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    Exam Review

    1. A nurse is working with a group of clients on stretching. Which of the following statements about muscles is correct?
      A)
      Muscles remain in a fixed position while the ligaments and tendons stretch.
      B)
      Spasticity is what allows the muscles to flex and relax.
      C)
      Muscles extend and stretch and then return back to the original size and shape.
      D)
      Contractility is the ability for the muscle to return to the original shape.
    2. Consider the impact of skin disorders on overall health. Which nursing actions are appropriate in monitoring and caring for a client with altered tissue integrity?
      (SATA)
      A)
      Educate on importance of hydration.
      B)
      Monitor for signs of infection.
      C)
      Allow prolonged sun exposure.
      D)
      Ignore changes in skin color or temperature.
    3. A nurse is caring for a patient post-total knee arthroplasty. Which intervention should be prioritized to prevent deep vein thrombosis (DVT)?
      A)
      Limiting fluid intake.
      B)
      Encouraging early ambulation.
      C)
      Frequent blood pressure monitoring.
      D)
      Application of ice packs.
    4. A nurse is analyzing cues during the evaluation of a client's altered tissue integrity. Which of the following findings should prompt differential diagnosis between cellulitis and dermatitis?
      A)
      Flaky skin.
      B)
      Presence of pustules.
      C)
      Sunburn appearance.
      D)
      Dry patches.
    Page 1 of 14

    Exam Review

    1. Which factor most increases the risk for complications in a patient undergoing total knee arthroplasty?
      A)
      Use of herbal supplements.
      B)
      Age under 40.
      C)
      Vegetarian diet.
      D)
      History of heart disease.
    2. What is the best nursing intervention to prevent skin complications in a patient experiencing fecal incontinence?
      A)
      Use an absorbent pad under the patient.
      B)
      Increase protein intake in the diet.
      C)
      Apply lotion to the perianal area.
      D)
      Implement frequent perineal care and apply moisture barrier cream.
    3. A nurse is caring for an elderly client recovering after a dermatologic surgery. The client reported increased redness and itching around the surgical site and the area appears slightly warm to touch. Which nursing actions are appropriate in monitoring and caring for a client with altered tissue integrity?
      (SATA)
      A)
      Educate on the importance of hydration.
      B)
      Monitor for signs of infection.
      C)
      Allow prolonged sun exposure.
      D)
      Ignore changes in skin color or temperature.
    4. For a patient with partial-thickness burns covering the arms and chest, what is the priority assessment?
      A)
      Capillary refill time.
      B)
      Lung sounds and respiratory effort.
      C)
      Pain score assessment.
      D)
      Skin color and moisture.
    Page 2 of 14

    Exam Review

    1. When planning care for a patient with severe burn injuries, what intervention should the nurse prioritize to promote healing?
      A)
      Providing regular baths with antiseptic soap.
      B)
      Administering antipyretics for fever.
      C)
      Initiating high-calorie, high-protein nutrition.
      D)
      Encouraging daily physical activity.
    2. In assessing a client with chronic venous insufficiency, which manifestation would provide a cue for the development of a venous ulcer?
      A)
      Pallor on elevation of the extremity.
      B)
      Intermittent claudication after walking.
      C)
      Cool and shiny skin on the affected area.
      D)
      Bronze-brown pigmentation of the lower extremities.
    3. During a postoperative assessment of a client who had a total knee arthroplasty, the nurse recognizes a sudden decrease in hemoglobin level. What should the nurse suspect?
      A)
      Joint dislocation.
      B)
      Infection at the surgical site.
      C)
      Hemorrhage or hematoma formation.
      D)
      Deep vein thrombosis.
    4. A nurse is collecting data from a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?
      A)
      When moving an object to one side, the client puts his weight on his heels.
      B)
      The client stands with his feet close together when lifting an object.
      C)
      The client faces the direction of movement when sliding an object across the floor.
      D)
      When pushing an object, the client moves his front foot backward.
    Page 3 of 14

