NCLEX style questions for exam 2 skills

14. A nurse is trimming the cast applied to the fractured leg of a client since the leg is healing. The cast was applied in such a way that the toes were exposed and the cast cannot be easily removed. Which of the following casts was applied to the client? A) Cylinder cast B) Spica cast C) Bivalved cast D) Body cast

Ans: A Feedback: A cylinder cast was applied to the client. A cylinder cast encircles an arm or leg and leaves the toes or fingers exposed. The cast extends from the joints above and below the affected bone in order to prevent movement and maintain correct alignment during healing. A spica cast is not the correct response because it cannot be trimmed, and is heavy and uncomfortable. A bivalved cast is not the correct response because it is usually used for upper extremities and half of it can easily be removed. A body cast is used to encircle the trunk of the body instead of an extremity.

14. A nurse is caring for a client whose legs have been amputated from above the knee due to a workplace accident. The client has been fitted with a prosthetic limb that attaches at his femur. Which of the following components can be found only in this prosthetic? A) Socket B) Shank C) Ankle

foot system D) Knee system /Ans: D Feedback: A knee system, which replaces the knee joint, is the component that can only be found in an above-the-knee prosthetic limb. Permanent prostheses for below-the-knee amputees and above-the-knee amputees include a socket, a shank, and an ankle/foot system.

7. A nurse is caring for a client who is being treated for burns. The client's bed has a cradle. Which of the following features does a cradle offer? A) It forms a shell over the person's lower legs to keep bed linen off the feet. B) It supports the body and equalizes the pressure per square inch over its surface. C) It creates wavelike redistribution of air, which relieves pressure over bony prominences. D) Its buoyant surface distributes the pressure on the client's underlying tissue.

Ans: A Feedback: A cradle forms a shell over the client's lower legs to keep bed linen off the feet or legs. It is often used for clients with burns, painful joint disease, and fractures of the leg. A water mattress supports the body and equalizes the pressure per square inch over its surface. An alternating air mattress creates wavelike redistribution of air, cyclically relieving pressure over bony prominences. A static air pressure mattress suspends the client on a buoyant surface, distributing the pressure on the underlying tissue.

17. An elderly client with a diagnosis of osteoporosis and early stage Alzheimer disease requires the use of an assistive device that will maximize stability during ambulation. What device will best meet this client's needs? A) Walker B) Axillary crutches C) Forearm crutches D) Cane

Ans: A Feedback: A walker provides greater stability than crutches or a cane.

13. A nurse is caring for a client who underwent surgery for the amputation of her right foot. The client has been fitted with a temporary prosthetic limb. Which of the following interventions or outcomes should the nurse prioritize during this period? A) The wound heals and no complications develop. B) The measurement for the prosthetic limb is accurate. C) The client is provided with an ambulatory device. D) The client is able to ambulate with assistance.

Ans: A Feedback: After amputation, the nurse needs to ensure that the client's wound heals and no complications such as joint contractures or infection develop. This is a priority in the client's recovery because complications delay rehabilitation. This action is a priority over measurements, provision of assistive devices, and even the client's ability to ambulate.

11. A nurse is caring for a 69-year-old client who is recovering from health problems. The physiotherapist has prescribed ambulatory exercise, for which the nurse needs to monitor and assist the client. Which of the following would the nurse assess most closely in order to determine if the activity is beyond the tolerance level of the client? A) Heart rate B) Oxygen saturation C) Body temperature D) Blood pressure

Ans: A Feedback: An increased heart rate in a client is an indication to the nurse that the activity is beyond the client's level of tolerance. The other vital signs are also important assessment parameters but heart rate is a priority assessment.

23. After having a consultation with the orthopedic surgeon, a nurse has learned that a client's fracture will be treated with external fixation rather than with a cast. The nurse should recognize that this chosen treatment heightens the client's risk of what nursing diagnosis? A) Risk for Infection B) Ineffective Coping C) Sleep Deprivation D) Risk for Trauma

Ans: A Feedback: Because external fixators involve a potential portal of entry for microorganisms, there is an increased risk of infection. External fixators do not have an increased risk of ineffective coping or sleep disturbance when compared to casting. Risk for trauma is present any time that a client is being treated for a fracture.

8. A nurse is observing the prescribed therapeutic activity for a middle-aged client who underwent a mastectomy to treat breast cancer. Which of the following active exercises or therapeutic activities should the client perform? A) Perform light exercise with the arm on the surgical side. B) Have the nurse perform passive ROM on the arm on the affected side. C) Perform weight-training with the arm on surgical side. D) Learn to perform activities of daily living with arm opposite the surgical side.

Ans: A Feedback: Clients who have undergone a mastectomy learn to exercise the arm on the surgical side by combing their hair, squeezing a soft ball, finger-climbing the vertical surface of a wall, and swinging a rope attached to a doorknob. Passive ROM would not significantly aid the client's recovery of normal function. Weight-training would pose a risk of injury and the client should aim to perform ADLs with the affected side rather than neglecting it.

3. A nurse is examining and documenting the physical condition of a client who is undergoing a prescribed stress electrocardiogram test at a health care facility. Which of the following observations should the nurse prioritize in an effort to ensure the test is performed safely? A) Client's breathing pattern B) Client's endurance level C) Client's running speed D) Client's muscle reflexes

Ans: A Feedback: During a stress electrocardiogram test, the nurse or the examiner notes the client's breathing pattern, heart rate and rhythm, blood pressure, and symptoms such as dizziness and chest pain. The client's endurance level, running speed, and muscle reflexes are part of the maximal activity performed by the client during the test but these variables do not directly indicate difficulty with completing the test or the presence of unintended health consequences.

19. A nurse is assessing a client's neuromuscular status by having the client perform movements that correlate with muscular functions controlled by the upper spine and peripheral nerve roots. Which of the following was applied to the client? A) Cervical collar B) Pelvic belt C) Molded splint D) Bivalved cast

Ans: A Feedback: During recovery from a slipped disc, the nurse assesses the client's neuromuscular status by having him or her wear a cervical collar. The nurse also performs movements that correlate with muscular functions controlled by the cervical spine and peripheral nerve roots. A pelvic belt is a part of skin traction, which is applied to the skeletal system with devices. A molded splint is used for chronic injuries or diseases. A bivalved cast is not applied to the neck.

17. A nurse is caring for a client with a cast on his left leg. Which of the following nursing interventions should the nurse perform to prevent the client from being at risk of peripheral neurovascular dysfunction? A) Elevate the affected leg higher than the client's heart. B) Avoid applying ice packs on the affected area. C) Tell the client to avoid wiggling his toes. D) Encourage the client to eat a diet rich in proteins and calcium.

Ans: A Feedback: Elevating the casted leg higher than the client's heart facilitates venous return of blood from distal areas to the heart. Applying ice packs on the cast over the area of injury and refilling the ice bag every 20 minutes helps to reduce swelling and pain. The nurse should ask the client to wiggle the toes of the affected leg every 15 minutes when awake to avoid stiffening. Exercising the toes also contracts the skeletal muscles, thereby compressing the capillaries and veins, which propels venous blood toward the heart. Encouraging the client to eat a healthy diet is important, but not a priority at this stage.

