Practice Test Flashcards

The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?

Answer: Halo traction

Halo traction is a type of cervical traction that provides rigid stabilization for cervical fractures and can be worn for an extended period, including at the time of discharge. It allows for patient mobility while maintaining spinal alignment, unlike other forms of traction (like Russell's, Buck's, or Crutchfield tong traction) which are typically used for shorter durations or are more restrictive and not suitable for discharge.

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?

Answer: “The CPM machine controls should be positioned distal to the site.”

CPM machines are designed to provide continuous passive motion to a joint, often post-operatively. Positioning the controls distal to the site allows for easy access and adjustment by the client or nurse without disturbing the surgical area or the machine's primary function. This ensures convenience and minimizes the risk of injury or discomfort during therapy.

Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?

Answer: 12-year-old male with a fractured femur

When assigning roommates, nurses prioritize client safety, age appropriateness, and infection control. A 12-year-old male with a fractured femur is the most suitable choice as he is in a similar age group and has a non-infectious condition, minimizing the risk of cross-contamination and providing a more compatible environment for the 6-year-old.

Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates understanding of the nurse’s teaching?

Answer: “I must flush the tube with water after feedings and clamp the tube.”

Flushing a percutaneous gastrostomy tube with water after feedings is essential to prevent clogging and maintain patency. Clamping the tube afterward prevents leakage of gastric contents and air from entering the stomach, ensuring proper function and client comfort. This indicates a correct understanding of critical gastrostomy tube care.

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?

Answer: Active

The active phase of labor is characterized by more rapid cervical dilation and effacement. A cervix dilated to 5 cm with 75% effacement falls within the typical parameters of the active phase, which generally begins around 4-6 cm dilation and progresses more quickly than the latent phase.

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?

Answer: High-seat commode

After a total hip replacement, clients must adhere to hip precautions, including avoiding hip flexion beyond 90 degrees to prevent dislocation. A high-seat commode elevates the seating surface, ensuring the hip joint remains in a safe position when sitting or standing, thereby assisting with activities of daily living while maintaining precautions.

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?

Answer: The client’s parents are skilled stained-glass artists.

Plumbism is lead poisoning, and exposure to lead is a common cause. Stained-glass artistry involves working with lead solder, which can release lead dust or fumes into the environment. Children living in such households are at a high risk of lead exposure through inhalation or ingestion, making this the most likely related factor.

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:

Answer: Allows 24 hours before bearing weight

Plaster-of-Paris casts require a significant amount of time to fully dry and achieve maximum strength. It typically takes 24 to 72 hours for a plaster cast to dry completely, depending on its thickness and environmental conditions. Bearing weight too soon can deform the cast, compromise immobilization, and potentially injure the client.

After the physician performs an amniotomy, the nurse’s first action should be to assess the:

Answer: Fetal heart tones

After an amniotomy, the most immediate and serious risk is umbilical cord prolapse, which can lead to fetal hypoxia. Therefore, the nurse's first action is to assess fetal heart tones to ensure fetal well-being and detect any signs of distress, such as bradycardia, indicating potential cord compression or prolapse.

The nurse is caring for a client with systemic lupus erythematosus (SLE). The major complication associated with systemic lupus erythematosus is:

Answer: Nephritis

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can affect multiple organ systems. Renal involvement, specifically lupus nephritis, is one of the most serious complications and a major cause of morbidity and mortality in SLE patients, often leading to kidney damage and failure.

The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:

Answer: Offering a pacifier

After a cleft lip repair, it is crucial to protect the surgical site and prevent tension on the delicate sutures. Offering a pacifier involves sucking motions that can put stress on the incision line, potentially disrupting the repair and impairing healing. Therefore, activities involving sucking should be avoided.

The physician has ordered Amoxil (amoxicillin) 500mg capsules for a client with esophageal varices. The nurse can best care for the client’s needs by:

Answer: Requesting an alternate form of the medication

Esophageal varices are fragile, dilated blood vessels in the esophagus that are highly prone to rupture and bleeding. Administering a capsule can cause mechanical irritation or trauma to these varices, significantly increasing the risk of hemorrhage. Requesting an alternate, safer form of medication, such as a liquid, is essential.

The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron?

Answer: Tomatoes

While tomatoes contain vitamin C, which enhances iron absorption, they are not a significant source of iron themselves. Legumes, dried fruits, and nuts are all recognized as good plant-based sources of iron. Therefore, tomatoes are the poor source of iron among the given options.

The nurse is teaching a client with Parkinson’s disease ways to prevent curvatures of the spine associated with the disease. To prevent spinal flexion, the nurse should tell the client to:

Answer: Periodically lie prone without a neck pillow

Parkinson's disease often leads to a characteristic stooped posture with spinal flexion. Lying prone without a neck pillow helps to counteract this flexion by promoting spinal and neck extension, stretching anterior muscles, and maintaining proper alignment. This can help prevent contractures and improve posture.

The nurse is planning dietary changes for a client following an episode of pancreatitis. Which diet is suitable for the client?

Answer: High calorie, low fat

In pancreatitis, the inflamed pancreas has difficulty producing digestive enzymes, especially lipase for fat digestion. A low-fat diet reduces the workload on the pancreas, minimizing enzyme stimulation and decreasing pain. A high-calorie diet is often necessary to meet nutritional needs due to malabsorption and increased metabolic demands.

A client with hypothyroidism frequently complains of feeling cold. The nurse should tell the client that she will be more comfortable if she:

Answer: Dresses in extra layers of clothing

Hypothyroidism causes a decreased metabolic rate, leading to a common symptom of cold intolerance. Dressing in extra layers of clothing provides effective insulation, trapping body heat and helping the client maintain a comfortable body temperature. This is a practical and safe method for managing this symptom.