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HAAD QUESTIONS

EXAM CODE HAAD 5

1. Which of the following statements reflect nursing interventions in the


care of the patient with osteoarthritis?

a. Encourage weight loss and an increase in aerobic activity.


b. Provide an analgesic after exercise.
c. Assess for the gastrointestinal complications associated with COX-2
inhibitors.
d. Avoid the use of topical analgesics.

2. A nurse is caring for a client who had a closed reduction of a


fractured right wrist followed by the application of a fiberglass cast 12
hours ago. Which finding requires the nurses immediate attention?

a. Capillary refill of fingers on right hand is 3 seconds


b. Skin warm to touch and normally colored
c. Client reports prickling sensation in the right hand
d. Slight swelling of fingers of right hand

3. The nurse is assessing an infant with developmental dysplasia of the


hip. Which finding would the nurse anticipate?

a. Unequal leg length


b. Limited adduction
c. Diminished femoral pulses
d. Symmetrical gluteal folds

4. A 3 year-old had a hip spica cast applied 2 hours ago. In order to


facilitate drying, the nurse should

a. Expose the cast to air and turn the child frequently


b. Use a heat lamp to reduce the drying time
c. Handle the cast with the abductor bar
d. Turn the child as little as possible

5. Osteoporosis is characterized by change in bone density or mass and


fragile bones that lead to fractures. A nurse is conducting a health
screening clinic for osteoporosis. The nurse determines that this client
seen in the clinic is at the greatest risk of developing the disorder.

a. A 25 year old female who jogs


b. A sedentary 65 year old female who smokes cigarettes
c. A 36 year old male who has asthma
d. A 70 year old male who consumes excess alcohol

6. The nurse is teaching the client with right leg fracture regarding the
physicians order for partial weight bearing status. The client understands
the health teaching if he verbalizes:

a. I should not bear weight on my fractured leg


b. I am allowed to put 10% of my actual weight on my right leg
c. I am not allowed to let my fractured leg touch the floor
d. I am allowed to put 40% of my weight on my right leg
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7. A nurse wants to assess if the clients brachial plexus was compromised


after undergoing shoulder arthroplasty due to rheumatoid arthritis. To
assess the cutaneous nerve status which of the following would the nurse
perform?

a. Let the client raise his forearm and monitor for flexion of the biceps
b. Ask the client move his thumb toward the palm and back to the
neutral position

c. have the client grasp the nurses hand while noting the clients
strength of the first and second fingers.
d. Have the client spread all the fingers wide and resist pressure.

8. A client has suffered from fall and sustained a leg injury. Which
appropriate question would the nurse ask the client to help determine if
the injury caused fracture?

a. Is the pain sharp and continuous?


b. Is the pain dull ache?
c. Does the discomfort feel like a cramp?
d. Does the pain feel like the muscle was stretched?

9. The Nurse is assessing the clients casted extremity for signs of


infection. Which of the following findings is indicative of infection?

a. Edema
b. Weak distal pulse
c. Coolness of the skin
d. Presence of hot spot on the cast

10. A 58 year old client is suffering from acute phase of rheumatoid


arthritis. Which of the following would the nurse in charge identify as
the lowest priority of the plan of care?

a. Prevent joint deformity


b. Maintaining usual ways of accomplishing task
c. Relieving pain
d. Preserving joint function

11. The nurse would include which nursing intervention in the care plan
for a client with an L5-S1 intervertebral disc herniation?

a. Assessing the skeletal traction insertion sites for infection


b. Encouraging the client to ambulate as much as possible
c. Positioning the client with his knees slightly flexed and the head of
bed elevated
d. Preparing the client for lumbar puncture

12. When discussing anticholinesterase agents with a client diagnosed with


myasthenia gravis, the nurse would include which discharge instruction?

a. "Ensure for available bathroom facilities due to increased urinary


frequency."
b. "Obtain serum drug levels every 3 months."
c. "Take the medication 30 minutes before activities to obtain peak
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effects."
d. "Take the medication on an empty stomach to increase absorption."