2. A nurse is assessing the body mass index of a client during a comprehensive assessment. Which of the following variables could the nurse include in a determination of the client's body composition? A) Skin thickness B) Pulse rate C) Blood pressure D) Body temperature

Ans: A Feedback: Factors that determine body composition include anthropometric measurements such as height, weight, body mass index, skinfold thickness, and mid-arm muscle circumference. Body composition is the amount of body tissue that is lean versus the amount that is fat. Pulse rate, blood pressure, and temperature do not determine body composition, but rather a person's vital signs and physical status.

22. An obese client has been advised to begin a program of fitness exercise. In preparation for the program, the nurse has taught the client the concept of metabolic energy equivalents (METs). An understanding of METs allows the client to A) Compare the relative intensity of different forms of activity. B) Match glucose intake to energy needs while exercising. C) Understand the energy needs of the body cells and heart. D) Perform exercise at the time of day when it will have maximum benefit.

Ans: A Feedback: METs allow a comparison of the relative energy demands of different activities; activities assigned higher METs consume more energy and are more vigorous. METs do not directly address glucose needs, cellular metabolism, or the timing of exercise.

2. A nurse is caring for a client whose fractured ankle is in a cast. The client needs crutches to ambulate. Which of the following would help strengthen this client's upper body in preparation for ambulation? A) Modified hand push-ups B) Isotonic exercises C) Parallel bars D) Tilt table

Ans: A Feedback: Modified hand push-ups strengthen the upper arms, thus helping the client to ambulate using crutches. An exercise regimen to strengthen the upper arms typically includes flexion and extension of the arms and wrists, raising and lowering weights with the hands, squeezing a ball or spring grip, and performing modified hand push-ups in bed. Isotonic exercise builds flexibility and stamina more than strength. Clients use parallel bars as hand rails to gain practice in ambulating. A tilt table is a device that helps clients adjust to being upright and bearing weight on their feet.

16. A nurse is helping to remove the leg cast of a client. Which of the following precautions should the nurse take when removing a cast? A) Bivalve the cast with an electric cutter. B) Cut the padding with the electric cutter. C) Use a knife or sharp object to split the cast. D) Soak the cast in water before cutting.

Ans: A Feedback: Most casts are removed with an electric cast cutter--an instrument that looks like a circular saw. The proper use of an electric cast cutter leaves the skin intact. Padding should be cut manually with clean scissors. A blunt knife or forceps should be used to split open the cut cast. A cast is not soaked in water before being cut.

13. A nurse suggests that an elderly client perform his exercises in shallow water at a pool near his home. Which of the following is a benefit for older adults of performing exercise in water? A) Reduces stress to the joints B) Keeps the body cool C) Reduces blood pressure D) Keeps heart rate low

Ans: A Feedback: Performing exercises in the water reduces stress on the joints. Swimming or exercising in water puts less stress on joints and is beneficial for older adults. Exercising in the water may help to keep the body cool, which is not necessary in this case. There is no indication that performing exercises in the water reduces blood pressure. The heart rate is more likely to increase when performing physical activities or exercises, even if the client is performing them in the water.

23. An 80-year-old client has been transferred from the neurological unit to a rehabilitative unit during her recovery from a stroke. The client's nursing care plan includes Risk for Disuse syndrome. What intervention should be performed to address this risk? A) Use a pressure-reducing device on the client's bed. B) Encourage the client to limit mobility in order to conserve energy. C) Provide the client with a low-fat, high-protein diet. D) Teach the client to limit fluid intake to reduce edema.

Ans: A Feedback: Pressure reduction is an important component of preventing disuse syndrome. Mobility should be encouraged, not limited. Fluid restriction and a low-fat diet are not necessarily indicated.

4. A client who tore his quadriceps muscle during a soccer match is being treated at a health care facility. The physician has prescribed exercise for the quadriceps muscles in order to rehabilitate the client. How should the client perform quadriceps setting exercises? A) By alternatively tensing and relaxing the muscles B) By performing modified hand push-ups in bed C) By sitting on the edge of the bed D) By contracting and relaxing the muscles

Ans: A Feedback: The client performs quadriceps setting exercises by alternatively tensing and relaxing the quadriceps muscles. Modified hand push-ups in bed would enable the client to strengthen the upper arms. The client dangles or sits at the edge of the bed in order to normalize blood pressure. Gluteal setting is contraction and relaxation of the gluteal muscles in order to strengthen and tone them.

8. Which of the following ambulatory aids could a nurse suggest to assist a client who has weakness in one side of his body? A) Cane B) Walker C) Axillary crutch D) Forearm crutch

Ans: A Feedback: The nurse could suggest the use of a cane to a client who has weakness in one side of his body in order to aid ambulation. Canes are hand-held ambulatory devices made of wood or aluminum. A walker is used by clients who require considerable assistance with balance. Clients who need brief, temporary assistance with ambulation are likely to use axillary crutches. Forearm crutches are generally used by experienced clients who need permanent assistance with walking.

16. A client with a fractured leg and arm needs to be transferred to the radiology unit. Which of the following nursing guidelines should be followed during client transfer? A) Assess the client's strength and mobility. B) Ask the client to transfer independently. C) Arrange the stretcher next to the client's weaker side. D) Unlock the wheels of the bed, wheelchair, or stretcher.

Ans: A Feedback: The nurse should assess the client's strength and mobility, because doing so helps to determine the need for additional personnel or a mechanical lifting device. Arrange the chair or stretcher next to or close to the bed on the client's stronger side, if there is one, to ensure safety. Locking the wheels of the bed, wheelchair, or stretcher prevents rolling and ensures safety. The client will not likely be able to transfer independently.

15. A nurse is preparing to assist a client to perform exercises in order to prevent ankylosis. What type of exercise should the nurse assist the client with in this case? A) ROM exercises B) Continuous passive motion machine C) Active exercises D) Aerobic exercises

Ans: A Feedback: The nurse should assist the client to perform ROM exercises in order to prevent ankylosis. ROM exercises are therapeutic activities that move the joints. They are performed to assess joint flexibility before initiating an exercise program, maintain joint mobility and flexibility in inactive clients, prevent ankylosis (permanent loss of joint movement), stretch joints before performing more strenuous activities, and evaluate the client's response to a therapeutic exercise program. A continuous passive motion machine is an electrical device used as a supplement or substitute for manual ROM exercise. Active exercise is therapeutic activity that the client performs independently after proper instruction. Aerobic exercise is an isotonic exercise that promotes cardiorespiratory conditioning and increases lean muscle mass.

10. A nurse is a caring for a diabetic client whose right leg had to be amputated below the knee due to the repeated development of osteomyelitis and gangrene. The client uses crutches to ambulate and is waiting to be fitted with a prosthetic leg. What gait should the nurse observe in this client? A) Swing-through B) Four-point C) One-point D) Two-point

Ans: A Feedback: The nurse should observe a swing-through gait in a client whose leg had to be amputated and who is waiting to be fitted with a prosthetic leg. Two-point and four-point gaits require the use of both legs. A one-point gait does not exist.

11. A nurse at a health care facility is caring for clients using crutches to ambulate. In which of the following clients would the nurse observe a four-point walking gait? A) Clients with disabilities such as arthritis or cerebral palsy B) Clients who have normal coordination and balance C) Clients with one amputated, injured, or disabled extremity D) Clients with amputated limbs who are learning to use prosthetic limbs

Ans: A Feedback: The nurse would observe a four-point gait in clients with disabilities such as arthritis or cerebral palsy and who use crutches to ambulate. Clients who have more coordination and balance are more likely to have a two-point gait. A three-point non-weight-bearing gait can be observed in clients with one amputated, injured, or disabled extremity. A client with an amputated limb learning to use prosthesis would have a three-point partial-weight-bearing gait.

