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Nursing model question paper 5
1.The patient has been admitted for hypertension. His
blood pressure is normally in the 160/90 range. He has been on bed rest for the
past few days, and the doctor has started him on a new blood pressure
medication. The nurse is assisting the patient to move from the bed to the
chair for breakfast, but when the patient tries to sit up on the side of the
bed, he complains of being dizzy and nauseous. The nurse lays the patient down
and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This
blood pressure is indicative of what?
a. A normal blood pressure for this patient
b. Orthostatic hypotension
c. Orthostatic hypertension
d. Effective baroreceptor function
ANS: B
2. The patient is an elderly gentleman who has been on
bed rest for the past several days. When getting the patient up, the nurse
should:
a. tell the patient not to move his legs when
dangling.
b. tell the patient to hold his breath while dangling.
c. raise the head of the bed and allow a few minutes
before dangling.
d. have the patient stand without dangling.
Ans: C
3. An appropriate technique for the nurse to use when
performing range of motion (ROM) exercises is to:
a. repeat each action five times during the exercise.
b. perform the exercises quickly and firmly.
c. support the proximal portion of the extremity being
exercised.
d. continue the exercise slightly beyond the point of
resistance.
Ans: A
4. A patient is admitted to the medical unit following
a cerebrovascular accident (CVA). Evidence of left-sided hemiparesis is noted,
and the nurse will be following up on ROM and other exercises performed in
physical therapy. The nurse should correctly teach the patient and family
members which of the following principles of ROM exercises?
a. Flex the joint to the point of discomfort.
b. Medicate the patient after the ROM exercise
session.
c. Move the joints quickly.
d. Provide support for distal joints.
Ans: D
5. A nurse should be concerned when observing a
patient performing isometric exercises if the patient is:
a. holding his or her breath while exerting.
b. performing the exercises four times per day.
c. tightening each muscle group for 8 seconds, then
relaxing.
d. repeating each exercise 8 to 10 times for each
muscle group.
Ans: A
6. A nurse encourages a patient to prevent venous
stasis by:
a. crossing the legs when sitting in a chair.
b. wearing thigh-length nylon stockings or garters.
c. elevating the legs on pillows while in bed.
d. increasing early ambulation.
Ans: D
7. Antiembolic stockings (TEDs) are ordered for the
patient on bed rest after surgery. The nurse explains to the patient that the
primary purpose for the elastic stockings is to:
a. keep the skin warm and dry.
b. prevent abnormal joint flexion.
c. apply external pressure.
d. prevent bleeding.
Ans: C
8. When assessing the patient for risk for DVT, the
nurse should consider which of the following an indicator of increased risk?
a. A positive Homans’ sign
b. Pallor to the distal area
c. Edema noted in the extremity
d. Fever or dehydration
Ans: D
9. An appropriate procedure for the nurse to use when
applying an elastic stocking is to:
a. remove the stockings every 24 hours.
b. keep the tops of the stockings rolled down
slightly.
c. turn the stocking inside out to apply from the toes
up.
d. wash stockings daily and dry in a dryer.
Ans: C
10. When using an SCD, the nurse should:
a. apply powder to the patient’s skin if redness and
itching are present.
b. leave a two-finger space between the patient’s leg
and the compression stocking.
c. keep the patient connected to the compression
device when transferring into and out of bed.
d. remove the elastic stockings before putting on the
sequential pneumatic compression stockings.
Ans: B
11. The patient is a paraplegic who possesses good arm
and hand strength. When the following devices are compared, which would be most
appropriate for this patient?
a. Axillary crutch
b. Platform crutch
c. Lofstrand crutch
d. Standard crook cane
Ans: C
12. An appropriate way for the nurse to measure a
patient for crutches is to:
a. have a flexion of 45 degrees at both of the
patient’s elbows.
b. have a space of two to three fingers between the
top of the crutch and the axilla.
c. place the crutch tips 1 foot to each side of the
patient’s feet, and observe the positioning of the crutches.
d. place the crutch tips 1 foot to the front of the
patient’s feet, and observe the positioning of the crutches.
Ans: B
13. The patient has been using crutches for the past 2
weeks. When she comes for her follow-up examination, she complains of tingling
and numbness in her hands and upper torso. Possible causes of these symptoms
are:
a. the patient’s elbows are flexed 15 to 30 degrees
when using the crutches.
b. crutch pad is approximately 2 inches below the
patient’s axilla.
c. patient holds the cane 4 to 6 inches to the side of
her foot.
d. handgrip does not allow for elbow flexion.
