Question 1

The nurse is caring for a five year-old child who has the left leg in skeletal traction. Which of the following activities would be an APPROPRIATE diversional activity?

Accepted Answer

Answer reason: A child in skeletal traction must avoid activities that involve leg movement or could disrupt alignment. Hand-held games provide distraction and entertainment without risking movement of the affected limb or traction equipment.

Question 2

A simple and cost-effective method for reducing the risk of hypostatic pneumonia in a bedridden patient is?

Accepted Answer

Answer reason: Changing the patient’s position frequently helps improve lung expansion and prevent accumulation of secretions in dependent lung areas, thereby reducing the risk of hypostatic pneumonia. Other listed measures do not directly address stasis of pulmonary secretions.

Question 3

The nurse is caring for a client with a long-leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend?

Accepted Answer

Answer reason: When a limb is immobilized in a cast, isometric muscle-setting exercises maintain muscle strength and circulation without joint movement, preventing atrophy and protecting fracture alignment. Aerobic, isotonic, or range-of-motion exercises would move the joint and are not appropriate for the immobilized extremity.

Question 4

The nurse is observing the ambulation of a client recently fitted with crutches. Which observation requires nursing intervention?

Accepted Answer

Answer reason: Weight should be supported through the hands, with 2–3 finger-widths between the axilla and the crutch top. Bearing weight on the axilla risks brachial plexus injury and requires immediate correction.

Question 5

The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help prepare the child for rehabilitative services?

Accepted Answer

Answer reason: Cerebral palsy affects motor control, including oral-motor function. Using suckers and pinwheels promotes tongue and oral muscle strength and breath control, preparing the child for speech and rehabilitative therapies. Eye patching treats amblyopia, musical tapes offer little motor benefit, and video games are not targeted oral-motor rehabilitation for a 4-year-old.

Question 6

After a tonsillectomy, in what position should a 6-year-old boy who is sleepy but easily awakened be placed?

Accepted Answer

Answer reason: Post-tonsillectomy clients should be positioned to promote drainage of secretions and reduce the risk of aspiration. Side-lying maintains airway patency and allows drainage; supine increases the risk of aspiration.

Question 7

The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who had a stroke 5 days ago. How should the nurse document this finding?

Accepted Answer

Answer reason: Immobility after stroke leads to prolonged pressure over bony prominences; tissue compression that causes localized skin injury is documented as a pressure ulcer. Maceration is moisture-related, abrasion is a superficial scraping, and excoriation results from scratching.

Question 8

A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia, but is easily awakened. The nurse should place the child in which of the following positions?

Accepted Answer

Answer reason: After a tonsillectomy, placing the child in the side-lying position promotes drainage of secretions/blood and helps prevent aspiration and airway obstruction. Supine is contraindicated; prone or side-lying are acceptable, with side-lying preferred.

Question 9

The best position for any procedure that involves a vaginal and cervical examination is?

Accepted Answer

Answer reason: Lithotomy provides optimal exposure and access to the vagina and cervix for examinations and procedures.

Question 10

To assess an immobilized patient, focus on the following, except:

Accepted Answer

Answer reason: Mobility assessment focuses on range of motion, activity tolerance, and body alignment. Psychological condition is important, but not a direct component of assessing mobility itself, making it the exception.

Question 11

In what position is a rectal examination performed on a client?

Accepted Answer

Answer reason: Left lateral Sims' position, with the upper leg flexed, provides optimal exposure of the anus and relaxes the sphincter for rectal examination. Dorsal recumbent, supine, and lithotomy positions are used for other exams (e.g., vaginal/gynecologic).

Question 12

What is the correct position to use during pleural tapping?

Accepted Answer

Answer reason: Thoracentesis (pleural tap) is performed with the patient sitting upright and leaning forward—the orthopneic position—to widen intercostal spaces and allow fluid to collect dependently.

Question 13

Which of the following clients is at highest risk for developing a pressure ulcer?

Accepted Answer

Answer reason: Greatest number of pressure-ulcer risk factors: advanced age, sensory deficit (paresthesia), and moisture from incontinence. Other options have fewer risk factors.

Question 14

The nurse is caring for a client with Parkinson's disease. The client spends more than one hour dressing for scheduled therapies. The most appropriate action for the nurse is to?

Accepted Answer

Answer reason: Clients with Parkinson's should be allowed extra time to perform ADLs to promote independence; hurrying increases stress and worsens motor function.

Question 15

The teenager with a fiberglass cast asks the nurse whether it will be okay to allow his friends to autograph his cast. Which response would be best?

Accepted Answer

Answer reason: Fiberglass casts can be safely signed (e.g., with a felt-tip marker) once dry; autographing will not weaken them. Option B incorrectly refers to plaster, C introduces an irrelevant restriction, and D is false.

Question 16

Which position is given to the patient for a vaginal examination?

