1. The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
A. Provide manual traction above and below the leg.
B. Cover the bone area with a sterile dressing.
C. Apply an Ace bandage around the entire lower limb.
D. Apply an immobilizer to the area.
2. The nurse has performed nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate a need for further teaching?
A. Broccoli
B. An orange
C. Chocolate cake
D. Fish
3. A 20-year-old with a football injury to the left leg has been instructed in the two-point gait crutch-walking technique. The nurse evaluates the client’s ability to use the crutches correctly when he:
A. Moves both crutches and the left leg in unison.
B. Move the left crutch and the right foot and then the right crutch and the left foot.
C. Moves both crutches forward and both legs swinging through.
D. Moves using the crutch under the left axilla for support.
4. Which client would be at greatest risk for fat emboli following a fracture?
A. A 50-year-old with a fractured fibula
B. A 20-year-old with a wrist fracture
C. A 21-year-old male with a fractured femur
D. An 8-year-old with a fractured arm
5. An elderly female is admitted with a fractured right femoral neck. Which assessment finding is expected?
A. Free movement of the right leg
B. Abduction of the right leg
C. Internal rotation of the right hip
D. Shortening of the right leg
6. The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate effective teaching?
A. “I should take the medication immediately before bedtime”
B. “I should remain in an upright position for 30 minutes after taking the medication”
C. “The medication is more effective if I take it with milk or dairy products”
D. “If I skip a dose, I can take two tablets the next time”
7. The nurse has a client with knee surgery who is receiving patient-controlled analgesia (PCA) of meperidine (Demerol). Which assessment finding would be a priority due to the use of this device and medication?
A. Pulse rate 108
B. 100 cc of green emesis
C. Respiratory rate of 10
D. Lack of pain relief
8. A client with a below-the-knee amputation is experiencing phantom limb pain. Which action by the nurse would be most effective in relieving the pain?
A. Acknowledging the presence of the pain
B. Elevating the stump on a pillow
C. Applying a transcutaneous nerve stimulator unit (TENS)
D. Rewrapping the stump
9. A client is being evaluated for a carpal tunnel syndrome. The nurse is observed asking the client to place the backs of her hands together and flex them at the same time. Which assessment is the nurse performing?
A. Phalen’s maneuver
B. Tinel’s sign
C. Kernig’s
D. Brudzinki’s
10. The nurse is caring for a client recovering from a fracture. Which diet selection would be best for this client?
A. Fried chicken, a loaded baked potato, and a tea
B. A dressed cheeseburger, French fries, and soda
C. Tuna fish salad on sour dough bread, potato chips and skim milk
D. Broiled chicken, Mandarin orange salad and milk
ANSWER RATIONALES
1. Answer B is correct. The client has an open fracture. The priority would be to cover the wound and prevent further contamination. Manual traction should not be attempted, answer A is incorrect. Swelling occurs with a fracture, making answer C an incorrect option. Preventing contamination would have priority over immobilization at this point, so answer D is incorrect.
2. Answer D is correct. Fish should be avoided on a low-purine-diet. Other foods to avoid include poultry, liver, lobsters, oysters, peas, spinach, and oatmeal. Answers A, B, and C are all foods included on a low-purine-diet, which makes them incorrect.
3. Answer A is correct. The two-point gait technique is when both crutches and the affected leg move in unison. The two-point gait permits limited weight bearing bilaterally. Answer B is wrong because it is the three-point gait, and answer C is wrong because it is swing through. Answer D is not named technique for crutch-walking, so it is incorrect.
4. Answer C is correct. Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults age 20-30. Answers A, B, and D are not high-risk incidents and do not fall in the greater risk category, so they are incorrect.
5. Answer D is correct. The symptoms of this fracture include shortened, abducted, and external rotation. Answer A is incorrect because the patient usually is unable to move the leg due to pain. Answer B is incorrect because the symptom is adduction, not abduction. Answer C is wrong because it’s external rotation, not internal rotation.
6. Answer B is correct. This is required to prevent esophageal problems. The medication should be taken in the morning before food or other medications, making it answer A incorrect. It should be taken with water; makes answer C and D incorrect option.
7. Answer C is correct. The patient is in danger of respiratory depression due to narcotic administration; therefore, this would be a priority assessment. Answer A does not relate to the PCA, so it’s incorrect. Answer B is not a priority, making it wrong. Pain relief in answer D would be important, but not as important as airway, so it’s incorrect.
8. Answer C is correct. The TENS unit is applied for pain relief. This is the only option that actually does anything about the pain the client is experiencing. Answers A, C, and D all might help the pain, but answer C would help more, so those answers are wrong.
9. Answer A is correct. The test is used to check for paresthesia in the median nerve. An abnormal result would be paresthesia within 60 seconds of performing the test. Answer B is incorrect because it is another test used in which the nurse taps over the median nerve in the wrist or uses a BP cuff inflated to the patient’s systolic pressure, resulting in pain and tingling. Answer C and D are both incorrect because these are methods of assessment for meningeal irritation and have nothing to do with carpal tunnel.
10. Answer D is correct. This diet selection is the most balanced and the best to promote healing. Answers A, B, and C are not as inclusive as answer D, so they’re incorrect.