    Exam Review

    1. A client presents with a surgical incision that is red, swollen, and warm to touch. How should the nurse prioritize the hypothesis regarding the cause?
      A)
      Pressure injury.
      B)
      Dehydration.
      C)
      Malnutrition.
      D)
      Infection.
    2. A nurse is collecting data from a client who is postoperative from a below-the-knee amputation and whose residual limb is wrapped with an elastic bandage to shrink the stump. Which of the following findings should alert the nurse to a possible complication?
      A)
      The dressing forming a cone shape over the stump.
      B)
      Looseness of the stump dressing.
      C)
      Pitting edema above the bandage.
      D)
      Figure-eight wrapping around the stump.
    3. What level of Braden Scale score indicates a high risk for developing pressure ulcers, requiring immediate intervention?
      A)
      A score of 10 to 12.
      B)
      A score of 15 to 18.
      C)
      A score of 19 to 23.
      D)
      A score of 24 to 30.
    4. When prioritizing care for a patient with burn injuries, which intervention should be considered first?
      A)
      Providing wound care.
      B)
      Assessing skin condition.
      C)
      Initiating nutritional support.
      D)
      Ensuring a patent airway.
    Page 4 of 14

    Exam Review

    1. Which factors place patients at higher risk of developing pressure injuries or skin integrity issues? (Select all that apply.)
      A)
      Incontinence.
      B)
      Immobility.
      C)
      Malnutrition.
      D)
      High protein diet.
      E)
      Frequent physical activity.
      F)
      Decreased sensory perception.
    2. A nurse is caring for a client who has sustained a gasoline burn to 25 percent of the body. Which of the following is a priority safety concern when caring for this client?
      A)
      Decontamination of the client.
      B)
      Asking the client when they last ate a meal.
      C)
      Elevation of the head of the bed by 30 degrees.
      D)
      Determining the amount of gasoline that the client encountered.
    3. A nurse is caring for a young adult client who is being evaluated for a stress fracture in the foot. The client is a competitive gymnast who states, "I am not sure why this keeps happening.”. Which of the following explanations by the nurse is appropriate?
      A)
      "You will have to ask the provider about this.”.
      B)
      "I am not sure. Did you fall off of the balance beam?"
      C)
      "I suspect that you do a lot of the routines repeatedly, which can cause a lot of stress on the bones.”.
      D)
      "These are usually caused by repeated falls from over 6 feet.”.
    4. A client presents with both a low-grade fever and suspected tissue injury. How should a nurse prioritize the potential diagnoses?
      A)
      Evaluate the tissue injury for complications.
      B)
      Administer fluids for hydration.
      C)
      Request labs for hematology profiles.
      D)
      Treat the fever with antipyretics.
    Page 5 of 14

    Exam Review

    1. A patient with full-thickness burns over 40 Which complication is vital for the nurse to anticipate and monitor?
      A)
      Hypokalemia.
      B)
      Hypothermia.
      C)
      Hypoglycemia.
      D)
      Hypertension.
    2. While performing an assessment on a client with alterations in tissue integrity, which of the following cues should a nurse recognize as indicative of possible infection?
      A)
      Dry and itchy skin.
      B)
      Increased pigmentation.
      C)
      Warmth and redness at the site.
      D)
      Presence of hair follicles.
    3. A nurse is attending to a patient in the intensive care unit. For each patient finding below, indicate whether the finding is consistent with fluid overload or dehydration in burn patients.
      A)
      Increased Heart Rate.
      B)
      Decreased Urine Output.
      C)
      Elevated Blood Urea Nitrogen (BUN).
      D)
      Decreased Hematocrit.
    4. A nurse is preparing to administer cefazolin 750 mg intramuscularly every 8 hours. The medication label reads cefazolin 1 gram per 2 mL. How many milliliters should the nurse administer per dose?
    Page 6 of 14