Ans: D
14. The patient has a leg injury and is being fitted
for a cane. The patient should be taught to:
a. hold the cane on the uninvolved side.
b. hold the cane on the weaker side.
c. extend the cane 15 inches from the foot when used.
d. maintain approximately 60 degrees of elbow flexion.
Ans: A
15. While ambulating, the patient becomes light-headed
and starts to fall. What should the nurse do first?
a. Call for help.
b. Try to reach for a chair.
c. Ease the patient down to the floor.
d. Push the patient back toward the bed.
Ans: C
16. When the four gaits listed below are compared,
which is the most stable of the crutch gaits?
a. Four-point gait
b. Three-point gait
c. Two-point gait
d. Swing-to gait
Ans: A
17. The nurse is caring for a patient who has just
been treated for a broken leg. She needs to teach the patient how to use
crutches. Which crutch gait is most appropriate for this patient?
a. Four-point gait
b. Three-point gait
c. Two-point gait
d. Swing-to gait
Ans: B
18. When teaching the use of a three-point crutch
gait, the nurse should instruct the patient to move:
a. both crutches and the affected leg first, then the
stronger leg.
b. the right crutch, left foot, left crutch, and right
foot in sequence.
c. the left crutch and right foot, then move the right
crutch and left foot.
d. both crutches, then lift and swing the legs forward
as far as the crutches.
Ans: A
19. A patient with left hemiparesis is using a quad
cane for ambulation. Which of the following is the correct technique for the
nurse to use in teaching the patient?
a. Use the cane on the right side, with the cane
moving forward first.
b. Use the cane on the left side, with the left leg
moving forward with the cane.
c. Use the cane in either hand, with the right leg
moving forward first.
d. Use the cane in either hand, with the left leg
moving beyond the forward placement of the cane.
Ans: A
20. The patient had a stroke and is currently
immobile. The nurse realizes that increasing mobility is critical because
immobility can result in alterations in which of the following? (Select all
that apply.)
a. Cardiovascular function
b. Pulmonary function
c. Skin integrity
d. Elimination
Ans: ALL OF THE ABOVE
21. The nurse is caring for an immobile patient. Which
of the following may help reduce the hazards associated with immobility? (Select
all that apply.)
a. A high-fiber diet
b. Frequent repositioning
c. Muscle and joint exercises
d. Increased fluid intake
Ans: ALL OF THE ABOVE
22. The nurse is applying a CPM machine to the
patient’s leg. To do so, she must: (Select all that apply.)
a. provide analgesia 1 hour before starting the CPM.
b. stop the CPM when in extension and place a
sheepskin on the machine.
c. align the patient’s joint with the CPM’s mechanical
joint.
d. secure the patient’s extremity tightly with Velcro
straps.
Ans: B, C
23. Factors that contribute to the development of DVT
are: (Select all that apply.)
a. elevated sodium (Na+) levels.
b. hypercoagulability of the blood.
c. venous wall damage.
d. stasis of blood flow.
Ans: B, C, D
24. ____________ refers to an ability to move about freely.
Ans:Mobility
25. A person’s inability to move about freely is known
as _______________.
Ans: Immobility
26. A drop in blood pressure that occurs when the
patient changes position from a horizontal to a vertical position is known as
_________________.
Ans: Orthostatic Hypotension
27. A drop in blood pressure that occurs when the
patient changes position from a horizontal to a vertical position is known as
_________________.
Ans: Orthostatic Hypotension
28. The patient is performing ROM exercises
independently. These are known as __________ exercises.
Ans: Active ROM
29. Static exercises that involve tightening or
tensing of muscles without moving a body part are known as ______________.
Ans: Isometric Exercises
30. _________________ increase muscle tension but do
not change the length of muscle fibers
Ans: Isometric Contractions
31. Virchow’s triad (hypercoagulability of blood,
venous wall damage, and stasis of blood flow) has been found to contribute to
________________.
Ans: DVT
32. The nurse is concerned that the patient may fall
while he is ambulating. To help her maintain control while the patient walks,
the nurse may apply a ______________ around the patient’s waist.
Ans: Gait Belt -Booorrriiinnnggggg
33. The nurse is concerned that the patient may fall
while he is ambulating. To help her maintain control while the patient walks,
the nurse may apply a ______________ around the patient’s waist.
