NCLEX-RN Practice Test 9
The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?
Halo traction will be ordered for the client with a cervical fracture. Options A and B: Russell’s traction is used for bones of the lower extremities, as is Buck’s traction. Option D: Crutchfield tongs are used while in the hospital and the client is immobile.
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?
The controller for the continuous-passive-motion device should be placed away from the client. Many clients complain of pain while having treatments with the CPM, so they might turn off the machine. The CPM flexes and extends the leg. Option A: The client is in the bed during CPM therapy. Option C: The client will experience pain with the treatment. Option D: Use of the CPM does not alleviate the need for physical therapy.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?
The 6-year-old should have a roommate as close to the same age as possible, so the 12-year-old is the best match. Option A: The client is too old and is female. Option C: The 10-year-old with sarcoma has cancer and will be treated with chemotherapy that makes him immune suppressed Option D: The 6-year-old with osteomyelitis is infectious.
Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?
The client’s family member should be taught to flush the tube after each feeding and clamp the tube. Options B and C: The placement should be checked before feedings, and indigestion can occur with the PEG tube, just as it can occur with any client. Option D: Medications can be ordered for indigestion, but it is not a reason for alarm. A percutaneous endoscopy gastrostomy tube is used for clients who have experienced difficulty swallowing. The tube is inserted directly into the stomach and does not require swallowing.
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?
The active phase of labor occurs when the client is dilated 4–7cm. Options B and D: The latent or early phase of labor is from 1cm to 3cm in dilation. Options C: The transition phase of labor is 8–10cm in dilation.
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?
The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. Option B: The recliner is good because it prevents 90° flexion but not daily activities. Option C: A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management. Option D: An abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis.
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?
Plumbism is lead poisoning. One factor associated with the consumption of lead is eating from pottery made in Central America or Mexico that is unfired. The child lives in a house built after 1976 (this is when lead was taken out of paint), and the parents make stained glass as a hobby. Stained glass is put together with lead, which can drop on the work area, where the child can consume the lead beads. Option A: Traveling out of the country does not increase the risk of plumbism. Option C: The house was built after the lead was removed with the paint. Option D: Having several siblings is unrelated to the stem.
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 plaster-of-Paris cast takes 24 hours to dry, and the client should not bear weight for 24 hours. Option A: The cast should be handled with the palms, not the fingertips. Option B: Petaling a cast is covering the end of the cast with cast batting or a sock, to prevent skin irritation and flaking of the skin under the cast. Option C: The client should be told not to dry the cast with a hair dryer because this causes hot spots and could burn the client. This also causes unequal drying.
After the physician performs an amniotomy, the nurse’s first action should be to assess the:
When the membranes rupture, there is often a transient drop in the fetal heart tones. The heart tones should return to baseline quickly. Any alteration in fetal heart tones, such as bradycardia or tachycardia, should be reported. Options A, C, and D: After the fetal heart tones are assessed, the nurse should evaluate the cervical dilation, vital signs, and level of discomfort.