Question 1

What position is best to promote oxygenation for an unconscious post-op client breathing shallowly?

Accepted Answer

Answer reason: The lateral (recovery) position with jaw support maintains airway patency in an unconscious client, helps prevent tongue obstruction and aspiration, and promotes ventilation after anesthesia.

Question 2

In palpating the client's abdomen, Which of the following is the best position for the client to assume?

Accepted Answer

Answer reason: Dorsal recumbent (supine with knees flexed) relaxes abdominal muscles, facilitating accurate palpation. Side-lying and lithotomy are inappropriate; flat supine can increase muscle tension.

Question 3

What is a complication of prolonged bed rest?

Accepted Answer

Answer reason: Immobility causes venous stasis, predisposing to deep vein thrombosis. Muscle strengthening and improved circulation are not complications of bed rest.

Question 4

What is the best position during a vaginal examination or procedure?

Accepted Answer

Answer reason: Lithotomy provides optimal exposure of the perineum and vagina, making it the standard position for vaginal examinations and procedures.

Question 5

The Norton scale is used to assess the risk of which condition?

Accepted Answer

Answer reason: The Norton scale evaluates factors like physical condition, mental state, activity, mobility, and incontinence to predict a patient’s risk for developing pressure ulcers.

Question 6

The nurse is caring for a client following a right nephrolithotomy. Post-operatively, the client should be positioned?

Accepted Answer

Answer reason: After kidney surgery on the right side, position the client on the nonoperative side to avoid pressure on the operative kidney and to promote drainage. Supine or prone are not preferred; right side is contraindicated.

Question 7

A newborn is diagnosed with respiratory distress syndrome (RDS). Which position is best for maintaining an open airway?

Accepted Answer

Answer reason: Newborn airway patency is best maintained in the sniffing position—supine with slight neck extension. Flexion can obstruct the airway; prone or side-lying are not preferred for airway maintenance.

Question 8

The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should?

Accepted Answer

Answer reason: Plaster-of-Paris casts should air-dry without heat sources. Frequent turning promotes even drying and prevents pressure areas. Using heaters or hair dryers can cause burns and uneven, cracked cast surfaces; allowing one side to fully dry first increases pressure risk.

Question 9

The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should?

Accepted Answer

Answer reason: First ambulation postpartum poses a risk of orthostatic hypotension. Dangling at the bedside allows cardiovascular adjustment before standing, reducing fall risk. The other actions are not required prior to first ambulation.

Question 10

The home health nurse is visiting a client with an exacerbation of rheumatoid arthritis. To prevent deformities of the knee joints, the nurse should?

Accepted Answer

Answer reason: In rheumatoid arthritis, gentle range-of-motion and activity within pain limits maintain joint function and prevent flexion contractures. Prolonged bed rest or sitting with knees flexed increases deformity risk; walking without bending knees is unrealistic.

Question 11

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

Accepted Answer

Answer reason: For cervical spine fractures, ambulatory immobilization at discharge is provided by a halo vest/halo traction. Buck’s and Russell’s are lower-extremity skin tractions, and Crutchfield tongs are acute in-hospital cervical traction.

Question 12

To maintain Bryant's traction, the nurse must make certain that the child's?

Accepted Answer

Answer reason: Bryant's traction for young children requires hips/buttocks slightly elevated off the bed to provide countertraction and both legs suspended vertically at 90 degrees to the body.

Question 13

Which factors of the Braden Scale should be considered in assessing a 75-year-old female patient's risk for pressure ulcers after hip surgery?

Accepted Answer

Answer reason: The Braden Scale includes sensory perception, moisture, activity, nutrition, mobility, and friction/shear. Age is not a Braden subscale.

Question 14

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?

Accepted Answer

Answer reason: Prone lying without a pillow promotes spinal extension and counteracts the flexed posture of Parkinson's disease. The other positions encourage or do not correct flexion.

Question 15

A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to?

Accepted Answer

Answer reason: Prone positioning promotes hip and knee extension and helps prevent or reduce knee flexion contractures. The other positions encourage joint flexion or malalignment.

Question 16

A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client?

Accepted Answer

Answer reason: Left lateral position relieves uterine pressure on the inferior vena cava, improving venous return and uteroplacental perfusion—especially important in pregnancy-induced hypertension. Supine can worsen vena cava compression; right side and knee-chest are not preferred.

Question 17

To prevent deformities of the knee joints in a client with an exacerbation of rheumatoid arthritis, the nurse should?

Accepted Answer

Answer reason: Gentle range-of-motion within pain limits maintains joint mobility and prevents contractures in RA flares. Prolonged bed rest or immobilization increases stiffness and deformity risk; passive ROM does not inherently worsen swelling.

Question 18

The nurse is caring for a client with an above-the-knee amputation (AKA). To prevent contractures, the nurse should?

Accepted Answer

Answer reason: After an above-the-knee amputation, prone positioning several times daily stretches the hip flexors and helps prevent hip flexion contractures. Elevating the limb or foot of bed promotes flexion and should be avoided; trochanter rolls are not the primary intervention for contracture prevention.