Ans: Gait Belt -Booring
34. According to the National Association of
Orthopaedic Nurses (NAON), which of the following is possibly the most
effective cleansing solution for pin-site care?
a. Normal saline
b. Hydrogen peroxide
c. Chlorhexidine
d. None of the above
Ans: C
35. The patient has a broken leg and needs to have a
cast applied. When plaster of Paris is compared and contrasted versus the newer
synthetic casts, which of the following statements is true?
a. Plaster of Paris can tolerate earlier weight
bearing than synthetic casts.
b. Plaster of Paris is more expensive than synthetic
casts.
c. Synthetic casts can withstand contact with water
better than plaster of Paris.
d. Synthetic casts are lighter but take longer to set
than plaster of Paris.
Ans: C
36. An expected outcome of cast application that the
nurse evaluates is:
a. skin irritation at the cast edges.
b. decreased capillary refill and pallor.
c. tingling and numbness distal to the cast.
d. slight edema, soreness, and limited range of
motion.
Ans: D
37. The patient is admitted for a fractured tibia. The
nurse is preparing for cast application and expects to administer a(n) _____ to
the patient minutes before the procedure.
a. oral analgesic 10
b. intramuscular (IM) analgesic 10
c. intravenous (IV) analgesic 2 to 5
d. muscle relaxant 10
Ans: C
38. An appropriate technique for the nurse to
implement for the patient who is being casted is to:
a. apply ice to the top of the cast.
b. maintain the extremity below heart level.
c. handle the wet cast with the fingertips.
d. fold the stockinette or padding over the outer cast
edges.
Ans: D
39. When teaching cast care, the nurse instructs the
patient to:
a. blow dry the wet cast on the “hot” setting.
b. report changes in sensation or mobility to the
area.
c. use only soft objects to slide down the cast for
scratching.
d. cut away the edges of the cast if the skin becomes
irritated.
Ans: B
40. For cast removal, which of the following
instructions should the nurse provide to the patient?
a. Discomfort will be felt from the cast saw.
b. An enzyme wash may be applied to intact skin.
c. The skin will be scrubbed very well after the
removal.
d. Aggressive range-of-motion exercises will be
performed after removal.
Ans: B
41. The patient is brought into the emergency
department after falling on the ice in her driveway. She is suspected of having
a fractured hip. After comparing different available types of traction, she anticipates
that which of the following will be used?
a. Bryant’s traction
b. Dunlop’s traction
c. Buck’s extension
d. Gallows traction
Ans: B
Buck’s extension provides temporary immobilization of
a hip fracture until open reduction and internal fixation (ORIF) can be
performed. It also reduces muscle spasms, contractures, and dislocations and
occasionally is used as an interim treatment for lumbosacral muscle spasms that
cause low back pain. Bryant’s traction (called Gallows in England) is no longer
used because of the risk for gravitational vascular draining of the extremities
and the possible tourniquet effect of bandages, triggering vasospasms and
avascular necrosis. Dunlop’s traction is a simultaneous horizontal form of
Buck’s extension to the humerus with an accompanying vertical Buck’s extension
to the forearm.
42. Which type of traction does the nurse anticipate
will be used for an adult patient with a fractured humerus?
a. Bryant’s traction
b. Dunlop’s traction
c. Gallows traction
d. Buck’s extension
Ans: B
Dunlop’s traction is a simultaneous horizontal form of
Buck’s extension to the humerus with an accompanying vertical Buck’s extension
to the forearm. Bryant’s traction (called Gallows in England) is no longer used
because of the risk for gravitational vascular draining of the extremities and
the possible tourniquet effect of bandages, triggering vasospasms and avascular
necrosis. Buck’s extension provides temporary immobilization of a hip fracture
until ORIF can be performed. It also reduces muscle spasms, contractures, and
dislocations and occasionally is used as an interim treatment for lumbosacral
muscle spasms that cause low back pain.
43. For a patient who is to be placed in Russell’s
traction, the nurse prepares the:
a. occipital area.
b. arm and forearm.
c. back and abdomen.
d. lower extremities.
Ans: D
Russell’s traction is a modification of Buck’s
extension in which Newton’s third law of motion (for each force in one
direction, there is an equal force in the opposite direction) is used to double
the amount of pull through the arrangement of ropes, pulleys, and weights.