13. A client sustained a C6 spinal cord injury and is placed in Crutchfield


tongs and skeletal traction. Which intervention should the nurse
implement?

a. Cleaning the tong insertion sites and assessing for infection


b. Instructing the client to perform active range-of-motion exercises daily
c. Placing the client in low-top tennis shoes with cotton socks
d. Removing the weights every 4 hours and turning the client

14. A client undergoes below the knee amputation following a vehicular


accident. Three days postoperatively, the client is refusing to eat, talk or
perform any rehabilitative activities. The best initial nursing approach
would be to:

a. Give him explanations of why there is a need to quickly increase his


activity
b. Emphasize repeatedly that with as prosthesis, he will be able to
return to his normal lifestyle
c. Appear cheerful and non-critical regardless of his response to attempts
at intervention
d. Accept and acknowledge that his withdrawal is an initially normal and
necessary part of grieving

15. The nurse performs full range of motion on a bedridden clients


extremities. When putting his ankle through range of motion, the nurse
must perform:

a. Flexion, extension and left and right rotation


b. Abduction, flexion, adduction and extension
c. Pronation, supination, rotation, and extension
d. Dorsiflexion, plantar flexion, eversion and inversion

16. Joy, an obese 32 year old, is admitted to the hospital after an


automobile accident. She has a fractured hip and is brought to the OR
for surgery.
After surgery Joy is to receive a piggy-back of Clindamycin phosphate
(Cleocin) 300 mg in 50 ml of D5W. The piggyback is to infuse in 20
minutes. The drop factor of the IV set is 10 gtt/ml. The nurse should set
the piggyback to flow at:

a. 25 gtt/min
b. 30 gtt/min
c. 35 gtt/min
d. 45 gtt/min

17. The physician orders non-weight bearing with crutches for Joy, who
had surgery for a fractured hip. The most important activity to facilitate
walking with crutches before ambulation begun is:

a. Exercising the triceps, finger flexors, and elbow extensors


b. Sitting up at the edge of the bed to help strengthen back muscles
c. Doing isometric exercises on the unaffected leg

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d. Exercising the biceps, flexion and extension of the unaffected leg

18. The nurse recognizes that a client understood the demonstration of


crutch walking when she places her weight on:

a. The palms and axillary regions


b. Both feet placed wide apart
c. The palms of her hands
d. Her axillary regions

19. The nurse includes the important measures for stump care in the
teaching plan for a client with an amputation. Which measure would be
excluded from the teaching plan?

a. Wash, dry, and inspect the stump daily.


b. Treat superficial abrasions and blisters promptly.
c. Apply a "shrinker" bandage with tighter arms around the proximal end
of the affected limb.
d. Toughen the stump by pushing it against a progressively harder
substance (e.g., pillow on a foot-stool).

20. A 70-year-old female comes to the clinic for a routine checkup. She
is 5 feet 4 inches tall and weighs 180 pounds. Her major complaint is
pain in her joints. She is retired and has had to give up her volunteer
work because of her discomfort. She was told her diagnosis was
osteoarthritis about 5 years ago. Which would be excluded from the
clinical pathway for this client?

a. Decrease the calorie count of her daily diet.


b. Take warm baths when arising.
c. Slide items across the floor rather than lift them
d. Increase the calorie count of her daily diet

21. The nurse is caring for a post-surgical client at risk for developing
deep vein thrombosis. Which intervention is an effective preventive
measure?

a. Place pillows under the knees


b. Use elastic stockings continuously
c. Encourage range of motion and ambulation
d. Massage the legs twice daily

22. 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?

a. Raise the head of the bed at least 30 degrees


b. Encourage ambulation within 24 hours
c. Maintain in a flat position, logrolling as needed
d. Encourage leg contraction and relaxation after 48 hours

23. 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

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a. Isometric
b. Range of motion
c. Aerobic
d. Isotonic

24. A client had a laminectomy and spinal fusion yesterday. Which


statement is to be excluded from your plan of care?

a. Before log rolling, place a pillow under the clients head and a pillow
between the clients legs.
b. Before log rolling, remove the pillow from under the clients head and
use no pillows between the clients legs.
c. Keep the knees slightly flexed while the client is lying in a semi-
Fowlers position in bed.
d. Keep a pillow under the clients head as needed for comfort.

