my basement that I can also use."
      B)
      "I will keep spare crutch tips handy."
      C)
      "I will bear the weight of my body on my hands."
      D)
      "I will inspect my crutches every day for signs of wear."
    2. A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take?
      A)
      Place the stockings on the client after the client ambulated to the restroom
      B)
      Ensure the client's toes are visible after placing the stockings on the client
      C)
      Measure the client's calf circumference and leg length from heel to knee.
      D)
      After applying the stockings, place two fingers between the client's leg and stocking to check the fit.
    3. A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
      A)
      Move body parts rapidly through the movements.
      B)
      Support extremities above and below joints.
      C)
      Stretch the body part just beyond the existing range of motion.
      D)
      Continue moving body parts if muscle spasticity occurs.
    4. A certified nursing assistant (CNA) is assisting a patient into a wheelchair. The nurse intervenes if the CNA has:
      A)
      left the patient with the lap robe tucked underneath.
      B)
      left the brakes of the wheelchair unlocked.
      C)
      placed the patient's feet centered on the footrests.
      D)
      placed slippers on the patient.
    Page 4 of 12

    Exam Review

    1. A 46-year-old male was injured in an industrial accident and has suffered a fractured left leg and left wrist. His wrist is treated with a cast and the leg is placed in skeletal traction. Because of immobilization of his leg, the patient is at risk for (Select all that apply.)
      A)
      venous thrombosis.
      B)
      pressure injury.
      C)
      foot drop.
      D)
      generalized edema.
      E)
      constipation.
    2. A nurse is assisting with the ambulation of a client with the use of a gait belt, who becomes light-headed and begins to fall. Which of the following actions should the nurse take?
      A)
      extend one leg and allow the client to slide down the leg to the floor.
      B)
      move both feet together when the client begins to fall
      C)
      wrap both arms around the client's arm and shoulders
      D)
      protect the client's extremities while lowering them to the floor.
    3. The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat
      A)
      respiratory alkalosis.
      B)
      atelectasis.
      C)
      hypostatic pneumonia.
      D)
      low oxygen saturation.
    4. When handling a freshly applied plaster cast while assisting a patient from stretcher to bed, the nurse should handle the cast using:
      A)
      palms only.
      B)
      palms and flat parts of fingers.
      C)
      fingertips and flat parts of fingers.
      D)
      fingertips and palms.
    Page 5 of 12

    Exam Review

    1. The nurse working with immobilized patients understands that monitoring for reports of pain with urination, changes in urination, and assessing fro frequency is essential in order to determine if an unwanted urinary problem is arising from her patient being immobile.
      A)
      True
      B)
      Maybe
      C)
      Perhaps
      D)
      False
    2. A nurse in an emergency department is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include?
      A)
      Hold the crutches on your unaffected side when preparing to sit in a chair
      B)
      Hold the crutches 9 inches in front and to the side of each foot
      C)
      Lean on the crutches to support your body weight when standing
      D)
      Fully extend your arms when holding onto the hand grips
    3. A nurse is collecting data from a client who has required strict bed rest for 1 week. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?
      A)
      Develops fatigue when assisting with morning hygiene care
      B)
      Needs assistance raising her legs to put on socks
      C)
      Performs active range-of-motion (ROM) exercises of all extremities
      D)
      Demonstrates mild dyspnea when eating breakfast
    4. The nurse placing a patient following knee replacement surgery into a continuous passive motion (CPM) machine has the responsibility to:
      A)
      raise the head of the bed to 30 to 45 degrees.
      B)
      elevate the machine at the foot of the bed on one pillow.
      C)
      set the proper flexion and extension limits.
      D)
      keep the operated knee warm.
    Page 6 of 12