Question 1

To prevent venous stasis, a client is to be measured for knee-high anti-embolus stockings. Which of the following are appropriate nursing actions?

Accepted Answer

Answer reason: Proper sizing of anti-embolus (TED) stockings requires measuring limb circumference at key points to apply graduated compression without impairing arterial flow. The ankle is the narrowest part of the lower leg and is routinely used to determine the correct stocking size and ensure appropriate pressure gradient. In contrast, measuring heel-to-gluteal fold corresponds to thigh-high length, not knee-high fitting, and foot length is not a standard parameter for TED sizing. Measuring heel to popliteal space addresses length, but circumference (especially at the ankle) is essential to select the correct size and prevent constriction or ineffective compression.

Question 2

When instructing a patient on deep breathing and coughing, the nurse explains that the patient should be sitting for these activities because?

Accepted Answer

Answer reason: Upright positioning promotes maximal lung expansion by improving diaphragmatic descent and ventilation to dependent lung areas. This increases airflow behind retained mucus, helping mobilize and clear secretions during coughing and reducing atelectasis risk. Comfort alone is not the primary clinical rationale for the position, and incision support can be done in any position using splinting. The key safety goal is enhancing effective airway clearance and gas exchange through better mechanics in sitting.

Question 3

The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which statement by the client indicates an understanding of the nurse’s instructions?

Accepted Answer

Answer reason: After thyroidectomy, supporting the neck during coughing and position changes reduces tension on the incision and helps prevent strain and discomfort. This technique helps maintain alignment and minimizes risk of wound stress while the tissues are healing. Antithyroid drugs are not routinely continued after removal of the thyroid; instead the more common long-term need is thyroid hormone replacement depending on extent of resection. Tingling around the lips/fingers/toes suggests hypocalcemia from potential parathyroid injury and should be reported immediately to the surgical team, but the statement’s “go to the emergency room” framing is not the standard postoperative instruction compared with contacting the provider promptly.

Question 4

Which is a nursing diagnosis?

Accepted Answer

Answer reason: This option reflects a functional limitation affecting movement and ability to perform activities, which can be addressed with mobility assistance, positioning, exercise, and safety planning. The other options are medical diagnoses identifying diseases (infection, chronic blood pressure disorder, and metabolic disease) that require provider-led medical management. Therefore, the best nursing diagnosis among the choices is the one centered on patient function and nursing-managed outcomes.

Question 5

A patient was admitted to the surgical unit after undergoing a right modified radical mastectomy. Which of the following should the nurse include in the patient's care plan?

Accepted Answer

Answer reason: After axillary node dissection, the affected arm is at higher risk for impaired lymphatic drainage, swelling, and discomfort. Elevating the operative-side arm helps promote venous/lymphatic return and reduces edema while supporting comfort and healing. In contrast, using the operative-side arm for blood pressure measurement or venipuncture increases the risk of lymphedema and tissue injury due to compromised lymph flow. Routine dressing assessment is important, but the key plan-of-care priority specific to this surgery is protection and positioning of the affected extremity to prevent swelling and complications.

Question 6

The nurse cares for a client with a fractured hip awaiting surgical correction. What interventions does the nurse include to reduce pain preoperatively?

Accepted Answer

Answer reason: Immobilization is a key principle for fracture pain control because movement at the fracture site increases tissue irritation and muscle spasm. Traction helps align the injured structures and limits painful motion while reducing spasm, which can significantly decrease discomfort while awaiting surgery. Passive range of motion of the affected extremity would tend to increase movement at the injury and worsen pain. Regular ibuprofen is less appropriate preoperatively due to bleeding risk and is not the primary nursing intervention emphasized for acute hip fracture stabilization.

Question 7

The nurse receives a client from the post-anesthesia care unit (PACU) following an above-the-knee amputation. Which should be the initial action the nurse takes to safely position the client?

Accepted Answer

Answer reason: Immediately post-amputation, positioning should prioritize preventing hemorrhage and edema while protecting the incision and promoting safe alignment. Slight elevation of the residual limb decreases swelling and supports venous return without placing the hip in flexion that can contribute to contracture risk. Side-lying on the operative side helps reduce hip flexion/abduction tendencies and supports proper stump positioning early after surgery. In contrast, elevating only the foot of the bed or using reverse Trendelenburg does not directly control residual-limb edema and may not provide optimal stump support.

Question 8

The nurse is caring for a client who will be taught to ambulate with a cane. Before cane-assisted ambulation instructions begin, what should the nurse check for as the priority to assure client safety?

Accepted Answer

Answer reason: Confidence is also essential because fear or hesitancy commonly leads to poor sequencing, reduced weight-bearing, and unsafe compensatory movements. Stamina is helpful but is not the immediate predictor of whether the first attempts with a cane will be safe. Full range of motion and feelings about using the cane may affect long-term function and adherence, but they are not the primary safety screen before initiating training.

Question 9

A nurse is providing instructions to a client regarding ambulation after the application of a fiberglass (nonplaster) cast to the lower leg. The nurse determines that the client understands the instructions if the client states that weight bearing on the casted leg can begin?

Accepted Answer

Answer reason: After application, the priority teaching is when ambulation can safely begin without deforming the cast or compromising fracture alignment. Fiberglass typically achieves sufficient strength for weight bearing in about 20–30 minutes (with full curing over a longer period), whereas 24–48 hours is characteristic of plaster casting. This timing supports early mobility while still emphasizing use of prescribed assistive devices and adherence to provider weight-bearing orders.

Question 10

The nurse is planning to assist a client with a half leg cast to go down a flight of stairs using crutches. Where will the nurse place themselves in relation to the client?