Accepted Answer

Answer reason: Vaginal examinations are performed with the patient in the lithotomy position, which provides optimal access with hips and knees flexed and feet supported.

Question 17

A patient who complains of difficulty breathing should be placed in which of the following positions?

Accepted Answer

Answer reason: Fowler's position (upright) promotes maximum lung expansion and reduces work of breathing, making it the best position for dyspnea. Supine, lateral, or prone do not optimize ventilation in respiratory distress.

Question 18

A 35-year-old male client has undergone spinal anaesthesia. The nurse should immediately position the client in which of the following positions?

Accepted Answer

Answer reason: After spinal anesthesia, the client should be kept flat in a supine position to minimize cerebrospinal fluid leakage and post-spinal headache and to maintain hemodynamic stability. Other positions are not recommended immediately post-procedure.

Question 19

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Accepted Answer

Answer reason: MS commonly causes fatigue and variable strength; prioritizing energy conservation by pacing and spacing activities helps prevent overexertion and manages weakness better than bed rest or non-therapeutic measures.

Question 20

A client has an amputation of a lower limb. What instructions should the nurse give the client to prevent a hip flexion contracture?

Accepted Answer

Answer reason: Prone positioning extends the hip and counteracts flexion, preventing hip flexion contracture after lower-limb amputation. Sitting increases hip flexion and should be limited; turning and quadriceps sets do not specifically prevent hip flexion contracture.

Question 21

A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?

Accepted Answer

Answer reason: Hyphema is bleeding into the anterior chamber of the eye. Elevating the head (semi-Fowler’s) helps reduce intraocular pressure and allows blood to settle inferiorly, lowering the risk of complications. Supine or lateral positions are not recommended.

Question 22

A simple and cost-effective method for reducing the risk of hypostatic pneumonia in a bedridden patient is?

Accepted Answer

Answer reason: Hypostatic pneumonia results from stasis of secretions due to immobility. Turning and repositioning frequently promotes lung expansion and drainage of secretions, making it the simplest, most cost-effective prevention. Antibiotics treat infection; nebulization and humidified oxygen do not address stasis from immobility.

Question 23

A 65-year-old client is admitted after a stroke. The nurse is concerned about skin breakdown and decubitus ulcer development. Which nursing intervention would best improve tissue perfusion to prevent skin problems?

Accepted Answer

Answer reason: Turning/repositioning and ROM relieve pressure and enhance blood flow, directly improving tissue perfusion to prevent pressure ulcers. Massaging erythematous areas is contraindicated; assessment and changing pads aid prevention but do not best improve perfusion.

Question 24

The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?

Accepted Answer

Answer reason: Trendelenburg tilts the patient head-down, shifting abdominal viscera cephalad to improve exposure of the lower abdomen and pelvis. Lithotomy is mainly for perineal/rectal/vaginal procedures, Sims’ for rectal interventions, and prone for posterior surgeries.

Question 25

The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?

Accepted Answer

Answer reason: CVA clients may have impaired gag and swallowing; if nausea/vomiting occurs, positioning on the side is the immediate priority to prevent aspiration. Other actions can follow once the airway is protected.

Question 26

A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?

Accepted Answer

Answer reason: Sternal bone marrow aspiration is performed on the anterior chest; placing the client supine provides direct access and stabilization of the sternum.

Question 27

The nurse is caring for a client with myasthenia gravis who is having trouble breathing. The nurse would encourage which of the following positions for maximal lung expansion?

Accepted Answer

Answer reason: Upright or high Fowler's maximizes diaphragmatic excursion and lung expansion, improving ventilation in a client with respiratory muscle weakness from myasthenia gravis. Supine, side-lying, or prone reduce lung expansion and can worsen breathing.

Question 28

When planning the care for a client after a posterior fossa (infratentorial) craniotomy, which action is contraindicated?

Accepted Answer

Answer reason: After infratentorial (posterior fossa) craniotomy, the client is kept flat or side-lying with the neck neutral and turned as a unit; elevating the head of the bed is avoided. Therefore HOB 30° is contraindicated.

Question 29

What is the ideal technique for testing the gag reflex in a patient with diminished cardiovascular reflexes?

Accepted Answer

Answer reason: With a diminished gag reflex the priority is airway protection; positioning the client in a side-lying position reduces aspiration risk during assessment. Offering water is unsafe, CN III/IV/VI are unrelated to gag reflex, and intervention is required.

Question 30

What is the best position to prevent tension on the suture line and edema for a post-thyroidectomy client?

Accepted Answer

Answer reason: After thyroidectomy, placing the client in Semi-Fowler’s with the neck supported reduces venous congestion and minimizes tension on the cervical suture line, preventing edema and stress on the incision.

Question 31

Which of the following is a key nursing intervention to promote graft viability post-operatively?