25. A client is to undergo lumbar puncture. Which is least important


information about LP?

a. Specimens obtained should be labeled in their proper sequence.


b. It may be used to inject air, dye or drugs into the spinal canal.
c. Assess movements and sensation in the lower extremities after the
d. Force fluids before and after the procedure

26. Contractures are among the most serious long-term complications of


severe burns. If a burn is located on the upper torso, which nursing
measure would be least effective to help prevent contractures?

a. Changing the location of the bed or the TV set, or both, daily


b. Encouraging the client to chew gum and blow up balloons
c. Avoiding the use of a pillow for sleep, or placing the head in a
position of hyperextension
d. Helping the client to rest in the position of maximal comfort

27. The physician orders application of warm compress to an athlete who


sustained ankle sprain. To be effective, the nurse instructed the client
that the appropriate temperature for the compress should be:

a. 19.0 to 26' C
b. 26.6 to 33.3' C
c. 34.5 to 36' C
d. 36.6 to 40.5' C

28. A patient with complaints of pelvic and long bones pain was ordered
to undergo an x-ray. Findings showed " punche-out" appearance of bone
with increase bone thickness. These manifestations are indicative of which
bone disease?

a. Rhuematoid arthritis
b. Paget's disease
c. Gouty arthritis
d. Osteoarthritis

29. Which findings will you expect to be elevated in a client with


diagnosis of Paget's disease?

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a. Serum calcium level


b. Serum Phosphate level
c. Serum alkaline phosphatase level
d. Serum parathyroid hormone level

30. All of the following medications are used to prevent excessive


osteoclast activity in the bones except:

a. Alendronate (Fosamax)
b. Pamidronate (Aredia)
c. Calcium supplements
d. Human calcitonin ( Cibacalcin

31. Adults rickets also known as:

a. Osteomalacia
b. Osteitis deformans
c. Hyperurecemia
d. Degenerative joint disease

32. All of the following medications are used to prevent excessive


osteoclast activity in the bones except:

a. Alendronate (Fosamax)
b. Pamidronate (Aredia)
c. Calcium supplements
d. Human calcitonin ( Cibacalcin)

33. While doing your assessment, Lucky asks you "Do I have fracture? I
don't want to have cast". The most appropriate nursing response would
be:

a. "Why do you sound so scared? It is just a cast and it's not painful".
b. "You have to have an x-ray first to know if you have a fracture".
c. "Based on my assessment, there doesn't seem to be a fracture".
d. "You seem to be concerned about being in a cast".

34. Troy is a day one post open reduction and internal fixation(ORIF) of
the left hip and is in pain. Which of the following observation would
prompt you to call the doctor?

a. BP 114/78, pulse of 82 beats/min


b. Left foot is cold to touch and pedal pulse is absent
c. Left leg in limited functional anatomic position
d. Dressing is intact but partially soiled

35. In some hip surgeries, an epidural catheter for Fentanyl epidural


analgesia is given. What is your nursing priority care in such a case?

a. Instruct client to observe strict bed rest


b. Check for epidural catheter drainage
c. Administer analgesia through epidural catheter as prescribed
d. Assess respiratory rate carefully

36. A drug that has been used for the prevention and treatment of acute
gout attacks is:
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a. Hydrocotisone
b. Aspirin
c. Colchicine
d. Probenecid

37. Luzida, 43 years old, has recently been diagnosed with rheumatoid
arthritis. The diet that the nurse should provide the client will have to
be:

a. Low residue diet


b. Diet as tolerated
c. alkaline diet
d. High protein, low calcium

38. After total hip replacement surgery, the nurse should avoid placing
the client in the:

a. Orthopneic position
b. Supine position
c. Lateral position
d. Standing position

39. Most common risk factor of osteoarthritis is:

a. Inherited condition
b. Advance age
c. Trauma
d. Obesity

40. Lerry tells the nurse that her mother has osteoporosis. She aks what
is th difference of her diagnosis to her mother's diagnosis. The nurse
explains to the patient that rheumatoid arthritis is a disease of the:

a. Bones
b. Joints
c. Connective tissues
d. Muscles

41. Which client goal would be most appropriate for a client diagnosed
with Osteoarthritis?

a. Perform passive range-of-motion exercises.


b. Maintain optimal functional ability.
c. Client will walk three (3) miles every day.
d. Client will join a health club.