4. A nurse is caring for a client who is bedridden following a stroke. The client has been lying in bed for a long time. Which of the following body positions has the highest potential for causing foot drop in a bedridden client? A) Supine B) Prone C) Lateral D) Sims'

Ans: A Feedback: The supine position, in which a person lies on his or her back, creates the potential for foot drop. Foot drop makes the client drag his or her toes on the ground during walking unless a steppage gait is used. The lateral, prone, and Sims' positions do not have as great a potential to create foot drop.

21. A nurse on an orthopedic trauma unit is providing care for a client who has had Buck's traction applied after suffering multiple trauma in a motorcycle accident. The essential characteristic of all types of traction is the application of: A) Pulling force to aid healing or relieve symptoms B) Twisting force to prevent complications of immobility C) Therapeutic pressure on an injured body part D) Pushing injured bones together to promote reunion

Ans: A Feedback: There are several different types of traction, but each involves the therapeutic application of pulling force. Twisting, pressure, and pushing are not main components of traction.

9. A nurse is caring for a client with a fractured wrist that is currently in a cylinder cast. Which of the following actions should the nurse perform to assess the neuromuscular function of the client? A) Monitor the mobility of the fingers. B) Assess the sensation in the exposed fingers. C) Observe the color of the client's nail beds. D) Measure pulse oximetry on an exposed finger.

Ans: A Feedback: To identify the neuromuscular function of the client, the nurse should monitor the mobility of the fingers. Assessing the sensation in the exposed fingers provides data about neurovascular complications. The nurse can observe the color of the nail beds only if he or she compresses them and determines the time for the color to return following blanching.

6. A nurse is caring for a client in Buck's skin traction. Which of the following indicates a need for corrective action? A) The traction weights are touching the floor. B) The traction is being applied continuously. C) The countertraction is opposite to the pull of traction. D) The client's mobility is limited.

Ans: A Feedback: To maintain an effective traction, the traction weight should be suspended without interference and not touching the floor. The nurse should keep the traction applied continuously to get the desired effect unless there are medical orders otherwise. The countertraction must be maintained in a direction opposite to the pull of traction for effective traction. The client's position is limited as per the standards of care to avoid any interference in the traction pull and counterpull action.

18. A nurse has applied a trochanter roll in the care of a client with impaired mobility. What is the purpose of the trochanter roll? A) To prevent the legs from turning outward B) To preserve the functional ability to grasp C) To prevent skin breakdown and wrinkles D) To prevent unnatural curvature of the spine

Ans: A Feedback: Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the head of the femur near the hip. Placing a positioning device at the trochanters helps to prevent the leg from rotating outward. Hand rolls are devices that preserve the client's functional ability to grasp and pick up objects. A roller sheet is a helpful positioning device that prevents skin breakdown. A firm and comfortable mattress is used to permit good body alignment and prevent unnatural curvature of the spine.

1. A nurse is assisting a physician in applying an emergency splint to a client who injured his leg while skateboarding. Which of the following actions should the nurse remember when applying an emergency splint? A) Avoid changing the position of the injured part. B) Remove the client's high-top shoe in case of ankle injury. C) Avoid covering the open wound at the injury site. D) Select a flexible splinting material.

Ans: A Feedback: When applying an emergency splint, the nurse should avoid changing the position of the injured part to prevent additional injuries. The nurse should leave a high-top shoe in place in case of ankle injury to reduce pain and swelling. Open wounds should not be left open but rather should be covered with a clean dressing to prevent dirt and pathogens from entering. The nurse should select rigid splinting material such as a flat board or a broom handle to provide support while restricting movement.

9. A client at a health care facility is to undergo amputation of the left leg due to intractable arterial and vascular ulcers. The client will be fitted with an immediate postoperative prosthesis (IPOP) after the surgery. What are the functions of the IPOP? Select all that apply. A) Reduces stump swelling B) Promotes intact body image C) Promotes early ambulation D) Helps to compress the vein walls E) Helps to absorb wound drainage from the surgical site

Ans: A, B, C Feedback: An IPOP facilitates early ambulation, promotes intact body image, and controls stump swelling in clients who have undergone surgery for amputation. An IPOP does not serve to absorb drainage or compress vein walls.

19. During discharge teaching with a client who has been treated for a hernia, the nurse has discussed the benefits of a regular regime of physical exercise. What benefits of regular exercise should the nurse cite? Select all that apply. A) Decreased low-density blood lipids B) Reduced blood pressure C) Reduced blood glucose levels D) Improved bowel function E) Increased urine concentration

Ans: A, B, C, D Feedback: There are multiple benefits of regular exercise, including cholesterol reduction, decreased blood pressure, reduced blood glucose, and regularity of bowel function. Increased urine concentration, however, is not a noted benefit of physical activity.

22. A nurse is working with an elderly client who possesses numerous risk factors for disuse syndrome. When assessing this client for disuse syndrome, what assessments should the nurse prioritize? Select all that apply. A) Assess the client's cognition. B) Assess the client's bowel elimination patterns. C) Assess the client's temperature and blood pressure. D) Assess the client's current level of mobility. E) Assess the client's skin integrity.

Ans: A, B, D, E Feedback: A potential for disuse syndrome necessitates a comprehensive assessment that includes such elements as cognition, skin integrity, mobility, and bowel elimination. Temperature and blood pressure may be relevant but they are less directly related to the signs and symptoms of this syndrome.

22. A middle-aged male client suffered multiple lower leg injuries after being struck by a vehicle while cycling. The client has had external fixation applied to his left leg as part of his treatment regimen. What client education should the nurse provide to this man? A) "The most important thing is to always make sure that the weights are hanging freely." B) "Together, we'll work on ways to maximize your mobility while you have the device in place." C) "I'll teach you exercises to maintain your strength and circulation while you're restricted to bed." D) "Your fixators will feel intrusive and restrictive at first, but you'll get used to them over the next several months."

Ans: B Feedback: Although the external fixator immobilizes the area of injury, the client is encouraged to be active and mobile. External fixation does not use weights and the fixators are not left in place for several months.

24. A 79-year-old woman who lives independently has been admitted to the emergency department after falling on the ice on the sidewalk outside her house. The nurse should be aware that this client is most likely to have suffered what type of fracture? A) Ankle fracture B) Hip fracture C) Knee fracture D) Rib fracture

Ans: B Feedback: Among older adults, falls frequently result in hip fractures. These injuries are associated with numerous health consequences and are especially common among women. Hip fractures are a more common consequence of falls than rib fractures, knee fractures, or ankle fractures.

23. An adult client and his nurse have collaboratively calculated the client's maximum heart rate for his age. The client has no major health problems but has very minimal experience with performing fitness exercise. The client's target heart rate during exercise should be no more than what approximate percentage of his maximum heart rate? A) 35% B) 50% C) 65% D) 80%

Ans: B Feedback: Beginners should not exceed 50% of maximum heart rate.

20. An older adult has been admitted to a long-term care facility after unsuccessful attempts to continue living independently. The nurse's admission assessment reveals the presence of long, ingrown toenails that appear to contribute to the resident's unsteady gait and decreased mobility. How should the nurse follow up this assessment finding? A) Have the client tested for type 2 diabetes. B) Arrange for the client to be seen by a podiatrist. C) Cut the client's toenails using a sharp blade rather than regular nail clippers. D) Soak the client's feet in Epson salts and trim them short.

