1. After the physician performs an amniotomy, the nurse’s first action should be to assess the:
a. Degree of cervical dilation
b. Fetal heart tones
c. Client’s vital signs
d. Client’s level of discomfort
2. A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?
3. A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:
a. Teaching the mother to provide tactile stimulation
b. Wrapping the newborn snugly in a blanket
c. Placing the newborn in the infant seat
d. Initiating an early infant-stimulation program
4. A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
a. Checking for cervical dilation
b. Placing the client in a supine position
c. Checking the client’s blood pressure
d. Obtaining a fetal heart rate
5. The nurse is aware that the best way to prevent post- operative wound infection in the surgical client is to:
a. Administer a prescribed antibiotic
b. Wash her hands for 2 minutes before care
c. Wear a mask when providing care
d. Ask the client to cover her mouth when she coughs
6. The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?
c. Cool extremity
d. Absence of pedal pulses
7. The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
a. Lack of exercise
b. Hormonal disturbances
c. Lack of calcium
d. Genetic predisposition
8. A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?
a. The infant no longer complains of pain.
b. The buttocks are 15° off the bed.
c. The legs are suspended in the traction.
d. The pins are secured within the pulley.
9. A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
a. Utilizes a Steinman pin
b. Requires that both legs be secured
c. Utilizes Kirschner wires
d. Is used primarily to heal the fractured hips
10. The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:
a. Serum collection (Davol) drain
b. Client’s pain
c. Nutritional status
11. Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?
a. "I must flush the tube with water after feedings and clamp the tube."
b. "I must check placement four times per day."
c. "I will report to the doctor any signs of indigestion."
d. "If my father is unable to swallow, I will discontinue the feeding and call the clinic."
12. The nurse is assessing the client with a total knee replacement 2 hours post-operative. Which information requires notification of the doctor?
a. Bleeding on the dressing is 3cm in diameter.
b. The client has a temperature of 6°F.
c. The client’s hematocrit is 26%.
d. The urinary output has been 60 during the last 2 hours.
13. The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?
a. The client has traveled out of the country in the last 6 months.
b. The client’s parents are skilled stained-glass artists.
c. The client lives in a house built in 1
d. The client has several brothers and sisters.
14. A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?
a. High-seat commode
c. TENS unit
d. Abduction pillow
15. An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:
a. Administer oxygen via nasal cannula
b. Have narcan (naloxane) available
c. Prepare to administer blood products
d. Prepare to do cardioresuscitation
16. Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?
a. 16-year-old female with scoliosis
b. 12-year-old male with a fractured femur
c. 10-year-old male with sarcoma
d. 6-year-old male with osteomylitis
17. A client with osteoarthritis has a prescription for Celebrex (celecoxib). Which instruction should be included in the discharge teaching?
a. Take the medication with milk.
b. Report chest pain.
c. Remain upright after taking for 30 minutes.
d. Allow 6 weeks for optimal effects.
18. A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates understanding of a plaster-of-Paris cast? The nurse:
a. Handles the cast with the fingertips
b. Petals the cast
c. Dries the cast with a hair dryer
d. Allows 24 hours before bearing weight
19. The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?
a. "It will be alright for your friends to autograph the cast."
b. "Because the cast is made of plaster, autographing can weaken the cast."
c. "If they don’t use chalk to autograph, it is okay."
d. "Autographing or writing on the cast in any form will harm the cast."
20. The nurse is assigned to care for the client with a Steinmen pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?
a. Assisting the LPN with opening sterile packages and peroxide
b. Telling the LPN that clean gloves are allowed
c. Telling the LPN that the registered nurse should perform pin care
d. Asking the LPN to clean the weights and pulleys with peroxide
21. A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?
a. Check the bowel sounds
b. Assess the blood pressure
c. Offer pain medication
d. Check for swelling
22. The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
a. Russell’s traction
b. Buck’s traction
c. Halo traction
d. Crutchfield tong traction
23. A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?
a. "Use of the CPM will permit the client to ambulate during the therapy."
b. "The CPM machine controls should be positioned distal to the site."
c. "If the client complains of pain during the therapy, I will turn off the machine and call the doctor."
d. "Use of the CPM machine will alleviate the need for physical therapy after the client is discharged."
24. A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
a. Palms rest lightly on the handles
b. Elbows are flexed 0°
c. Client walks to the front of the walker
d. Client carries the walker
25. When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
a. Attempt to replace the cord
b. Place the client on her left side
c. Elevate the client’s hips
d. Cover the cord with a dry, sterile gauze
View Answers and Rationale