Accepted Answer

Answer reason: Elevation reduces edema and venous congestion, improving perfusion and helping the graft take. Ice can impair blood flow; frequent dressing changes risk shearing the graft; restricting activity for only 24 hours is insufficient and not the key intervention.

Question 32

Which statement by a patient recovering from Guillain-Barré Syndrome indicates the need for further education?

Accepted Answer

Answer reason: During recovery from Guillain-Barré, activity should be gradual and paced to avoid fatigue and setback; strenuous exercise is inappropriate. Monitoring respiration, attending follow-ups, and knowing residual weakness may persist are correct.

Question 33

What position helps prevent further damage in a patient with suspected retinal detachment?

Accepted Answer

Answer reason: For suspected retinal detachment, minimize eye and head movement to prevent further tearing. Keep the patient on bedrest with the head elevated and the affected eye immobilized/patches until definitive treatment.

Question 34

The nurse suspects the patient is having a seizure. The nurse knows to?

Accepted Answer

Answer reason: Side-lying maintains airway patency and allows secretions to drain, reducing aspiration risk during a seizure. Prone and Fowler’s compromise airway protection, and doing nothing may not ensure safety.

Question 35

What is the correct head position during active epistaxis?

Accepted Answer

Answer reason: During a nosebleed the head should be tilted slightly forward to prevent blood from flowing into the throat and risking aspiration; leaning back or upward is contraindicated.

Question 36

In a baby with myelomeningocele, how should the nurse position the hips and feet to maintain proper alignment?

Accepted Answer

Answer reason: In myelomeningocele, positioning aims to prevent hip subluxation and foot contractures. Abducting the hips and keeping the feet in a neutral position maintains alignment and reduces deformity risk.

Question 37

What is the appropriate position for a postoperative total hip replacement client?

Accepted Answer

Answer reason: Post–total hip replacement, the hip must be kept abducted to prevent dislocation; a pillow or abduction device is used between the legs. Adduction and certain side-lying positions risk dislocation.

Question 38

In which position will the nurse place a client prepared to receive an epidural patch for a postlumbar puncture headache?

Accepted Answer

Answer reason: An epidural blood patch is placed like an epidural injection; the lateral decubitus (side-lying) position with spine flexed provides stability and optimal access to the epidural space.

Question 39

In which position should the nurse place a client prepared to receive an epidural patch for a post-lumbar puncture headache?

Accepted Answer

Answer reason: For an epidural blood patch, the client is typically positioned in a lateral (side-lying) curled position to flex the spine and allow access to the epidural space. Dorsal recumbent and lithotomy are inappropriate; upright may be used but side-lying is the standard preparatory position.

Question 40

When moving the left arm away from the trunk of the body in a client with right-sided stroke, which muscular movement is the nurse performing?

Accepted Answer

Answer reason: Moving a limb away from the body's midline is abduction. Adduction moves toward the midline; rotation turns a part around its axis; inversion applies to the foot.

Question 41

In which position should a client with an ischemic stroke be placed?

Accepted Answer

Answer reason: Elevating the head of the bed 30–45 degrees keeps the head midline, reduces risk of aspiration, and helps limit intracranial pressure after stroke.

Question 42

In which position should a nurse place an 8-year-old child who is sleepy but easily awakened after a tonsillectomy?

Accepted Answer

Answer reason: After tonsillectomy, place the child lateral (or prone) to allow drainage of secretions and reduce risk of aspiration/airway obstruction; avoid supine and Trendelenburg.

Question 43

You were assigned to a patient. Upon assessment, the patient elicited Homan’s sign. What is the nursing priority using this assessment?

Accepted Answer

Answer reason: A positive Homan’s sign suggests possible DVT. The priority nursing focus is to promote venous return and prevent thrombus formation/extension by encouraging good venous circulation. Airway, fluids/electrolytes, and skin care are not the immediate priority for this finding.

Question 44

The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?

Accepted Answer

Answer reason: Multiple myeloma causes bone demineralization and osteoporosis, placing the client at high risk for pathologic fractures; therefore use extreme caution and assist carefully during position changes. Other options are not priority or not typical (e.g., hypercalcemia rather than hyperkalemia).

Question 45

The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which of the following interventions should take PRIORITY in planning care?

Accepted Answer

Answer reason: Clients with spinal cord injury have immobility and decreased sensation, placing them at high risk for pressure injury. The priority is to reduce pressure, shear, and friction by using a pressure-reducing support surface. Hydration, caloric intake, and skin products are helpful but not the first priority for preventing breakdown.

Question 46

The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

Accepted Answer

Answer reason: Immediately after spinal fusion, the spine must be kept aligned and protected; the bed remains flat for at least the first 24 hours and turning is done with logrolling. Early HOB elevation or ambulation risks injury, and leg exercises should start earlier than 48 hours.

Question 47

The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that?