Ans: B Feedback: Elderly clients' problematic toenails may warrant referral to podiatry. It may risk complications to cut them very short or with a sharp blade. Clients with diabetes are particularly at risk for foot complications but the presence of long toenails does not suggest the presence of diabetes.

21. A public health nurse has been asked to participate in an initiative that is aimed at promoting the use of ergonomics. What is the most likely goal of this initiative? A) To promote rehabilitation among postsurgical clients B) To promote comfort and health in workplace settings C) To reduce the health consequences of chronic disease D) To increase older adults' awareness of the importance of mobility

Ans: B Feedback: Ergonomics is defined as the field of engineering science devoted to promoting comfort, performance, and health in the workplace. The principles are certainly consistent with the other health goals that are listed, but the primary focus is on the workplace.

13. A nurse is caring for a client with dyspnea. The nurse assists the client into Fowler's position. Which of the following advantages does Fowler's position offer a client with dyspnea? A) It makes it easier for the client to eat, talk, and look around. B) It relieves pressure on the diaphragm, allowing easy breathing. C) It reduces the possibility of developing foot drop. D) It provides good drainage from bronchioles.

Ans: B Feedback: Fowler's position is especially helpful for clients with dyspnea because it causes the abdominal organs to drop away from the diaphragm. Relieving pressure on the diaphragm allows the exchange of a greater volume of air. The lateral position reduces the possibility of foot drop. The prone position provides good drainage from bronchioles, stretches the trunk and extremities, and keeps the hips in an extended position.

4. A nurse is caring for a client with pin insertions in his left thigh. Which of the following actions should the nurse perform to prevent infection to the pin site? A) Avoid removing crusted secretions. B) Avoid applying moisturizing ointment to pin sites. C) Teach the client to cleanse the pin sites. D) Cleanse the skin at the pin sites moving inward.

Ans: B Feedback: In order to prevent infection to the pin site, the nurse should avoid applying ointment to pin sites unless prescribed because it reduces moisture at the site and occludes drainage. The nurse should gently remove crusted secretions because it helps in removing debris that supports the growth of microorganisms. The nurse should teach the client not to touch the pin sites in order to prevent the transmission of pathogens. The nurse should cleanse the skin at the pin sites moving outward in a circular manner to prevent microorganisms from moving toward the areas of open skin.

15. A nurse is assisting a physician who is manipulating a client's fractured arm into its correct alignment. Which type of traction is being applied to the client? A) Skin traction B) Manual traction C) Skeletal traction D) Electric traction

Ans: B Feedback: Manual traction is used to realign a broken bone or replace a dislocated bone into its original position within a joint. Electric traction is done by using alternating current and direct current. Skin traction is a pulling effect on the skeletal system done by applying devices. Skeletal traction is the pull exerted directly on the skeletal system by attaching wires, pins, or tongs into or through a bone.

24. A roller sheet has been placed under an elderly client who is receiving treatment for failure to thrive. When using a roller sheet in a client's care, the nurse must A) Keep the siderails raised to prevent the client from rolling off the side of the bed. B) Ensure that the roller sheet is kept dry and wrinkle-free. C) First ensure that the client is able to roll side-to-side independently. D) Insert an indwelling urinary catheter to protect the roller sheet from urine.

Ans: B Feedback: Nurses use the roller sheet to change the client to an alternate position while avoiding any stooping, reaching, or twisting. The sheet is removed after being used or kept dry and free of wrinkles to prevent skin breakdown. It does not require that the siderails be raised and a client who can move independently is unlikely to require a roller sheet. The sheet must be kept dry but a urinary catheter should not be inserted for this sole reason.

9. A nurse at a health care facility is assisting a client during a prescribed passive therapeutic exercise. Passive exercise is most suitable for which of the following clients? A) Clients who have undergone mastectomy surgery B) Clients who are paralyzed from a stroke or spinal injury C) Clients who have respiratory conditions D) Clients who have had prior cardiac-related symptoms

Ans: B Feedback: Passive exercise is most suitable for clients who are comatose or paralyzed from a stroke or spinal injury. Nurses perform exercises that maintain muscle tone and flexible joints. Active exercise is performed independently by clients who have undergone mastectomy surgery in order to exercise the arm on the surgical side. Isotonic exercise is the activity performed by clients to promote cardiorespiratory conditioning and increase lean muscle. Clients who have had prior cardiac-related symptoms, such as chest pain, or have major health risks use a stress electrocardiogram to assess their heart response to physical activity.

9. A nurse instructs a client with cognitive impairment due to Alzheimer disease to get into the Sims' position. The client, whose word recall is diminished, is unable to understand the instruction. What should the nurse do when instructing clients with cognitive impairment? A) Use illustrations of the desired action to the client. B) Demonstrate the position to convey the message. C) Use simple and clear words when giving instructions. D) Ask the client to use the side rails when moving.

Ans: B Feedback: Since the client's word recall is diminished, the nurse should demonstrate the position to convey the message. Using illustrations, photographs, or simple and clear words to convey the message would also help, but would not be relevant for a client with reduced word recall.

6. A nurse needs to transfer a client who has paraplegia but who has strong arms and upper body muscles from a bed to a stretcher. Which of the following transfer devices will be most suitable for the client? A) Transfer belt B) Transfer board C) Transfer handle D) Transfer bed

Ans: B Feedback: Some clients with strong arm and upper body muscles can use a transfer board independently. Transfer boards are positioned in such a way that the client's buttocks or body can slide across--what would otherwise be an open space or a gap in height between two surfaces. A transfer handle, transfer belt, or transfer bed would not be suitable in this case because the client has polio and his lower body is not active. A transfer belt is used as a walking belt to provide safety and security while assisting a client with ambulation. A transfer handle supports the client's weight when exiting and returning to bed, but in this case, the client is unable to walk independently.

3. A nurse is caring for a client with a strained gluteal muscle at a health care facility. The nurse should understand that which of the following is the primary function of the gluteal muscles? A) Aid in supporting body weight B) Aid in extending the legs C) Aid the client in standing D) Aid in strengthening the upper arms

Ans: B Feedback: The gluteal muscles aid the client in extending the legs. As a group, the gluteal muscles in the buttocks aid in extending, abducting, and rotating the legs; these functions are essential to walking. Exercising the quadriceps enables clients to stand and support their body weight. Exercises such as modified hand push-ups help in strengthening the upper arms.

12. A nurse needs to bathe and clean the fractured arm of a client with a bivalved cast. Which of the following actions is most suitable when removing a bivalved cast? A) Remove both halves of the cast sequentially. B) Remove one half of the shell. C) Obtain a sharply defined x-ray of the arm. D) Assess the fingers for blood circulation.

Ans: B Feedback: The most important action when removing a bivalved cast is to remove half of the shell temporarily for hygiene and assist the client to a prone position when removing the posterior half of the cast, if approved by the physician. Removing both the casts simultaneously can lead to further injury. A sharp x-ray is obtained when the bivalved cast is created--not when it is removed temporarily. To assess the client's fingers for blood circulation is not necessary when removing a cast.

