AH2 Practice Exam with 100% correct Answers

AH2 Practice Exam with 100% correct Answers A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of mobility? a) a reddened area over the sacrum b) Stiffness in the lower extremities c) difficulty moving the upper extremities d) difficulty hearing some types of sounds - answera-this is a complication of immobility A nurse is assessing a client who has carpal tunnel syndrome. The nurse should expect which of the following findings? a) Decreased radial pulse b) Positive Chvostek's sign c) cool extremities d) positive Phalen's sign - answerd-this test is specifically for carpal tunnel (positive for tingling and numbness after wrist flexion for 60 seconds) A nurse is caring for a client who is postoperative following knee arthroplasty and has a continuous passive motion (CPM) machine. Which of the following actions should the nurse take? a) Store the CPM machine on the floor when not in use b) Use a special pillow to rotate the affected knee internally c) set the CPM to fully flex the knee joint d) apply ice to the operative knee - answerd-reduces edema, pain, and bruising A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a MVA. Identify the sequence of actions the nurse should take. 1) Perform GCS assessment 2) Establish IV access 3) Open the airway using jaw-thrust maneuver 4) determine effectiveness of ventilator efforts 5) remove clothing for a thorough assessment - answer3,4,2,1,5 A (airway), B (breathing), C (circulation), D (disability), E (exposure) A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (sata) a) Hypotension b) Polyuria c) Hyperthermia d) Absence of bowel sounds e) Weakened gag reflex - answera, d, e -hyperthermia isn't a concern for this, but hypothermia would be -polyuria is incorrect, we would look for b