1.

A trochanter roll is usually placed on the outer part of a paralyzed patient’s leg to
a. prevent external rotation of leg
2. Bone usually heal
a. 4-6 weeks
3. A disease is said to be endemic in character if
a. there is an accepted number of cases over a period of time
4. PRBC have been prescribed for a pt with low hemoglobin and hematocrit levels. The nurse takes the pt’s temp before
hanging the BT and records 100.6 F orally. Which action should the nurse take?
a. Delay hanging the blood and notify the physician
5. A pt is receiving a first-time BT of PRBC. How long should the nurse stay and monitor the pt to ensure a transfusion
reaction will not occur?
a. 15 minutes
6. A nurse is preparing to administer a cleansing enema to an adult pt in preparation for a diagnostic procedure. Which of
the ff are appropriate steps for the nurse to take?
a. Warm the enema solution prior to installation, position the pt on the left side with the right leg flexed forward
& lubricate the rectal tube or nozzle.
7. You pt has a chest tube. You are assessing the water seal chamber and you note that the water moves up as the pt
inhales and then moves down when the pt exhales. What may be causing this to happen?
a. This is normal and expected.
8. Following a thoracotomy, a pt has a pleural chest tube connected to water seal drainage. The pt suddenly has labored
breathing with an increase in heart rate & respiratory rate. Which of the ff actions will the nurse perform first?
a. Assess tubing for impaired drainage & patency
9. You are assisting a MD with the removal of a chest tube. What activity may the MD have the pt perform while the chest
tube is being removed?
a. Valsalva maneuver
10. Which nursing action would help to optimize the pt’s cerebral perfusion pressure (CPP)?
a. Treat fever with antipyretic as ordered
11. A pt being measured for crutches asks the nurse why the crutches can’t rest up underneath the arm for extra support.
The nurse’s response is based on the understanding that this could result in:
a. Injury to the brachial plexus nerves
12. Which of the ff is the most effective cleansing solution to complete pin site care?
a. Chlorhexidine
13. A pt whose left leg is in balanced suspension traction for a femur fracture needs to be moved to a new bed. The nurse
understands that this can be safely done as long as?
a. The line of pull is maintained on the left leg
14. Which intervention below would be appropriate to the nurse to teach the pt with a cast on his left arm?
a. Cover your plaster cast with plastic before taking a bath or shower
15. A fireman fell off a roof while fighting a house fire and fractured his femur. Approximately 24 hrs after the incident, the
nurse finds him dyspneic, tachypneic, with scattered crackles in his lung fields; he is coughing up large amounts of thick,
white sputum. The nurse correctly interprets this as?
a. Fat embolism syndrome r/t femur fracture
16. Which assessment would indicate the resolution of spinal shock?
a. Spastic involuntary movements in affected limbs
17. Based on the situation above, how would you position the pt on bed?
a. Semi fowler’s with head tilted to one side
18. Which of the ff assessments warrants the nurse to perform oropharyngeal suctioning?
a. Crackles
19. Which nursing precaution would you observe in relation to ketorolac administration?
a. Take bp before and after administration
20. An S2 medical license is required for the prescription of:
a. Regulated drugs
21. A nurse is going to feed a pt with stroke through NG tube. Which nursing responsibility is most important?
a. Aspirate gastric contents before feeding