1. A nurse at a care facility assists with numerous aspects of residents' care. Which of the following ergonomic hazards is the nurse likely to face when providing care? A) Assisting with dressing B) Lifting heavy loads C) Carrying medical equipment D) Administering physiotherapy

Ans: B Feedback: The nurse is vulnerable to the ergonomic hazard of lifting a heavy load. Other ergonomic hazards include reaching and lifting loads far from the body, twisting while lifting, and unexpected changes in load demand during a lift, among others. A nurse is not likely to face an ergonomic hazard when assisting the client with dressing, carrying medical equipment, or administering physiotherapy.

11. A nurse needs to frequently document client data in clients' electronic health records. Which of the following ergonomic recommendations should the nurse follow when working at a computer? A) Use assistive devices to avoid twisting the trunk or neck. B) Keep the elbows flexed no more than 100° to 110°. C) Sit on a stool or a backless chair. D) Take frequent breaks and crane the neck slightly.

Ans: B Feedback: The nurse should keep the elbows flexed no more than 100° to 110° or use wrist rests to keep the wrists in a neutral position when working at a computer. The nurse should also work under nonglare lighting to avoid eye strain. Craning the neck sideways is not an ergonomic recommendation. Assistive devices are not relevant to computer work.

18. A nurse is caring for a client who recently underwent hip replacement surgery. Which of the following may benefit this client in order to restore muscle and joint functioning while not exceeding safe limits? A) Active exercises B) Continuous passive motion machine C) Isometric exercises D) Isotonic exercises

Ans: B Feedback: The nurse should suggest a continuous passive motion machine to the client who recently underwent hip surgery. A continuous passive motion machine is an electrical device used as a supplement or substitute for manual ROM exercises. Machine-assisted ROM sometimes is preferred during the rehabilitation of clients who have experienced burns or have had knee or hip replacement surgery, because the machine precisely controls the degree of joint movement and can increase it in specific increments throughout recovery. The other types of exercise do not include specific safety limits on the client's joint motion.

6. When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for in order to ensure safety? A) Length of stride B) Pallor or dizziness C) Upper arm strength D) Tone of lower body muscles

Ans: B Feedback: When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, the nurse should observe the client for pallor, weakness, or dizziness. Strength, gait, and muscle tone would be closely observed by the nurse but these variables do not have such a direct bearing on safety.

18. A 22-year-old woman has begun using axillary crutches following open reduction and internal fixation of an ankle fracture that she suffered during a basketball game. What assessment finding by the nurse should suggest that the client's crutches are fitted correctly? A) The client's elbow joint is locked when she stands upright and grasps the handgrips. B) The client's wrist is slightly hyperextended when she stands upright and grasps her crutches. C) The level of the handgrips is at the client's waist when she stands upright with her crutches. D) The axillary bar is 3 to 4 in. below the client's axilla when she stands upright.

Ans: B Feedback: With axillary crutches, there should be 30 degrees of elbow flexion and slight hyperextension of the wrist when the client is standing in place. The level of the handgrips will be near the client's thigh and the axillary bar should be adjusted within two fingers' space of the axilla.

3. A nurse is collaborating with a cast technician in applying a fiberglass cast to a client. Which of the following is a feature of a fiberglass cast as compared to a plaster of Paris (POP) cast? A) Inexpensive B) Easy to apply C) Durable D) Non-porous

Ans: C Feedback: A fiberglass cast is durable, lightweight, porous, allows immediate weight bearing, and is unaffected by water. It is expensive compared to a POP cast, which is inexpensive. A POP cast is easy to apply but heavy and is prone to cracking and crumbling. Although fiberglass is porous, it is not recommended for severe injuries or those accompanied by excessive swelling.

25. A client's plan of care specifies that he should spend the majority of his time in a high Fowler's position. When following this guideline, the nurse would elevate the client's head at: A) 45° B) 55° C) 60° to 90° D) 75° to 105°

Ans: C Feedback: A high Fowler's position is an elevation of 60° to 90°.

19. A nurse is using a mechanical lift to assist a client with limited mobility. Which client will benefit the most from a mechanical lift? A) An agitated client B) A frail client C) A heavy client D) A pregnant client

Ans: C Feedback: A mechanical lift is best for heavy clients or those with limited mobility. A mechanical lift or repositioning sling is recommended when major repositioning is required.

12. The right leg of a client who was involved in a motor vehicle accident needs to be amputated due to complications. When would a permanent prosthetic limb be constructed for this client? A) As soon as wound drainage ceases B) Four to 6 weeks after the leg has been amputated C) When the stump size stabilizes D) Ten to 12 months after the amputation of the leg

Ans: C Feedback: A permanent prosthetic leg is constructed once the stump size has stabilized. Construction of a permanent prosthesis is delayed for several weeks or months until the wound heals and the stump size is relatively stable. It is the condition of the stump, rather than absolute time, that determines the appropriate point for introducing a permanent prosthesis.

11. A nurse has used a commercial arm sling to support a client's arm. Which of the following functions does a sling perform? A) Reduces muscle spasms B) Reduces transmission of pathogens C) Provides elevation to body parts D) Encloses the client's forearm

Ans: C Feedback: A sling is a cloth device used to elevate, cradle, and support parts of the body. A sling does not reduce transmission of pathogens, but washing hands thoroughly does. Traction is used to reduce muscle spasms with its pulling effect on the affected part of the skeletal system. The sling not only encloses the client's forearm, but also the wrist.

A nurse needs to administer the prescribed fitness test to a client who has had prior cardiac-related symptoms. Which of the following fitness test methods is likely the most suitable for the client? A) Cross-trainer fitness test B) Maximal fitness test C) Ambulatory electrocardiogram D) Stress electrocardiogram/

Ans: C Feedback: An ambulatory electrocardiogram is used when the person has had prior cardiac-related symptoms, such as chest pain, or has major health risks that contraindicate a stress electrocardiogram. It is a less taxing version of a stress electrocardiogram. A stress electrocardiogram tests electrical conduction through the heart during maximal activity and is performed in an acute care facility or outpatient clinic. A cross-trainer fitness test is a normal fitness test done on a cross-trainer fitness machine. A maximal fitness test would tax the client to exhaustion and would be a safety risk.

8. A nurse is caring for a client who is recovering from a hip fracture and who is awaiting surgery. Which device will allow the bedridden client to maintain as much independence as possible? A) Bed cradle B) Bed board C) Trapeze D) Side rails

Ans: C Feedback: An overbed trapeze is an excellent device for helping a bedridden client to increase his or her activity. It is a triangular piece of metal hung by a chain over the head of the bed that the client can grasp to lift the body and move about in bed. Side rails help clients in changing their positions. A bed cradle is used for clients with burns and painful joint diseases. A bed board provides additional skeletal support to the client.

4. A client is wearing a Holter monitor in order to undergo a prescribed ambulatory electrocardiogram. Which of the following precautions should the client take during an ambulatory electrocardiography test? A) Insulate all metal detectors. B) Avoid taking sponge baths. C) Avoid showering or swimming. D) Use an electric blanket rather than heavy cloth blankets.

Ans: C Feedback: During a prescribed ambulatory electrocardiography test, the client should not shower or swim; a sponge bath is permitted as long as the monitor does not get wet. The client also should avoid magnets, metal detectors, electric blankets, and high-voltage areas that may cause artifacts on the recordings that interfere with an accurate interpretation of the test results.