42. The occupational health nurse is teaching a class on the risk factors
for developing osteoarthritis. Which is a modifiable risk factor for
developing OA?

a. Being overweight.
b. Increasing age.
c. Previous joint damage.
d. Genetic susceptibility.

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43. The HCP prescribes glucosamine and chondroitin for a client diagnosed
with OA. What is the scientific rationale for prescribing this medication?

a. It will help decrease the inflammation in the joints.


b. It improves tissue function and retards breakdown of cartilage.
c. It is a potent medication that decreases the clients joint pain.
d. It increases the production of synovial fluid in the joint.

44. The nurse is administering 0730 medications to clients on a medical


orthopedic unit.
Which medication would be administered first?

a. The daily cardiac glycoside to a client diagnosed with back pain and
heart failure.
b. The routine insulin to a client diagnosed with neck strain and Type 1
diabetes.
c. The oral proton pump inhibitor to a client scheduled for a laminectomy
this A.M.
d. The fourth dose of IV antibiotic for a client diagnosed with a surgical
infection.

45. The 34-year-old male client presents to the outpatient clinic


complaining of numbness and pain radiating down the left leg. Which
further data would the nurse assess?

a. Posture and gait.


b. Bending and stooping.
c. Leg lifts and arm swing.
d. Waist twists and neck mobility.

46. The client diagnosed with OA is prescribed a nonsteroidal anti-


inflammatory drug (NSAID). Which instruction should the nurse teach the
client?

a. Take the medication on an empty stomach.


b. Make sure the client tapers the medication when discontinuing.
c. Apply the medication topically over the affected joints.
d. Notify the health-care provider if vomiting blood.

47. The client is diagnosed with osteoarthritis. Which sign/symptom would


the nurse expect the client to exhibit?

a. Severe bone deformity.


b. Joint stiffness.
c. Waddling gait.
d. Swan neck fingers.

48. The nurse is caring for clients on an orthopedic floor. Which client
should be assessed first?

a. The client diagnosed with back pain who is complaining of a 4 on a


110 scale.
b. The client who has undergone a myelogram who is complaining of a
slight headache.
c. The client 2 days postop disc fusion that has a T 100.4, P 96, R 24,
and BP 138/78.
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d. The client diagnosed with back pain who is being discharged and
whose ride is here.

49. The nurse working on a medical-surgical floor feels a pulling in the


back when lifting a client up in the bed. Which should be the first
action taken by the nurse?

a. Continue working until the shift is over and then try to sleep on a
heating pad.
b. Go immediately to the emergency department for treatment and muscle
relaxants.
c. Inform the charge nurse and nurse manager on duty and document the
occurrence.
d. See a private health-care provider on the nurses off time but charge
the hospital.

50. The nurse is admitting the client with OA to the medical floor. Which
statement by the client indicates an alternative form of treatment for
OA?

a. I take medication every two (2) hours for my pain.


b. I use a heating pad when I go to bed at night.
c. I wear a copper bracelet to help with my OA.
d. I always wear my ankle splints when I sleep.

51. The client is 12-hours post-lumbar laminectomy. Which nursing


interventions should be implemented?

a. Assess ability to void and log roll every two (2) hours.
b. Medicate with IV steroids and keep the bed in a Trendelenburg
position.
c. Place sand bags on each side of the head and give cathartic
medications.
d. Administer IV anticoagulants and place on O2 at eight (8) L/min.

52. The nurse is discussing the importance of an exercise program for


pain control to a client diagnosed with OA. Which intervention should the
nurse include in the teaching?

a. Wear supportive tennis shoes with white socks when walking.


b. Carry a complex carbohydrate while exercising.
c. Alternate walking briskly and jogging when exercising.
d. Walk at least 30 minutes three (3) times a week.

