The nurse is developing a plan of care for a 65-year-old ANSWER: D
patient, focusing on preventive health care. While planning
this care, the nurse understands that the aging process is Rationale: Immobility drives muscle and bone loss, cardiac and respiratory decline,
most affected by which factor? and skin breakdown, making it the biggest physiologic driver of aging decline.
Hobbies and interests affect psychosocial wellbeing, not the physical aging process.
A. Hobbies and interests Financial issues affect access to resources and care, not physiology. Age at
B. Financial issues retirement is just a life-stage marker with no direct physiologic effect.
C. Age at retirement
D. Immobility
What disorder may cause immobility in the older adult? ANSWER: A
A. Stroke Rationale: Stroke can cause hemiparesis, hemiplegia, or significant motor and
B. Carpel tunnel balance deficits, directly leading to prolonged immobility in older adults. Carpal
C. Minor burns tunnel syndrome affects wrist and hand function but does not typically cause overall
D. Multiple personalities immobility. Minor burns are localized and generally do not impair mobility
significantly. Multiple personalities is a psychiatric condition with no direct physical
mobility impact.
A female patient with systemic lupus erythematosus (SLE) ANSWER: C
complains of photosensitivity. The LPN/LVN should instruct
the patient on which self-care measure? Rationale: Photosensitivity in SLE means UV exposure can trigger or worsen skin
rashes and disease flares, so sunblock and sun protective measures are the key
A. Include foods high in betacarotene in her diet. self-care instruction. Betacarotene has no established role in managing
B. Use a tanning bed once per week to help with rashes. photosensitivity. Tanning beds directly worsen photosensitivity and can trigger
C. Wear sunblock whenever she is outdoors. flares. Managing joint pain with medication is important general SLE care but does
D. Manage joint pain with prescribed medications. not address the photosensitivity complaint specifically.
The patient presents to the clinic after falling from her bike ANSWER: A, B, D, E, F
and is diagnosed with a Grade II ankle sprain. The nurse
should make which statements to the patient regarding the Rationale: RICE therapy is the standard for ankle sprains, rest, ice for swelling
treatment of her sprained ankle? (Select all that apply.) control, compression with an elastic bandage, and elevation to reduce edema all
apply. Stimulant laxatives are appropriate teaching since narcotic pain medications
A. Rest your ankle as much as possible. commonly cause constipation. Option C is incorrect because a Grade II sprain
B. Place an ice pack on your ankle for 30 minutes every 4 involves partial ligament tearing with instability, so early full ambulation within 24
hours. hours risks re-injury.
C. Begin walking on your injured ankle after 24 hours, and
increase your ambulation as tolerated.
D. You should wrap your ankle with an elastic bandage.
E. Prop your ankle on pillows while resting.
F. Take stimulant laxatives with your narcotic pain
medication.
The patient presents to the clinic with a compound fracture ANSWER: D, E
of the right leg. The nurse anticipates the administration of
which classes of medications? (Select all that apply.) Rationale: A compound fracture breaks the skin, creating a direct portal for bacterial
contamination, so tetanus prophylaxis and IV antibiotics are standard anticipated
A. Hepatitis B vaccine treatment to prevent tetanus and wound infection or osteomyelitis. Hepatitis B
B. Aspirin vaccine is not indicated for fracture management. Aspirin is not the anticipated
C. Corticosteroids medication class here and can increase bleeding risk in trauma. Corticosteroids are
D. Tetanus booster not part of standard open fracture management and can impair wound and bone
E. IV antibiotics healing.
The nurse is preparing to care for a patient who requires ANSWER: D
skeletal traction. The nurse knows which statement is true
regarding skeletal traction? Rationale: Skeletal traction involves pins or wires inserted directly into the bone,
creating an open pathway for pathogens, so pin site infection and osteomyelitis are
A. It uses a series of removable pins, ropes, and weights significant risks. Option A is incorrect because pins are surgically inserted, not
to realign bones. simply removable. Option B is incorrect because weights are prescribed and should
B. It requires nurses to frequently assess and modify the never be adjusted by the nurse without a provider's order. Option C is incorrect
amount of weight applied. because skeletal traction can be used for fractures of the upper extremities, cervical
C. It is used for only fractures of the lower extremity bones. spine, and other sites.
D. It has a high risk of infection.
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, Medical-Surgical Nursing 2 Exam 1 | Practice Questions & Answers | Comprehensive Exam Prep
Which nursing action is most appropriate for monitoring a ANSWER: C
patient with a casted lower extremity for infection?