21. After being diagnosed with type 2 diabetes, a client has expressed her intention to "turn over a new leaf" and commit to a vigorous exercise regime. The nurse has emphasized the importance of having her fitness level assessed before beginning the exercise program. What is the main rationale for the nurse's advice? A) To provide a baseline against which to compare improvements B) To determine if the client's fitness matches norms for her age and gender C) To identify any risks for injury that might be posed by an exercise program D) To ensure that the client understands how to carry out the necessary exercises

Ans: C Feedback: Existing health problems can result in injury during exercise. Therefore, before a client begins an exercise program, assessment of his or her fitness level is necessary. This safety measure is more important than establishing baselines or teaching the correct techniques, though these may also be addressed.

13. A nurse is fitting a custom-made knee brace in order to provide stability to the client's unstable knee joint when ambulating. Which of the following support devices is most suitable for the client? A) Invisalign braces B) Prophylactic braces C) Functional braces D) Rehabilitative braces

Ans: C Feedback: Functional braces are most suitable for the client because they can provide stability for an unstable joint. Braces are custom-made or custom-fitted devices designed to support weakened structures. Prophylactic braces are not suitable because they are used to prevent or reduce the severity of a joint injury. Rehabilitative braces allow protected motion of an injured joint that has been treated operatively. Invisalign braces are a type of orthodontic braces that are used to correct the alignment of teeth and their position with regard to bite.

5. A nurse needs to examine the rectum of a constipated client for the presence of stool. The nurse should instruct the client to lie in which position? A) On the back with legs slightly stretched on the bed B) Flat on the stomach with legs slightly stretched to the sides C) On the left side with the right knee drawn up toward the chest D) Flat on the abdomen with slightly outstretched arms

Ans: C Feedback: In the Sims' position, the client lies on her left side with her right knee drawn up toward her chest. This position is used for conducting examinations and procedures involving the rectum and vagina. Prone and supine positions are not typically used for a rectal examination.

17. A nurse at a health care facility is suggesting the use of isometric exercise to a client. What is the major purpose of isometric exercise? A) To prevent ankylosis B) To promote cardiorespiratory conditioning C) To increase lean muscle mass D) To maintain flexible joints

Ans: C Feedback: Isometric exercise consists of stationary exercises generally performed against a resistive force. Isometric exercises increase muscle mass, strength, and tone and define muscle groups. Although they improve blood circulation, they do not promote cardiorespiratory function. The nurse should suggest isotonic exercises in order to maintain cardiorespiratory conditioning and increase lean muscle mass. Passive exercises help to maintain flexible joints. Isometric exercise is not primarily intended to prevent ankylosis.

7. A physician has encouraged an obese client to join an aerobic exercise class to promote cardiorespiratory conditioning, reduce fat, and increase lean muscle mass. Which of the following fitness exercises is most suitable for the client? A) Passive ROM exercises B) Isometric exercise C) Isotonic exercise D) Submaximal exercise

Ans: C Feedback: Isotonic exercise is most suitable for an obese client, as it involves movement and work. The prime example is aerobic exercise, which involves moving all body parts at a moderate to slow speed without hindering the ability to breathe. To promote cardiorespiratory conditioning and increase lean muscle mass, a person should perform isotonic exercise at his or her target heart rate. Isometric exercise does not promote cardiorespiratory conditioning; in fact, strenuous isometric exercises elevate blood pressure temporarily. Passive ROM will not achieve the identified health goals. "Submaximal" is not a category of exercise.

16. A nurse is caring for an elderly client at a health care facility. What problem might a nurse observe in an elderly client as a result of age-related postural changes? A) Use of a four-point gait B) Decreased gluteal setting C) Limited or unsteady mobility D) Appearance of corns or calluses

Ans: C Feedback: Limited or unsteady mobility may be a problem for some older adults as a result of age-related postural changes. Limited or unsteady mobility may lead to the development of a swaying or shuffling gait. A four-point gait is specific to the use of crutches and is not an age-related change. Gluteal setting is a specific exercise that is performed to prepare for ambulation; it is not a problem with mobility.

7. A nurse is caring for an elderly client with an upper extremity fracture. Which of the following therapies is more commonly used with elderly clients than with younger adults to treat fractures of the upper extremities? A) Traction B) An external fixator C) Immobilization D) Acupressure

Ans: C Feedback: Some fractures, particularly of the upper extremities, are treated nonsurgically with immobilization. Occupational and physical therapists are helpful in assisting older adults to regain function and range of motion following any period of immobilization in order to prevent a decrease in or permanent loss of function. An external fixator is a metal device surgically inserted into and through the broken bones of a client to stabilize fragments during healing. Traction is a treatment measure for musculoskeletal trauma and disorders. Acupressure and massage may not be suitable to treat fractures of the upper extremities among elderly clients as they may lead to further complication and injury. Both acupressure and massage involve exertion of physical pressure on the different parts of the body by hand, elbow, or with the aid of various devices.

5. A nurse is assisting a client at a health care facility to dangle before the client ambulates. The nurse assists the client into the Fowler's position for a few minutes. Which of the following is a possible reason for this action? A) To maintain warmth and show respect for the client's modesty B) To allow the client to use the floor for support C) To maintain safety should the client become dizzy or faint D) To help the client tolerate the sitting position

Ans: C Feedback: The nurse places the client in Fowler's position for a few minutes before dangling to maintain safety should the client feel dizzy or faint due to postural hypotension. The nurse lowers the height of the bed so that the client can use the floor for support. The nurse provides the client with a robe and slippers to maintain warmth and show respect for the client's modesty. The nurse helps the client pivot a quarter of a turn to swing the legs over the side and sit on the edge of the bed, which helps the client adjust to a sitting position.

16. A comatose client is being treated in the intensive care unit of a health care facility. What exercises should the nurse assist this client to perform in order to maintain the muscle tone and flexibility of the client's joints? A) Isotonic exercise B) Isometric exercise C) Passive exercise D) Active exercise

Ans: C Feedback: The nurse should assist the comatose client in performing passive exercise in order to maintain muscle tone and flexibility. Passive exercise is a therapeutic activity that the client performs with assistance and is provided when a client cannot move one or more parts of the body. An isotonic exercise is an activity that involves movement and work. Isometric exercise consists of stationary exercises generally performed against a resistive force. Active exercise is therapeutic activity that the client performs independently after proper instruction.

18. A client with a severe muscle spasm in her lower back has been prescribed traction. Which of the following should the nurse confirm before helping to apply traction to the client? A) Number of pulleys B) Availability of gloves C) Prescribed amount of weight D) Infrared heat of the lamp

Ans: C Feedback: The nurse should check the prescribed amount of weight that needs to be applied to create the necessary pulling effect on the affected body part. This is a priority over the number of pulleys or the availability of gloves. Applying infrared heat with a lamp is used to treat pain, but it is not part of traction.

15. A wheelchair-bound client complains of the "hammock effect" each time he sits in the wheelchair. Which of the following devices should the nurse place in the wheelchair to prevent the hammock effect? A) A buttock board B) An upholstered cushion C) A gel or foam cushion D) A plastic molded support

Ans: C Feedback: The nurse should place gel and foam cushions in the wheelchair to prevent the "hammock effect," or the posterior and lateral compression, that occurs when sitting in a slinglike seat. Gel is an alternative substance used to fill cushions and mattresses. It differs from foam in that it suspends and supports the body part. Rigid supports are not used as they would increase the risk of skin breakdown.