53. The client diagnosed with OA is a resident in a long-term care


facility. The resident is refusing to bathe because she is hurting. Which
instruction should the nurse give the unlicensed nursing assistant?

a. Allow the client to stay in bed until the pain becomes bearable.
b. Tell the assistant to give the client a bed bath this morning.
c. Try to encourage the client to get up and go to the shower.
d. Notify the family that the client is refusing to be bathed.

54. The client newly diagnosed with osteoporosis is prescribed calcitonin


by nasal spray.

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Which assessment data would indicate an adverse effect of the


medication?

a. The client complains of nausea and vomiting.


b. The client is drinking two (2) glasses of milk a day.
c. The client has a runny nose and nasal itching.
d. The client has had numerous episodes of nosebleeds.

55. The client is complaining of joint stiffness, especially in the morning.


Which diagnostic tests would the nurse expect the health-care provider to
order to R/O osteoarthritis?

a. Full body magnetic resonance imaging scan.


b. Serum studies for synovial fluid amount.
c. X-ray of the affected joints.
d. Serum erythrocyte sedimentation rate (ESR).

56. Which member of the health-care team should the nurse refer the
client diagnosed with OA who is complaining of not being able to get in
and out of the bathtub?

a. Physiatrist.
b. Social worker.
c. Physical therapist.
d. Counselor.

57. The nurse is working with an unlicensed nursing assistant. Which


action by the assistant warrants immediate intervention?

a. The assistant feeds a client 2 days postoperative cervical laminectomy


a regular diet.
b. The assistant calls for help when turning to the side a client who is
post-lumbar
laminectomy.
c. The assistant is helping the client who weighs 300 pounds and
diagnosed with back pain to the chair.
d. The assistant places the call light within reach of the client who had
a disc fusion.

58. The client has been diagnosed with OA for the last 7 years and has
tried multiple medical treatments and alternative treatments but still has
significant joint pain. Which psychosocial client problem would the nurse
identify?

a. Severe pain.
b. Body-image disturbance.
c. Knowledge deficit
d. Depression

59. The 84-year-old client is a resident in a long-term care facility.


Which intervention should be implemented to help prevent complications
secondary to osteoporosis?

a. Keep the bed in the high position.


b. Perform passive range-of-motion exercises.
c. Turn the client every two (2) hours.
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d. Provide nighttime lights in the room.

60. The client diagnosed with osteoporosis asks the nurse, Why does
smoking cigarettes cause my bones to be brittle? Which response by the
nurse would be most appropriate?

a. Smoking causes nutritional deficiencies that contribute to


osteoporosis.
b. Tobacco causes an increase in blood supply to the bones, causing
osteoporosis.
c. Smoking low-tar cigarettes will not cause your bones to become
brittle.
d. Nicotine impairs the absorption of calcium, causing decreased bone
strength.

61. The occupational health nurse is planning health promotion activities


for a group of factory workers. Which activity would be an example of
primary prevention for clients at risk for low back pain?

a. Teach back exercises to workers after returning from an injury.


b. Place signs in the work area about how to perform first aid.
c. Start a weight-reduction group that would meet at lunchtime.
d. Administer a nonnarcotic analgesic to a client complaining of back
pain.

62. The nurse is caring for the following clients. After receiving the shift
report, which client should the nurse assess first?

a. The client with a total knee replacement who is complaining of a cold


foot.
b. The client diagnosed with osteoarthritis who is complaining of stiff
joints.
c. The client who needs to receive a scheduled intravenous antibiotic.
d. The client diagnosed with back pain who is scheduled for a lumbar
myelogram.

63. The nurse is caring for an elderly client diagnosed with a herniated
nucleus pulposus of L4-L5. Which scientific rationale explains the incidence
of a ruptured disc in the elderly?

a. The client did not use good body mechanics when lifting an object.
b. There is an increased blood supply to the back as the body ages.
c. Older clients develop atherosclerotic joint disease as a result of fat
deposits.
d. Clients develop intervertebral disc degeneration as they age.

64. Which signs/symptoms would make the nurse suspect that the client
has developed osteoporosis?

a. The client has lost one (1) inch in height.


b. The client has lost 12 pounds in the last year.
c. The clients hands are painful to the touch.
d. The clients serum uric acid level is elevated.