44. The nurse places the patient in traction. Expected
outcomes would include which of the following?
a. Alignment of fracture fragments with formation of
callus within 24 hours
b. Verbalization of pain level as a “4” on a scale of
0 to 10
c.Distal skin tissue becoming cooler, with capillary
refill greater than 3 secondsVerbalization of immediate relief of symptoms
Ans: B
45. While in Buck’s extension traction, the patient
may be positioned on the back:
a. with the head of the bed elevated 45 degrees.
b. turning to the unaffected side for 10- to 15-minute
periods.
c. with the buttocks slightly elevated off of the bed.
d. with the bed tilted toward the side that is
opposite the traction.
Ans: B
46. An appropriate technique for the nurse to
implement for a patient who is being placed in traction is to:
a. apply a traction boot tightly.
b. drop the weights after the traction is attached.
c. assess neurovascular status every 1 to 2 hours for
the first day.
d. shave the hair off the area where traction is to be
placed.
Ans: C
47. For a patient in traction who has skeletal pins,
the nurse should:
a. use povidone-iodine to cleanse the pin site.
b. apply antiseptic ointment and cover with a split
dressing.
c. use hydrogen peroxide as a rinse before a dressing
is applied.
d. do both pin sites at the same time, with the same
swab and solution.
Ans: B
48. For a patient with a fractured femur, a nurse is
alert to the possibility of a fat embolus. What should the nurse specifically
watch for?
a. Bradypnea
b. Restlessness
c. Bradycardia
d. Calf pain
Ans: B
49. In planning nursing care, the nurse knows that she
will need to provide an abduction pillow for which patient?
a. A patient who will be immobilized for a long time
b. A patient who has undergone repair of a fractured
right arm
c. A patient who is post hip replacement surgery
d. A patient who has a severely sprained ankle
Ans: C
50. The nurse is caring for a patient who has had a
new cast applied. The nurse is performing a neurovascular assessment so as to
detect signs of possible compartment syndrome. Which of the following are signs
of compartment syndrome? (Select all that apply.)
a. Inability to move body parts distal to the cast
b. Pain on passive motion of distal body parts
c. Hyperventilation
d. Tachycardia
Ans: ALL OF THE ABOVE
51. The patient is in traction and is at risk for fat
embolism syndrome. Signs and symptoms of fat embolism include which of the
following? (Select all that apply.)
a. Chest pain
b. Tachypnea
c. Tachycardia
d. Apprehension
e. Altered LOC
Ans: ALL OF THE ABOVE
53. The patient has been in skeletal traction for
external fixation of his femur for 2 days. Suddenly, he calls the nurse
complaining of chest pain and shortness of breath. The nurse notes that the
patient appears anxious, and that his pulse and respirations are elevated. She
should do which of the following? (Select all that apply.)
a. Massage the lower extremity
b. Elevate the head of the bed
c. Administer oxygen
d. Notify the physician
Ans: B, C, D
54. Skeletal traction is implemented primarily for:
(Select all that apply.)
a. simple fracture.
b. multiple trauma.
c. fractured ankle.
d. acetabular fracture.
e. cervical fracture.
Ans: B, C, D, E
55. __________________ involves monitoring for the
five Ps (pain, pallor, pulselessness, paresthesia, and paralysis).
Ans: Neurovascular Assessment
56. The patient has fallen and broken her leg. To keep
the leg bones aligned and to reduce muscle spasms, the physician orders the
patient to be placed in ____________.
Ans: Buck's Traction
57. A _______________ is an externally applied
structure that holds musculoskeletal tissues in a specific position to permit
healing of injuries or fractures or to align malpositioned tissues.
Ans: Cast
58. After application of the cast, the nurse ensures
that plaster crumbs are removed and rough edges are _________ to prevent skin
breakdown.
Ans: petaled
59. When applying a plaster of Paris cast, it is
important to keep the cast exposed for at least _____________ minutes.
Ans: 15 min
60. After applying a cast, the nurse should be able to
insert _______ fingers between the cast and the limb.
Ans: 2
61. _________________ may occur when pressure within a
casted extremity increases.
Ans: Compartment Syndrome
62. _____________________ applies a pull indirectly to
the bone via straps attached to the skin around the structure.
Ans: Skin Traction
63. ____________________ consists of a metal frame
that secures pins inserted through the bone above and below the fracture site.
It stabilizes a fracture with hardware visible outside the body.
Ans: External Fixation
64. An immobilization device used to immobilize and
protect a body part is known as a ________.
Ans: Splint
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