7. A nurse at a health care facility suggests the use of parallel bars for a client who has recently been fitted with a prosthetic limb. How would parallel bars most significantly help this client? A) By providing support if the client loses balance B) By improving the client's lower body strength C) By helping the client to practice ambulating D) By enabling the client to increase confidence

Ans: C Feedback: Using parallel bars as hand rails helps the client gain practice when ambulating. Some clients still need assistance to ambulate independently even after performing strengthening exercises. Support, confidence, and lower body strength are secondary considerations in the use of parallel bars, since the major aim is to help the client practice mobilizing.

8. A nurse is assessing the neck injury of a client who has been wearing a cervical collar for over 2 weeks. Which of the following could occur if the client wears the cervical collar for a prolonged period? A) Swallowing difficulty B) Ischemic stroke C) Permanent neck stiffness D) Faster revascularization

Ans: C Feedback: Wearing a cervical collar for a prolonged period can lead to permanent stiffness in the neck. Clients are required to wear cervical collars almost continuously, even while sleeping, for 10 days to 2 weeks. They remove them to do gentle range of motion neck exercises. The sooner a client performs exercise, the faster the revascularization and recovery occurs. A cervical collar does not result in dysphagia or stroke.

15. A nurse is applying a leg prosthesis to a client at a health care facility. Why is it important for the nurse to observe the ease or difficulty of inserting the stump into the socket when applying the prosthesis? A) To determine the client's muscle strength B) To determine if prosthetic maintenance is required C) To check the number of stump socks that are required D) To determine if lubrication of the joints is required

Ans: C Feedback: When applying a leg prosthesis to a client at a health care facility, the nurse observes the ease or difficulty with which the client inserts the stump into the socket in order to determine the number or thickness of stump socks that would be required. The nurse inspects the stump for evidence of bleeding, edema, skin abrasions, and blisters in order to detect any complications that may delay healing and rehabilitation or interfere with ambulation. Joint connections in the prosthetic limbs need to be examined to determine if lubrication or prosthetic maintenance is required.

3. A nurse frequently needs to change the soiled linen and body position of a client who is confined to bed and has a decreased level of consciousness. Which of the following general principles should the nurse follow? A) Fasten drainage tubes to the bed linen. B) Tuck in pillows and positioning devices. C) Raise the bed to the height of the nurse's elbow. D) Change the client's position every half hour.

Ans: C Feedback: When caring for clients, the nurse should raise the bed to the height of his or her elbow. The nurse should also change the position of a client who is confined to bed at least every 2 hours, ask for the assistance of at least one other caregiver, remove pillows and positioning devices, unfasten drainage tubes from the bed linen, and use a low-friction fabric or gel-filled plastic sheet, among other things.

21. An elderly client is being seen at the clinic after experiencing a fall inside his home. He appears to have suffered no ill effects of the fall but his wife has asked the nurse he might benefit from the use of a cane. The nurse should be aware of what criterion for the safe use of a cane? A) The client's weakness must be bilaterally equal. B) The client must be able to support his full body weight on his arms and upper body. C) The client should first demonstrate that a walker does not provide sufficient support during ambulation. D) The client's weakness must be primarily limited to one side of his body.

Ans: D Feedback: A client who has weakness on one side of the body uses a cane. The client does not need to be able to support his or her full body weight with the upper body in order to use a cane safely and effectively. A walker provides more support than a cane.

19. A nurse is liaising with the physical therapist to help a frail, female client up from a dangling position to ambulate for the first time in several days. In preparation, the nurse has applied a walking belt around the client's waist while she dangles at the bedside. This device will assist in what way during the client's ambulation? A) It provides tactile feedback to the client if she exceeds her safe abilities. B) It can be loosely attached to the client's walker to provide support during rest periods. C) It provides support to the client's abdominal muscles to aid stability during ambulation. D) It provides a point where the nurse can support the client in case she loses balance.

Ans: D Feedback: A walking belt is applied around the client's waist. If the client loses balance, the nurse can support him or her and prevent injuries. It is not intended to provide muscular support or tactile feedback to the client. Attaching the belt to the walker would be unsafe and counterproductive.

14. A nurse is observing a client who is lying on an oscillating bed. Which of the following pressure-relieving actions does an oscillating bed offer? A) Maintains capillary pressure B) Prevents skin irritation and maceration C) Promotes a sense of control D) Relieves skin pressure

Ans: D Feedback: An oscillating bed relieves skin pressure and helps to mobilize respiratory secretions. A circular bed promotes a sense of control among otherwise dependent clients. An air-fluidized bed allows the client to "float" and prevents skin irritation and maceration from moisture. A low-air-loss bed maintains capillary pressure well below that which can interfere with blood flow.

20. A nurse is caring for a client with chronic back pain. The client attributes the pain to her teaching job, which involves long hours of standing in the classroom coupled with movements to assist her young students. Which of the following positions can contribute to a good standing posture and relieve the pain? A) Keep the knees locked whenever possible B) Maintain the left hip slightly higher than the right C) Hold the chest slightly backward. D) Distribute weight equally on both feet.

Ans: D Feedback: Distributing weight equally on both feet provides a broad base of support. Maintain the hips at an even level. Bend the knees slightly to avoid straining the joints. Hold the chest up and slightly forward, and extend or stretch the waist to give internal organs more space and maintain good alignment of the spine.

20. A nurse is conducting an admission assessment of a client who has presented to the hospital with complications of pregnancy. The nurse has asked the client to rate her perceived level of fitness. The nurse should be aware that fitness is defined as: A) Resistance to physical injury B) Ability to weight bear C) Objective evidence of cardiac output D) Capacity to exercise

Ans: D Feedback: Fitness means capacity to exercise. Weight-bearing and resistance to injury may be outcomes of fitness but they are not synonymous with it. Increased cardiac output facilitates fitness and is influenced by fitness but is not definitive of the term.

17. A nurse is caring for a client who had a stroke. The client is lying in a supine position and is unable to reach the foot board. What should the nurse do to prevent foot drop in the client? A) Use an adjustable bed. B) Use a water mattress. C) Give a foot massage. D) Use a foot splint.

Ans: D Feedback: If the client is unable to reach the foot board, a foot splint is used. A foot splint allows more variety in body positioning while maintaining the foot in a functional position. If a foot splint or foot board is not available, the nurse can use a pillow and a large sheet. Giving a foot massage or using an adjustable bed or water mattress will not prevent foot drop.

2. A nurse is caring for a client who is in rehabilitation. The nurse observes that the client tends to use incorrect sitting posture. Which of the following sitting positions should the nurse encourage the client to adopt? A) The client's knees should be touching one another. B) Both feet should be on the floor directly below the buttocks. C) The ankles should be slightly extended. D) Buttocks and upper thighs should become the base of support.

Ans: D Feedback: In a good sitting position, the buttocks and upper thighs become the base of support. Both feet rest on the floor. The knees are bent with the posterior of the knee free from the edge of the chair to avoid interfering with distal circulation. The knees should be separated by a small distance to maintain a neutral position. The feet should be flat on the floor; consequently, they would not be directly below the buttocks but would rather be below the position of the knees.