65. Which intervention is an example of a secondary nursing intervention


when discussing osteoporosis?
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a. Obtain a bone density evaluation test.


b. Perform nonweight-bearing exercises regularly.
c. Increase the intake of dietary calcium.
d. Refer clients to a smoking cessation program.

66. The client diagnosed with cervical neck disc degeneration has
undergone a laminectomy.
Which interventions should the nurse implement?

a. Position the client prone with the knees slightly elevated.


b. Assess the client for difficulty speaking or breathing.
c. Measure the drainage in the Jackson-Pratt bulb every day.
d. Encourage the client to postpone the use of narcotic medications.

67. The female client diagnosed with osteoporosis tells the nurse that she
is going to perform swim aerobics for 30 minutes every day. Which
response would be most appropriate by the nurse?

a. Praise the client for committing to do this activity.


b. Explain that walking 30 minutes a day is a better activity.
c. Encourage the client to swim every other day instead of daily.
d. Discuss that sedentary activities help prevent osteoporosis.

68. The nurse instructs the client with a right BKA to lie on the stomach
for at least 30 minutes a day. The client asks the nurse, Why do I need
to lie on my stomach? Which statement would be the most appropriate
statement by the nurse?

a. This position will help your lungs expand better.


b. Lying on your stomach will help prevent contractures.
c. Many times this will help decrease pain in the limb.
d. The position will take pressure off your backside.

69. The client is being evaluated for osteoporosis. Which diagnostic test
is the most accurate when diagnosing osteoporosis?

a. X-ray of the femur.


b. Serum alkaline phosphatase.
c. Dual-energy x-ray absorptiometry (DEXA).
d. Serum bone Gla-protein test.

70. The nurse is discussing osteoporosis with a group of women. Which


factor will the nurse identify as a nonmodifiable risk factor?

a. Calcium deficiency.
b. Tobacco use.
c. Female gender.
d. High alcohol intake.

71. When assessing a client with a fractured left tibia and fibula, which
data should the nurse report to the health-care provider immediately?

a. Localized edema and discoloration occurring hours after the injury.


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b. Generalized weakness and increasing sensitivity to touch.


c. Capillary refill time of nine (9) seconds and increasing pain.
d. Pain relieved after taking four (4) mg hydromorphone, a narcotic
analgesic.

72. The client admitted with a diagnosis of a fractured hip is complaining


of severe pain.
Which pain management technique would be best for the nurse to
implement for this client?

a. Adjust the patient-controlled analgesia (PCA) machine for a lower dose.


b. Ensure that the weights of the Bucks traction are off the floor and
hang freely.
c. Raise the head of the bed to 45 degrees and the foot to 15 degrees.
d. Turn the client to the affected leg using pillows to support the other
leg.

73. The 27-year-old client has a right above-the-elbow amputation


secondary to a boating accident. Which statement by the rehabilitation
nurse indicates the client has accepted the amputation?

a. I am going to sue the guy that hit my boat.


b. The therapist is going to help me get retrained for another job.
c. I decided not to get prosthesis. I dont think I need it.
d. My wife is so worried about me and I wish she wouldnt.

74. The nurse is caring for a client with a right below the knee
amputation. There is a large amount of bright red blood on the clients
residual limb dressing. Which intervention should the nurse implement
first?

a. Notify the clients surgeon immediately.


b. Assess the clients blood pressure and pulse.
c. Reinforce the dressing with additional dressing.
d. Check the clients last hemoglobin and hematocrit level.

75. The client is taking calcium carbonate (Tums) to help prevent further
development of osteoporosis. Which teaching should the nurse implement?

a. Encourage the client to take Tums with at least eight (8) ounces of
water.
b. Teach the client to take Tums with the breakfast meal only.
c. Instruct the client to take Tums 30 to 60 minutes before a meal.
d. Discuss the need to get a monthly serum calcium level.

76. Which foods should the nurse recommend to a client when discussing
sources of dietary calcium?

a. Yogurt and dark-green, leafy vegetables.


b. Oranges and citrus fruits.
c. Bananas and dried apricots.
d. Wheat bread and bran.