Accepted Answer

Answer reason: Descending stairs increases fall risk because the body’s momentum moves downward and balance demands are higher. Standing behind provides support if the client loses balance, and aligning to the affected side allows the nurse to guard the side most likely to buckle or bear less stable weight due to the cast. Being in front would reduce the nurse’s ability to catch/steady the client effectively during a backward loss of balance on descent.

Question 11

A client comes to the clinic reporting chronic low back pain. He asks the nurse to recommend specific exercises for him. Which of the following activities should the nurse suggest?

Accepted Answer

Answer reason: This option provides buoyancy that decreases compressive forces on the lumbar spine while allowing gentle strengthening of core and paraspinal muscles and improved flexibility. It is generally better tolerated than land-based sports that involve twisting, sudden starts/stops, or impact. A common pitfall is recommending activities with repetitive trunk rotation (e.g., racquet sports), which can exacerbate mechanical back pain.

Question 12

The nurse has taught the family member of a client with Parkinson's disease. Which of the following statements by the family member would indicate a correct understanding of the teaching?

Accepted Answer

Answer reason: " Parkinson’s disease commonly causes shuffling gait and freezing episodes due to impaired initiation and scaling of movement. Using external cueing strategies (visual cues like stepping over an imaginary line) can help bypass basal ganglia dysfunction and improve gait initiation and stride length, reducing freezing and fall risk. Thin liquids are typically harder to control and increase aspiration risk with dysphagia, so thickened liquids are often safer. Sedative/hypnotics can worsen confusion, orthostatic hypotension, and falls and are not used PRN for tremor exacerbations.

Question 13

The nurse is asked to revise a list of goals for 4 clients who have spinal cord injuries. Which of the following would be a realistic nursing goal after considering the level of injury described?

Accepted Answer

Answer reason: Functional ability after spinal cord injury depends on which muscle groups are innervated above the lesion, with thoracic injuries generally preserving full upper-extremity strength and hand function. At approximately T5, the client retains arm/hand control needed for most self-care tasks, and dressing can be a realistic independence goal with training and adaptive techniques. In contrast, a C3 injury typically causes severe tetraplegia with inability to independently reposition in bed, and a C6 injury often requires adaptive equipment/tenodesis strategies to feed independently. A T2 injury is usually paraplegia with poor trunk balance and no lower-extremity motor function, making ambulation (even with assistance) generally unrealistic in standard outcomes.

Question 14

The nurse enters the room of a patient complaining of lower back pain after a left hip replacement surgery. What non-pharmacological intervention would not be appropriate?

Accepted Answer

Answer reason: After total hip arthroplasty, maintaining hip precautions is essential to prevent dislocation and protect the operative extremity. Turning the patient onto the operative side can increase discomfort and may place the hip in unsafe alignment depending on positioning and degree of rotation/adduction. In contrast, back massage, gentle heat to the back (if not contraindicated), and positioning changes that reduce lumbar strain can relieve postoperative low back pain without stressing the new hip joint. The safest nonpharmacologic choices prioritize neutral hip alignment and avoid pressure or twisting on the surgical side.

Question 15

The nurse is observing a client using a walker. Which observation by the nurse should determine that the client is using the walker correctly?

Accepted Answer

Answer reason: The client should then bear weight through the hand grips to unload the lower extremities as indicated and maintain balance. After the walker is stable and weight is supported through the arms, the client steps forward into the walker space rather than pushing it too far ahead. Options that omit ensuring all four points are flat or that have the client step into the walker before it is stabilized increase fall risk.

Question 16

The LPN/LVN reinforces how to use a standard aluminum walker with an elderly client. Which of the following behaviors by the client indicates that the teaching was effective?

Accepted Answer

Answer reason: Safe walker gait uses a stable sequence: move the walker a short distance ahead, then step into it while keeping body weight supported through the hand grips. Advancing the walker about 6–10 inches prevents overreaching and reduces fall risk from a widened base of support. Taking several small steps forward after placing the walker maintains continuous stability rather than lunging or leaning excessively. Options describing pushing/sliding the walker or moving it too far forward (e.g., 12–18 inches) encourage leaning and can destabilize the client, increasing risk for falls.

Question 17

The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client?

Accepted Answer

Answer reason: Safe walker technique requires keeping all four legs of the walker on the floor to maximize stability and reduce fall risk. Tilting the walker forward shifts the center of gravity and can cause the device to slip, especially as the client transitions from sit-to-stand when balance is most compromised. In contrast, advancing the walker a short distance and maintaining 15–30° elbow flexion reflect proper fit and gait mechanics that support weight bearing through the arms. The client should push up from the chair/armrests (not pull on or tilt the walker) before grasping the walker handles once standing.

Question 18

The clinic nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement made by one of the parents indicates an understanding of the use of the harness?

Accepted Answer

Answer reason: ” The Pavlik harness treats developmental dysplasia of the hip by maintaining the hips in flexion and abduction continuously so the femoral head stays properly seated in the acetabulum. Effective treatment depends on uninterrupted positioning; routine removal can allow malalignment and reduce therapeutic benefit. Parents should perform care such as feeding and diaper changes with the harness on and monitor skin integrity and strap position as instructed. Intermittently taking it off for routine tasks is a common misunderstanding that can compromise correction.

Question 19

An older adult client in a long-term care facility had a cerebrovascular accident (CVA) 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

Accepted Answer

Answer reason: Nonblanchable erythema over the sacrum is an early, clinically important sign of skin breakdown requiring prompt offloading and repositioning. Stiffness and difficulty moving extremities are expected sequelae of stroke-related weakness/spasticity and deconditioning rather than a specific complication signal. Hearing changes are not a typical immobility complication and point to an unrelated sensory issue.

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