Accepted Answer

Answer reason: Alternating ambulation with periods of bed rest and leg elevation promotes venous/lymphatic return to reduce peripheral edema and helps mobilize ascitic fluid. Continuous bed rest or unrestricted activity without elevation is less effective.

Question 48

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?

Accepted Answer

Answer reason: Correct cast care includes petaling the edges to prevent skin irritation and soiling. A is incorrect (use palms, not fingertips), C is unsafe (avoid heat to dry plaster), and D is inaccurate because plaster typically requires 24–48+ hours before weight bearing.

Question 49

In which of the following positions does a patient lie face down?

Accepted Answer

Answer reason: Prone position is lying on the abdomen with the face down. Dorsal/supine is face up, erect is standing, and lateral is side-lying.

Question 50

In planning discharge teaching for a client after a lumbar laminectomy, the nurse would instruct the client to exercise regularly to strengthen which muscles?

Accepted Answer

Answer reason: Post–lumbar laminectomy teaching emphasizes core strengthening to support the lumbar spine; abdominal muscles stabilize the back and reduce strain. The other muscles do not provide lumbar support for this condition.

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The nurse is caring for a five year-old child who has the left leg in skeletal traction. Which of the following activities would be an APPROPRIATE diversional activity?

A simple and cost-effective method for reducing the risk of hypostatic pneumonia in a bedridden patient is?

The nurse is caring for a client with a long-leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend?

The nurse is observing the ambulation of a client recently fitted with crutches. Which observation requires nursing intervention?

The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help prepare the child for rehabilitative services?

After a tonsillectomy, in what position should a 6-year-old boy who is sleepy but easily awakened be placed?

The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who had a stroke 5 days ago. How should the nurse document this finding?

A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia, but is easily awakened. The nurse should place the child in which of the following positions?

The best position for any procedure that involves a vaginal and cervical examination is?

To assess an immobilized patient, focus on the following, except:

In what position is a rectal examination performed on a client?

What is the correct position to use during pleural tapping?

Which of the following clients is at highest risk for developing a pressure ulcer?

The nurse is caring for a client with Parkinson's disease. The client spends more than one hour dressing for scheduled therapies. The most appropriate action for the nurse is to?

The teenager with a fiberglass cast asks the nurse whether it will be okay to allow his friends to autograph his cast. Which response would be best?

Which position is given to the patient for a vaginal examination?

A patient who complains of difficulty breathing should be placed in which of the following positions?

A 35-year-old male client has undergone spinal anaesthesia. The nurse should immediately position the client in which of the following positions?

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

A client has an amputation of a lower limb. What instructions should the nurse give the client to prevent a hip flexion contracture?

A client arrives in the emergency department following an automobile crash. The client's forehead hit the steering wheel and a hyphema is diagnosed. The nurse should place the client in which position?

A simple and cost-effective method for reducing the risk of hypostatic pneumonia in a bedridden patient is?

A 65-year-old client is admitted after a stroke. The nurse is concerned about skin breakdown and decubitus ulcer development. Which nursing intervention would best improve tissue perfusion to prevent skin problems?

The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?

The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?

A client is scheduled to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?

The nurse is caring for a client with myasthenia gravis who is having trouble breathing. The nurse would encourage which of the following positions for maximal lung expansion?

When planning the care for a client after a posterior fossa (infratentorial) craniotomy, which action is contraindicated?

What is the ideal technique for testing the gag reflex in a patient with diminished cardiovascular reflexes?

What is the best position to prevent tension on the suture line and edema for a post-thyroidectomy client?

Which of the following is a key nursing intervention to promote graft viability post-operatively?

Which statement by a patient recovering from Guillain-Barré Syndrome indicates the need for further education?

What position helps prevent further damage in a patient with suspected retinal detachment?

The nurse suspects the patient is having a seizure. The nurse knows to?

What is the correct head position during active epistaxis?

In a baby with myelomeningocele, how should the nurse position the hips and feet to maintain proper alignment?

What is the appropriate position for a postoperative total hip replacement client?

In which position will the nurse place a client prepared to receive an epidural patch for a postlumbar puncture headache?

In which position should the nurse place a client prepared to receive an epidural patch for a post-lumbar puncture headache?

When moving the left arm away from the trunk of the body in a client with right-sided stroke, which muscular movement is the nurse performing?

In which position should a client with an ischemic stroke be placed?

In which position should a nurse place an 8-year-old child who is sleepy but easily awakened after a tonsillectomy?

You were assigned to a patient. Upon assessment, the patient elicited Homan’s sign. What is the nursing priority using this assessment?

The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?

The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which of the following interventions should take PRIORITY in planning care?

The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that?

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?

In which of the following positions does a patient lie face down?

In planning discharge teaching for a client after a lumbar laminectomy, the nurse would instruct the client to exercise regularly to strengthen which muscles?

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