Question 19

A client with breast cancer is returned to the room following a right total mastectomy. The nurse should?

Accepted Answer

Answer reason: After mastectomy, the affected arm should be elevated to promote lymphatic drainage and reduce edema. A dependent position or placing it across the body increases swelling and risk of complications.

Question 20

Which activity is best suited to the 12-year-old with juvenile rheumatoid arthritis?

Accepted Answer

Answer reason: Swimming provides low-impact aerobic exercise that maintains joint range of motion and muscle strength with minimal stress on inflamed joints; video games and crossword puzzles do not promote mobility, and softball increases joint stress.

Question 21

Which activity is suitable for a client who suffered an uncomplicated myocardial infarction (MI) 2 days ago?

Accepted Answer

Answer reason: After an uncomplicated MI, activity is advanced gradually. At 48 hours, sitting in a chair for short periods is appropriate; strict bed rest is unnecessary, hallway ambulation is too advanced, and dangling for 5 minutes is too limited.

Question 22

The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states?

Accepted Answer

Answer reason: For hemiplegia, the cane is held on the stronger, unaffected side to widen the base of support and allow weight bearing on the strong limb; with right-sided weakness, the cane should be held in the left hand. A is incorrect (weak side). B is imprecise; the cane is advanced first then the weak leg moves to it, not strictly simultaneously. C is unnecessary.

Question 23

Measure the leg circumference of a client with bipedal edema is best done in what position?

Accepted Answer

Answer reason: Circumference should be measured with the client lying to avoid dependent pooling; dorsal recumbent relaxes leg muscles and provides consistent, gravity-minimized measurements. Sitting or standing increases dependent edema; supine is acceptable but dorsal recumbent is the preferred specific position.

Question 24

Ben is diagnosed with a retinal detachment at the inner aspect of the right eye. Into which position would the nurse place the client?

Accepted Answer

Answer reason: Position the detached retinal area dependently so gravity helps appose the retina. A right-eye medial (inner) detachment is best positioned with the client on the left side, making the nasal retina dependent.

Question 25

A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches?

Accepted Answer

Answer reason: Proper axillary crutch fitting leaves clearance of about 2–3 inches (or 2–3 finger breadths) between the axilla and the crutch pad to prevent neurovascular compression; other options give incorrect distances or elbow angle.

Question 26

The first exercise that should be performed by the client who had a mastectomy 1 day earlier is?

Accepted Answer

Answer reason: Day 1 after mastectomy, initial exercises are gentle hand and wrist movements (e.g., squeezing a ball) to promote circulation and prevent lymphedema. Shoulder elevation activities like wall climbing or combing hair are introduced later; sweeping is too strenuous.

Question 27

A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?

Accepted Answer

Answer reason: Semi-Fowler promotes drainage of peritoneal exudate and limits spread of infection after perforated appendix; flat or prone positions do not facilitate drainage.

Question 28

The nurse is planning care for a client with increased intracranial pressure. The BEST position for this client is?

Accepted Answer

Answer reason: Head of bed elevated about 30 degrees with head midline (semi-Fowler's) promotes venous drainage from the brain and lowers ICP. Trendelenberg and flat positions increase ICP; prone also impedes venous outflow.

Question 29

A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should?

Accepted Answer

Answer reason: Fresh casts should air-dry; frequent turning exposes surfaces and prevents pressure. Heat lamps risk burns, the abductor bar is not a handle, and limiting turning hinders drying and increases pressure injury risk.

Question 30

The nurse is teaching a client who has a hip prostheses following total hip replacement. Which of the following should be included in the instructions for home care?

Accepted Answer

Answer reason: Crossing the legs adducts the hip and increases risk of dislocation after total hip replacement. The other options are unnecessary restrictions (patients may use walkers, sleep in various positions with precautions, and can use stairs with instruction).

Question 31

The Braden Scale is used for assessing the risk for which condition?

Accepted Answer

Answer reason: The Braden Scale assesses risk for pressure injuries (pressure/decubitus ulcers) using factors like sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Question 32

The nurse is caring for several 70-80 year-old clients on bed rest. What is the MOST important measure to prevent skin breakdown?

Accepted Answer

Answer reason: Frequent turning relieves pressure on bony prominences, the key strategy to prevent pressure ulcers. Massaging bony areas can damage tissue, lotions alone do not prevent pressure, and heat to reddened areas can worsen injury.

Question 33

Which position is used in sigmoidoscopy?

Accepted Answer

Answer reason: The knee-chest position straightens and opens the rectosigmoid area, facilitating insertion and visualization during sigmoidoscopy.

Question 34

What is the suitable position for a rectal examination?

Accepted Answer

Answer reason: The left lateral Sims position provides optimal exposure of the anus and rectum and is the standard position for rectal examinations and enemas; the other positions do not provide as effective access.

Question 35

A two year-old child has recently been diagnosed with Cystic Fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?

Accepted Answer

Answer reason: Children with cystic fibrosis should be encouraged to participate in normal physical activity, which helps mobilize secretions and supports development. There is no need to restrict activities or isolate from peers, and routine frequent rest is not indicated.