77. The nurse is teaching a class to pregnant teenagers. Which


information is most important when discussing ways to prevent
osteoporosis?
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a. Take at least 1200 mg of calcium supplements a day.


b. Eat foods low in calcium and high in phosphorus.
c. Osteoporosis does not occur until around age 50 years.
d. Remain as active as possible until the baby is born.

78. The nurse is caring for clients on a surgical unit. Which nursing task
would be most appropriate for the nurse to delegate to an unlicensed
nursing assistant?

a. Help the client with a 2-day postop amputation put on the prosthesis.
b. Request the assistant double-checks a unit of blood that is being
hung.
c. Change the surgical dressing on the client with a Syme amputation.
d. Ask the assistant to take the client to the physical therapy
department.

79. The 62-year-old client diagnosed with Type 2 diabetes who has a
gangrenous right toe is being admitted for a BKA amputation. Which
nursing intervention should the nurse implement?

a. Assess the clients nutritional status.


b. Refer the client to an occupational therapist.
c. Determine if the client is allergic to IVP dye.
d. Start a 22-gauge Angiocath in the right arm.

80. The Jewish client with peripheral vascular disease is scheduled for a
left AKA. Which question would be most important for the operating room
nurse to ask the client?

a. Have you made any special arrangements for your amputated limb?
b. What types of food would you like to eat while youre in the
hospital?
c. Would like the rabbi to visit you while you are in the recovery
room?
d. Will you start checking your other foot at least once a day for
cuts?

81. The recovery room nurse is caring for a client that has just had a
left BKA. Which intervention should the nurse implement?

a. Assess the clients surgical dressing every two (2) hours.


b. Do not allow the client to see the residual limb.
c. Keep a large tourniquet at the clients bedside.
d. Perform passive range-of-motion exercises to the right leg.

82. The client is 3 hours postoperative left AKA. The client tells the
nurse, My left foot is killing me. Please do something. Which
intervention should the nurse implement?

a. Explain to the client that his left leg has been amputated.
b. Medicate the client with a narcotic analgesic immediately.
c. Instruct the client on how to perform biofeedback exercises.
d. Place the clients residual limb in the dependent position.

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83. The client with a right AKA is being taught how to toughen the
residual limb. Which intervention should the nurse implement?

a. Instruct the client to push the residual limb against a pillow.


b. Demonstrate how to apply an elastic bandage around the residual limb.
c. Encourage the client to apply vitamin B12 to the surgical incision.
d. Teach the client to elevate the residual limb at least three times a
day.

84. During the morning assessment, the nurse determines that the 80-
year-old client admitted with a fractured right femoral neck is confused.
Which action should the nurse implement first?

a. Check for a positive Homans sign.


b. Encourage the client to take deep breaths and cough.
c. Assess the left pedal pulse.
d. Monitor the clients Bucks traction.
Musculoskeletal
85. A persons right thumb was accidentally severed with an axe. The
amputated right thumb was recovered. Which action would preserve the
thumb so that it could possibly be reattached in surgery?

a. Place the right thumb directly on some ice.


b. Put the right thumb in a glass of warm water.
c. Wrap the thumb in a clean piece of material.
d. Secure the thumb in a plastic bag and place on ice.

86. The nurse is preparing the plan of care for the client with an open
fracture of the right arm. Which problem has the highest priority?

a. Anger related to the inability to perform ADLs.


b. Sleep disturbances related to loss of work.
c. Infection related to exposed tissue.
d. Altered body image related to scarring.

87. When preparing the nursing care plan for a client with a fractured
lower extremity, which would be the most appropriate treatment outcome
for the nurse to include?

a. The client will maintain function of the leg.


b. The client will ambulate with assistance.
c. The client will be turned every two (2) hours.
d. The client will have no infection.

88. When assessing the client 6 hours after having a right total knee
replacement, which data should the nurse report to the surgeon?

a. A total of 100 mL of red drainage in the auto transfusion drainage


system.
b. Pain relief after using the patient-controlled analgesia (PCA) pump.
c. Cool toes, distal pulses palpable, and pale nail beds bilaterally.
d. Urinary output of 60 mL of clear yellow urine in 3 hours.