6. A nurse is calculating the maximum heart rate of a 20-year-old client who has undergone a prescribed fitness level test. What should this client's maximum heart rate be? A) 120 beats per minute B) 150 beats per minute C) 170 beats per minute D) 200 beats per minute

Ans: D Feedback: Maximum heart rate is calculated by subtracting a person's age from 220. Thus, a 20-year-old's maximum heart rate is 200 beats per minute (bpm), whereas a 50-year-old client's maximum heart rate is 170 bpm. The target heart rate is 60% to 90% of the maximum heart rate. Beginners should not exceed 60%, intermediates can exercise at 70% to 75%, and competitive athletes can tolerate 80% to 90% of their maximum heart rate.

10. A nurse is assisting a client in performing prescribed range-of-motion (ROM) exercises. What is the main reason that ROM exercises are performed? A) To maintain joint mobility and flexibility in active clients B) To stretch muscles before performing more strenuous activities C) To promote cardiorespiratory function and reduce body fat D) To test a client's ability to weight bear

Ans: D Feedback: ROM exercises are therapeutic activities that move the joints. They are performed to assess joint flexibility before initiating an exercise program, to maintain joint mobility and flexibility in inactive clients, to prevent ankylosis or permanent loss of joint movement, to stretch joints before performing more strenuous activities, and to evaluate the client's response to a therapeutic exercise program. Weight-bearing is not tested with ROM exercises.

12. A nurse is assessing the home environment of an elderly client with limited mobility. What recommendation by the nurse would most likely increase the client's confidence in ambulation in the home environment? A) Placement of scatter rugs to soften the walking surface B) Placement of trapeze handles on pathway C) Installation of nonglare lighting in the pathway D) Strategically placed handrails

Ans: D Feedback: Strategically placed handrails promote confidence in ambulation. Placement of rugs may pose a fall risk. A trapeze is a triangular piece of metal hung by a chain over the head of the bed. It is more useful for bedridden clients. Nonglare lighting increases safety but not necessarily the confidence.

5. A client has been ordered to undergo a step test. Which of the following arrangements is of greatest importance during a step test? A) Reduce the height of the step test machine platform. B) Make arrangements for a metronome and a stopwatch. C) Shorten the test time when the client's heart rate is rapid. D) Make provisions for possible cardiopulmonary resuscitation.

Ans: D Feedback: The most important arrangement that a nurse should make during a step test is to ask for the assistance of personnel certified in cardiopulmonary resuscitation and the use of an automatic cardiac defibrillator if there is an adverse cardiac event. The step test is used with caution; hence, test time is shortened if the client develops discomfort. The examiner uses a metronome and a stopwatch to keep track of the rate and the time, but this is not the most important arrangement. The height of the step test machine platform is prescribed as per the client.

12. A nurse is caring for a client at a health care facility who has been prescribed physical exercises by the physiotherapist. Which of the following beverages should the nurse encourage the client to avoid before or during physical activities? A) Mineral water B) Apple juice C) Pineapple juice D) Black tea

Ans: D Feedback: The nurse should eliminate tea from the diet of older adults before or during physical activities. Older adults need to eliminate their intake of caffeinated and alcoholic beverages before and during physical activity to avoid depleting fluid volume. Water is the preferred drink for fluid replacement, and thus the client is permitted to drink mineral water or juice.

1. A nurse at a health care facility has been assigned the care of an elderly client. For which of the following reasons would the nurse use a tilt table when preparing this client for ambulation? A) To promote the client's muscle tone and strength B) To improve the client's upper arm strength C) To normalize client's blood pressure prior to ambulating D) To help the client adjust to bearing weight on his or her feet

Ans: D Feedback: The nurse would use a tilt table to help the client bear weight on his or her feet. A tilt table is a device that raises the client from a supine to a standing position. It helps clients adjust to being upright and bearing weight on their feet. Dangling helps normalize a client's blood pressure, which may drop when the client rises from a reclining position. The client should perform isometric exercises to improve muscle tone and strength; isotonic exercise would help the client to improve upper arm strength.

14. A nurse is caring for client at a health care facility whose treatment includes therapeutic exercises. Which of the following nursing diagnoses is most likely for this client? A) Ineffective breathing pattern B) Perioperative-positioning injury C) Impaired social interaction D) Delayed surgical recovery

Ans: D Feedback: The nursing diagnosis of delayed surgical recovery should be treated with exercises. Some of the other nursing diagnoses that need to be treated with exercise are impaired physical mobility, disuse syndrome, unilateral neglect, and activity intolerance. The nursing diagnoses of ineffective breathing pattern, perioperative-positioning injury, or impaired social interaction do not require treatment with exercise.

2. A nurse is cleansing the skin around the pin site of a client. Which of the following signs confirms the need to obtain a wound culture? A) Numbness at the site B) Cool temperature at the site C) Swelling distal to the site D) Purulent drainage from the site

Ans: D Feedback: The presence of purulent drainage at the pin site indicates the need to obtain a wound culture. Redness, swelling, and increased tenderness around the pin site are also signs that provide data for current and future comparisons. The nurse should also check if the client has a temperature and pain as it indicates the possibility of infection.

20. A client has had a cylinder cast applied to her tibia after suffering a fracture during a soccer game. What is the primary purpose of a cast? A) To maintain constant tension on injured bones to promote healing B) To temporarily reduce the weight-bearing ability of the injured limb C) To preserve the neurovascular function of the injured limb D) To immobilize injured bones to facilitate reunion

Ans: D Feedback: The purpose of the cast is to immobilize the injured structure. Casts do not provide tension. Maintaining neurovascular function is imperative when a client has a cast in place, but this is not the purpose of the cast itself. Similarly, reduction of weight-bearing undoubtedly occurs, but this is not the central purpose of a cast.

10. A nurse is showing a group of clients the correct way to move their body parts during their daily exercise regimen at a health care facility. Which of the following effects occurs when a person adheres to proper body mechanics? A) Reduced skin breakdown B) Increased peripheral blood perfusion C) Reduced range of motion D) Increased muscle effectiveness

Ans: D Feedback: The use of proper body mechanics increases muscle effectiveness, reduces fatigue, and helps to avoid repetitive strain injuries or disorders that result from cumulative trauma to musculoskeletal structures. Body mechanics alone will not necessarily prevent skin breakdown, or increase circulation. Correct body mechanics have the potential to increase, rather than limit, range of motion.

10. A nurse is caring for a client who developed severely contracted muscles while recovering at home from a stroke. Which of the following splints is most suitable for pulling contracted muscles? A) Emergency splint B) Immobilizer C) Inflatable splint D) Traction splint

Ans: D Feedback: Traction splints are metal devices that immobilize and pull on contracted muscles. Immobilizers are more suitable for injuries to the neck and knee. Inflatable splints are used to limit motion and reduce swelling and blood flow. Emergency splints are basically applied as a first-aid measure with materials such as a board, a broom handle, or a golf club, among other things.

5. A nurse is participating in the application of a fiberglass cast to a client's hand. Which of the following procedures must the nurse avoid when applying premoistened rolls of fiberglass? A) Wash the client's skin with soap and dry it well. B) Cover the skin with a protective padding. C) Administer a pain-relief medication. D) Open all the foil packets at once.

Ans: D Feedback: When using premoistened rolls of fiberglass, the nurse should open the foil packets one at a time to reduce the risk of the material rapidly drying and becoming unfit for use. Regardless of whether the nurse applies a plaster cast or premoistened rolls of fiberglass, the nurse washes the client's skin with soap, dries it well, and covers the skin with a protective padding. The nurse should administer pain-relief medication to the client only if it is prescribed by the physician.