1.

A client who has experience a cerebrovascular accident (CVA) has partial

hemiplegia of the left leg. The straight-leg cane formerly used by the client is not
quite sufficient now. The nurse interprets that the client could benefit from the
somewhat greater support and stability provided by which of the following?

A. Quad-cane
B. Wooden crutch
C. Lofstrand crutch
D. Wheelchair

2. A nurse witness a client sustain fall and suspect that the leg may be broken.
Which of the following actions is the highest priority of the nurse?

A. Take a set of vital signs

B. Call the radiology department
C. Reassure the client that everything will be alright
D. Immobilize the leg before moving the client

3. A nurse is giving the client with a left leg cast crutch-walking instructions using
the three-point gait. The client is allowed touchdown of the affected leg. The
nurse tells the client to advance the:

A. Left leg and right crutch, then right leg and left6 crutch
B. Crutches and then both legs simultaneously
C. Crutches then the right leg, then advance the left leg
D. Crutches and the left leg, then advance the right leg

4. A client has undergone fasciotomy to treat compartment syndrome of the leg. The
nurse would plan to provide which type of wound care to the fasciotomy site?

A. Dry sterile dressing

B. Moist sterile saline dressings
C. Hydrocolloid dressings
D. One-half strength Betadine dressings

5. A nurse is caring for an elderly client who had a pinned hip after being fractured.
In planning nursing care, which of the following would the nurse avoid to
minimize the chance for further injury?

A. Side rails up in the up position

B. Use of a nightlight in hospital room and bathroom
C. Call bell placed within reach
D. Delays in the responding to the call light
6. A nurse has taught the client with a below-the-knee amputation about prosthesis
and stump care. The nurse would evaluate that the client has understood the
instructions if the client has states if he/she should:

A. Wear a clean nylon stump sock daily

B. Toughen the skin of the stump by rubbing it with alcohol
C. Prevent cracking of the skin of the stump by applying lotion daily
D. Using a mirror to inspect all areas of the stump each day

7. A nurse is planning to teach a client proper use of thoracolumbosacral orthosis

(TLSO) after spinal fusion with instrumentation. The nurse would plan to include
which of the following teaching points in the discussion with the client?

A. Areas of skin redness at the edge of the brace indicate a good, snug fit
B. The device is applied before getting out of bed in the morning
C. The brace should be applied directly next to the skin
D. The Velcro closures should be fairly loose to avoid constriction

8. A client with a herniated invertebral lumbar disk complains of knife-like stabbing

pain in the lower back, as well as pain radiating into the right buttock. The nurse
interprets that the sharp stabbing pain is probably the result of:

A. Muscle spasm in the area of the herniated disk

B. Pressure on the spinal cord
C. Pressure on the spinal nerve root
D. Excess CSF production in the area

9. A nurse has an order to place a client with a herniated lumbar invertebral disc on
bed rest in William’s position to minimize the pain. The nurse plans to put the
bed:

A. In high-fowler’s position with the foot of bed flat

B. In semi-fowler’s position with the knee gatch slightly raised
C. In semi-fowler’s position with the foot of the bed flat
D. Flat with the knee gatch raised

10. A client is being discharge to home after spinal fusion with insertion of
Harrington rods. The nurse would consult with the continuing care nurse about
the need for follow-up modification of the home environment if the client states
that:

A. The bedroom and the bathroom are on the second floor of the home
B. The bathroom has hand railings in the shower
C. The family has rented a commode for use by the client
D. There are three steps to get up to the front door
11. A client has just been admitted to the hospital with a fractured femur and pelvic
fractures. The nurse plans to monitor the client carefully for which of the
following signs and symptoms?

A. Tachycardia and hypotension

B. Bradycardia and hypertension
C. Fever, bradycardia
D. Fever, hypertension

12. A nurse in the emergency room is assessing a client with an open leg fracture. The
nurse inquires about the date of the client’s last:

A. Physical examination
B. Chest radiograph
C. Tetanus vaccine
D. Tuberculin test