Question 36

A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is MOST appropriate for this wound?

Accepted Answer

Answer reason: A red, moist partial-thickness pressure ulcer indicates granulation tissue. The best dressing is moisture-retentive and protective—an occlusive moist dressing. Wet-to-dry is for debridement of necrotic tissue, a dry dressing with antibiotic is not indicated, and transparent dressings are for superficial protection, not maintaining optimal moisture here.

Question 37

The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which of the following nursing diagnoses would be MOST appropriate for this client based on this assessment?

Accepted Answer

Answer reason: COPD client develops dyspnea with minimal exertion and must rest during ambulation, indicating decreased tolerance for activity due to chronic hypoxia. Other options (mobility impairment, self-care deficit, or airway clearance) are not directly supported by the assessment.

Question 38

The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which of the following nursing interventions is appropriate for this child?

Accepted Answer

Answer reason: In skeletal traction, maintain continuous traction and proper body alignment to ensure effective immobilization and prevent complications. Weights must hang freely (not touch the bed), the bed should not be adjusted without orders, and traction should not be released unless prescribed.

Question 39

The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize?

Accepted Answer

Answer reason: Weight-bearing activity reduces bone demineralization and calcium release from bone, helping prevent hypercalcemia. Dairy intake would increase calcium, fluid restriction is incorrect (hydration promotes calcium excretion), and tetany indicates hypocalcemia, not hypercalcemia.

Question 40

A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The MOST important reason for the nurse to elevate the casted leg is to?

Accepted Answer

Answer reason: Elevation decreases edema by enhancing venous return, which is the priority after cast application; comfort, drying time, and skin irritation are secondary considerations.

Question 41

A client with spinal cord injury is at risk of developing footdrop; what is the most effective preventive measure the nurse should use?

Accepted Answer

Answer reason: Posterior splints maintain the ankle in neutral dorsiflexion, preventing plantar-flexion contracture (foot drop). Heel protectors prevent pressure injury; pneumatic boots prevent DVT; a foot board is less effective and may promote plantar flexion.

Question 42

After removing a cast, which type of exercise is necessary?

Accepted Answer

Answer reason: After immobilization, muscles and joints need active movement to restore strength and function. Isotonic exercises provide dynamic contractions that improve range of motion and muscle strength. Isometric exercises are emphasized while the cast is on; hypertonic is not a standard exercise type; routine care alone is insufficient.

Question 43

A client who has multiple sclerosis is at increased risk for which condition?

Accepted Answer

Answer reason: Multiple sclerosis often leads to impaired mobility and decreased sensation, increasing the risk for pressure injuries. Heartburn is nonspecific, ptosis is more associated with myasthenia gravis, and rheumatic fever is unrelated.

Question 44

What is the best position used during spinal cord injury?

Accepted Answer

Answer reason: For suspected spinal cord injury, maintain spinal immobilization in a neutral supine position to prevent further cord damage; avoid prone, sitting, or knee-chest positions.

Question 45

Which position is best for unconscious patient to prevent aspiration?

Accepted Answer

Answer reason: In an unconscious patient, protective airway reflexes are impaired. Placing the patient in the side-lying (lateral) or recovery position allows secretions and vomitus to drain from the mouth, reducing aspiration risk and preventing the tongue from occluding the airway. Supine increases aspiration risk, Fowler’s requires intact gag and is less protective when unconscious, and prone is not recommended for aspiration prevention.

Question 46

Which position is best for dyspnea patient?

Accepted Answer

Answer reason: Upright positioning (Fowler’s, preferably high Fowler’s) maximizes chest expansion and lowers diaphragmatic pressure, improving ventilation and oxygenation in a dyspneic patient. Gravity aids in lung expansion and reduces work of breathing. Supine can worsen dyspnea by limiting diaphragmatic excursion, and Sims’ or lithotomy are not indicated for respiratory distress.

Question 47

Which position is used for abdominal examination?

Accepted Answer

Answer reason: Abdominal examination is best performed with the client in the supine position, which relaxes the abdominal muscles and allows optimal inspection, auscultation, percussion, and palpation. Prone positioning is used for back or spinal assessments. Fowler’s is for promoting ventilation and comfort when sitting up, and Sims’ is used for rectal procedures or enemas.

Question 48

Which position is best for tracheostomy care?

Accepted Answer

Answer reason: Semi-Fowler’s (30–45°) optimizes ventilation and allows better access to the tracheostomy site while reducing the risk of aspiration and promoting drainage of secretions. Supine can impair diaphragmatic excursion and increase aspiration risk. Trendelenburg worsens secretion pooling toward the airway and is contraindicated. Lateral may aid drainage in some cases but is not the standard position for routine tracheostomy care.

Question 49

Which position is used in postural drainage?

Accepted Answer

Answer reason: Postural drainage uses gravity to mobilize bronchial secretions from specific lung segments. For drainage of lower lobes, the bed is tilted so the head is down (Trendelenburg position), enhancing mucus movement toward the trachea for expectoration. Fowler’s improves ventilation but is not used for gravity-assisted drainage, and prone or Sims’ are not standard positions for postural drainage.

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