Rationale: A foul odor from the cast combined with rising temperature trends is a
A. Assess vital signs every hour while the patient is awake. classic early sign of infection developing underneath a cast. Removing the cast
B. Remove the cast weekly to check the wound for signs of weekly or bi-weekly is inappropriate and not standard practice, casts are only
infection. removed by a provider when clinically indicated. Hourly vital signs is excessive and
C. Assess temperature trends and sniff around the cast for not the targeted, appropriate monitoring approach.
signs of foul odor.
D. Remove the cast bi-weekly to check the wound for
signs of infection.
The nurse is caring for a client who is at risk for ANSWER: D
contracture after orthopedic surgery. Which of the following
would be an appropriate position to place the client in? Rationale: Dorsal recumbent positioning keeps the extremities in proper anatomical
alignment, helping prevent flexion contractures. Orthopneic positioning is used to
A. Orthopneic ease breathing, not contracture prevention. Lateral positioning can promote hip and
B. Lateral knee flexion if not carefully managed, increasing contracture risk. Dangling is a
C. Dangling transitional position used before ambulation, not a sustained position for contracture
D. Dorsal recumbent prevention.
The nurse is caring for a client who needs to be turned. ANSWER: B
What is the term for turning all of the client at one time?
Rationale: Log-rolling turns the entire body as one unit while maintaining spinal
A. Proning alignment, essential for clients with spinal precautions or after spinal or hip surgery.
B. Log-rolling Proning refers to positioning a client face-down. Ambulating refers to walking.
C. Ambulating Dangling refers to sitting at the edge of the bed with legs hanging.
D. Dangling
The LPN/LVN is caring for a patient in a long-term care ANSWER: C
setting. Which of these interventions is put into place when
a resident requires restraints? Rationale: Restraint use follows a strict hierarchy where alternatives must be
attempted and documented as ineffective before restraints are applied. Physician
A. The physicians order for restraint is renewed every 48 orders for restraints typically require renewal every 24 hours, not 48. Restrained
hours. residents need visual checks much more frequently than every 2 hours, typically
B. The nurse must obtain permission from family before every 15 to 30 minutes. Family permission is not the requirement, consent comes
applying restraints. from the patient or their legal decision-maker plus a provider's order.
C. Before applying a restraint, the least restrictive method
is tried first.
D. The restrained resident must be checked visually every
2 hours.
A patient with AIDS becomes short of breath and fatigued ANSWER: C
while completing activities of daily living. Which measure
should be included in the patient's care to promote Rationale: Alternating activity with rest allows the patient to complete ADLs within
independence? their energy limits while still promoting independence. Relaxation techniques help
with anxiety or stress but do not directly address energy conservation. Discouraging
A. Teaching relaxation techniques outside stimuli is not relevant to managing exertional dyspnea and fatigue.
B. Discouraging outside stimuli Assessing pain frequently does not address the stated problem, which is an energy
C. Alternating periods of activity with periods of rest tolerance issue, not a pain issue.
D. Assessing the patient's level of pain frequently
Which clinical sign or symptom might indicate a diagnosis ANSWER: B
of Hodgkins lymphoma?
Rationale: Painless lymphadenopathy, often first noticed in the neck, is a classic
A. Sudden weight gain presenting sign of Hodgkin's lymphoma. Sudden weight gain is not associated with
B. Lymphadenopathy in the neck Hodgkin's lymphoma, unintentional weight loss is one of the classic B symptoms
C. Diarrhea stools instead. Diarrhea is not a hallmark symptom. Hodgkin's lymphoma nodes are
D. Widespread painfully enlarged lymph nodes classically painless, not painfully enlarged.
The nurse is assisting the patient to use the 4-point gait ANSWER: B
with crutches. Which behavior by the patient demonstrates
understanding? Rationale: The 4-point gait follows a specific alternating sequence, right crutch, left
foot, left crutch, right foot, so advancing the right crutch first demonstrates correct
A. The patient initially advances the left crutch. understanding. Starting with the left crutch does not follow the standard teaching
B. The patient initially advances the right crutch. sequence. Advancing a foot first breaks the alternating crutch-then-opposite-foot
