Medical-Surgical Nursing II (MS2) – Exam 4: Chapter 47
Summary and Practice Questions
1. A nurse assesses a client with a fracture who is being treated with skeletal traction. Which
assessment should alert the nurse to urgently contact the health provider? A. Blood pressure
increases to 130/86 mm Hg
b. Traction weights are resting on the floor
c. Oozing of clear fluid is noted at the pin site
d. Capillary refill is less than 3 seconds - correct answer ✔✔ B
2. A nurse coordinates care for a client with a wet plaster cast. Which statement should the
nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)?
a. Assess distal pulses for potential compartment syndrome.
b. Turn the client every 3 to 4 hours to promote cast drying.
c. Use a cloth-covered pillow to elevate the clients leg.
d. Handle the cast with your fingertips to prevent indentations. - correct answer ✔✔ C
3. A nurse obtains the health history of a client with a fractured femur. Which factor identified in
the clients history should the nurse recognize as an aspect that may impede healing of the
fracture?
a. Sedentary lifestyle
b. A 30pack-year smoking history
c. Prescribed oral contraceptives
d. Pagets disease - correct answer ✔✔ D
4. An emergency department nurse cares for a client who sustained a crush injury to the right
lower leg. The client reports numbness and tingling in the affected leg. Which action should the
nurse take first?
, a. Assess the pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Loosen the traction. - correct answer ✔✔ A
5. A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The
nurse notes that the client is confused and restless. The clients vital signs are heart rate 98
beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%.
Which action should the nurse take first?
a. Administer oxygen via nasal cannula.
b. Re-position to a high-Fowlers position.
c. Increase the intravenous flow rate.
d. Assess response to pain medications. - correct answer ✔✔ A
6. A trauma nurse cares for several clients with fractures. Which client should the nurse identify
as at highest risk for developing deep vein thrombosis?
a. An 18-year-old male athlete with a fractured clavicle
b. A 36-year old female with type 2 diabetes and fractured ribs
c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis
d. A 74-year-old man who smokes and has a fractured pelvis - correct answer ✔✔ D
7. A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP).
Which statement should the nurse include when delegating hygiene care for this client?
a. Remove the traction when re-positioning the client.
b. Inspect the clients skin when performing a bed bath.
c. Provide pin care by using alcohol wipes to clean the sites.
d. Ensure that the weights remain freely hanging at all times. - correct answer ✔✔ D
Summary and Practice Questions
1. A nurse assesses a client with a fracture who is being treated with skeletal traction. Which
assessment should alert the nurse to urgently contact the health provider? A. Blood pressure
increases to 130/86 mm Hg
b. Traction weights are resting on the floor
c. Oozing of clear fluid is noted at the pin site
d. Capillary refill is less than 3 seconds - correct answer ✔✔ B
2. A nurse coordinates care for a client with a wet plaster cast. Which statement should the
nurse include when delegating care for this client to an unlicensed assistive personnel (UAP)?
a. Assess distal pulses for potential compartment syndrome.
b. Turn the client every 3 to 4 hours to promote cast drying.
c. Use a cloth-covered pillow to elevate the clients leg.
d. Handle the cast with your fingertips to prevent indentations. - correct answer ✔✔ C
3. A nurse obtains the health history of a client with a fractured femur. Which factor identified in
the clients history should the nurse recognize as an aspect that may impede healing of the
fracture?
a. Sedentary lifestyle
b. A 30pack-year smoking history
c. Prescribed oral contraceptives
d. Pagets disease - correct answer ✔✔ D
4. An emergency department nurse cares for a client who sustained a crush injury to the right
lower leg. The client reports numbness and tingling in the affected leg. Which action should the
nurse take first?
, a. Assess the pedal pulses.
b. Apply oxygen by nasal cannula.
c. Increase the IV flow rate.
d. Loosen the traction. - correct answer ✔✔ A
5. A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The
nurse notes that the client is confused and restless. The clients vital signs are heart rate 98
beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%.
Which action should the nurse take first?
a. Administer oxygen via nasal cannula.
b. Re-position to a high-Fowlers position.
c. Increase the intravenous flow rate.
d. Assess response to pain medications. - correct answer ✔✔ A
6. A trauma nurse cares for several clients with fractures. Which client should the nurse identify
as at highest risk for developing deep vein thrombosis?
a. An 18-year-old male athlete with a fractured clavicle
b. A 36-year old female with type 2 diabetes and fractured ribs
c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis
d. A 74-year-old man who smokes and has a fractured pelvis - correct answer ✔✔ D
7. A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP).
Which statement should the nurse include when delegating hygiene care for this client?
a. Remove the traction when re-positioning the client.
b. Inspect the clients skin when performing a bed bath.
c. Provide pin care by using alcohol wipes to clean the sites.
d. Ensure that the weights remain freely hanging at all times. - correct answer ✔✔ D