89. The male nurse is helping his friend cut wood with an electric saw.
His friend cut two fingers of his left hand off with the saw. Which
action should the nurse implement first?
Exam Code HAAD5
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a. Wrap the left hand with towels and apply pressure.


b. Instruct the neighbor to hold his hand above his head.
c. Apply pressure to the radial artery of the left hand.
d. Go into the neighbors house and call 911.

90. The unlicensed nursing assistant (NA) notifies the nurse of the vital
signs of a 28-yearold male client admitted the previous day with a
fractured femur. The NA reports a temperature of 101_F; pulse 115;
respiratory rate 28; copious amounts of thick, white sputum; and globs
floating in the urinal. What intervention should the nurse implement first?

a. Assess the client for dyspnea, breath sounds, and altered mental
status.
b. Draw blood for arterial blood gases and order a portable chest x-ray.
c. Call the health-care provider for an order to administer an antibiotic.
d. Instruct the assistant to encourage the client to deep breathe.

91. Which statement by the client diagnosed with a fractured ulna would
indicate that the nurse needs to do further teaching?

a. I need to eat a high-protein diet to ensure healing.


b. I need to wiggle my fingers every hour to increase circulation.
c. I need to take my pain medication before my pain is too bad.
d. I need to keep this immobilizer on when lying down only.

92. The nurse is preparing a plan of care for the client who has had a
total hip replacement. Which outcome would be most appropriate for this
client?

a. The client has limited amount of pain relief.


b. The client will have limited ability to ambulate.
c. The client will have hip instability for several months.
d. The client will have adequate hip joint motion.

93. An 88-year-old client is admitted to the orthopedic floor with the


diagnosis of fractured pelvis. What intervention should the nurse
implement first?

a. Insert an indwelling catheter.


b. Administer a Fleets enema.
c. Assess abdomen for bowel sounds.
d. Apply Bucks traction.

94. When preparing the discharge teaching for the 12-year-old with a
fractured humerus, which information should the nurse include regarding
cast care?

a. Keep the arm at heart level.


b. Handle the cast with the tips of the fingers only.
c. Apply an ice pack to any area that itches.
d. Foul smells are expected occurrences.

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95. When preparing the client for the transition to home rehabilitation
after having a total knee replacement, which information regarding
discharge teaching would the nurse include?

a. Deep breathe and cough every two (2) hours.


b. Procedure for emptying Jackson-Pratt drainage.
c. Burning or frequency of urination is expected.
d. Modify the home for altered mobility.

96. The client that is 1 day postoperative total hip replacement complains
of hearing a popping sound when turning. What assessment data should
the nurse report immediately to the surgeon?

a. Dark redpurple discoloration.


b. Equal length of lower extremities.
c. Groin pain in the affected leg.
d. Edema at the incision site.

97. The nurse is caring for the client who had a total knee replacement
(TKR). Which data would the nurse observe to determine if the nursing
interventions are effective?

a. The clients lungs have bilateral crackles.


b. The clients knee has flexion of 45 degrees.
c. The client participates in self-care activities.
d. The client has reduced pain using a single approach.

98. The nurse is preparing the preoperative client for a total hip
replacement. Which information should the nurse include concerning
postoperative care?

a. Keep abduction pillow in place between legs at all times.


b. Cough and deep breathe at least every 4 to 5 hours.
c. Turn to both sides every 2 hours to prevent pressure ulcers.
d. Sit in a high-seated chair for a flexion of less than 90 degrees.

99. The nurse is assessing the client who is immediately postoperative


from a total knee replacement. Which assessment data would warrant
immediate intervention?

a. T 99_F, HR 80, RR 20, and BP 128/76.


b. Pain in the unaffected leg during dorsiflexion of the ankle.
c. Bowel sounds heard intermittently in four quadrants.
d. Diffuse, crampy abdominal pain.

100. When assessing the wound of a client who had a total hip
replacement, the nurse finds small, fluid-filled lesions on the right side of
the dressing. What explanation is the most probable rationale for this
occurrence?

a. These were caused by the cautery unit in the operating room.


b. These are papular wheals from herpes zoster.
c. These are blisters from the tape used to anchor the dressing.
d. These macular lesions are from a latex allergy.

Exam Code HAAD5


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