C. The patient initially advances the right foot. sequence that defines this gait.
D. The patient initially advances the left foot.
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, Medical-Surgical Nursing 2 Exam 1 | Practice Questions & Answers | Comprehensive Exam Prep
The nurse is caring for a patient who has had a knee ANSWER: C
replacement. On postoperative day 1, the LPN/LVN can
likely anticipate which change in the plan of care? Rationale: Quadriceps setting exercises are typically initiated early, often
postoperative day 1, to maintain muscle strength and prevent atrophy. Walker
A. Walker training training usually comes slightly later once the patient is medically stable and cleared
B. Cessation of pain medication by physical therapy. Pain medication is not stopped this early. Enemas until clear
C. Quadriceps setting exercises are not part of standard postoperative knee replacement care.
D. Enemas until clear
The nurse is providing education to a middle-aged female ANSWER: A, B, D
about her changing health needs. The nurse should be
sure to include information on which age-related changes? Rationale: Decreased height occurs due to vertebral disc thinning and loss of bone
(Select all that apply.) density with aging. Decreased muscle mass is a well-documented age-related
change. Loss of bone mass, especially significant in postmenopausal women, is a
A. Decrease in height key age-related change to teach. Mineral exchange actually decreases with aging,
B. Decreased muscle mass not increases. Circulation typically decreases with aging due to vascular changes,
C. Increased mineral exchange not increases.
D. Loss of bone mass
E. Increased circulation
When assigned to care for a patient who has gout, the ANSWER: C
LPN/LVN should assess for which condition?
Rationale: Gout classically presents with acute swelling and severe pain in a single
A. Decreased range of motion of most joints joint, most often the big toe, due to uric acid crystal deposition. Decreased range of
B. Evidence of unilateral joint deformity motion of most joints is more characteristic of osteoarthritis or rheumatoid arthritis.
C. Swelling and pain in the big toe or other joint Unilateral joint deformity is not the classic presenting sign of gout. Vertebral
D. Signs of compression of the spine from collapsed compression is associated with osteoporosis, not gout.
vertebrae
The nurse is providing teaching to a group of nursing ANSWER: A, B, E
students regarding CVA (stroke). The students
demonstrate an understanding of the teaching when listing Rationale: Hemorrhagic stroke results from vessel rupture, and ischemic stroke
which factors as being the possible cause of a stroke? results from atherosclerotic plaque leading to thrombosis, both are established
(Select all that apply.) stroke mechanisms. Meningococcal meningitis and cerebral encephalitis are
infectious or inflammatory conditions that can cause neurologic symptoms but are
A. Cerebral hemorrhage not classified as causes of stroke itself.
B. Atherosclerosis of the arteries in the head and neck
C. Meningococcal meningitis
D. Cerebral encephalitis
E. Cerebral thrombosis
The nurse is caring for a patient who has undergone a ANSWER: A
lumbar puncture in order to run tests on the cerebrospinal
fluid (CSF). The nurse knows which laboratory value is Rationale: Normal CSF WBC count is 0 to 5/mm3, so 100/mm3 is markedly
abnormal? elevated and indicates infection or inflammation. Glucose 60 mg/100 mL, a clear
colorless appearance, and total protein 40 mg/100 mL all fall within normal CSF
A. White blood cells (WBCs) 100/mm3 reference ranges.
B. Glucose 60 mg/100 mL
C. Clear, colorless appearance
D. Total protein 40 mg/100 mL
The student nurse is assisting the nurse in turning a ANSWER: D
patient who is in cervical traction. What is most important
for the LPN/LVN to instruct the student to do when Rationale: This is the log-rolling principle, essential to maintaining spinal alignment
assisting in turning the patient? during cervical traction. Keeping the spine slightly flexed, flexing the knees and
hips, or flexing the neck with a pillow would risk spinal malalignment, when cervical
A. Place the patient's back in traction so that the spine will traction specifically requires neutral positioning.
be kept slightly flexed.
B. Flex the knees and hips before turning the patient.
C. Support the patient's head with a pillow so that his neck
is flexed.
D. Turn the patient slowly and as one unit to avoid twisting
the spine.
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