EMS 105 EXAM 2 QUESTIONS WITH 100%
CORRECT ANSWERS.
The nurse is monitoring a confused older client admitted to the hospital with a hip fracture.
Which data obtained by the nurse could place the client at increased risk for disturbed
thought processes?
1.Relatives at the bedside
2.Eyeglasses left at home
3.Familiar hospital setting
4.Hearing aid available and in working order
2
The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate
food items to include in the diet. The nurse tells the client that which food item would
provide the least amount of calcium?
1.Pork
2.Seafood
3.Sardines
4.Plain yogurt
1
The nurse is caring for a client who has had spinal fusion with insertion of hardware. The
nurse should be especially concerned with which finding?
1.An oral temperature of 101° F orally
2.Complaints of discomfort during repositioning
3.Old bloody drainage outlined on the surgical dressing
4.Discomfort during coughing and deep breathing eercises
1
,The nurse is caring for a client following total hip replacement who has a wound suction
drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the
wound-suction device. Based on this amount of drainage, which action is appropriate?
1.Document the findings.
2.Place the leg in a flat position.
3.Check the client's blood pressure.
4.Immediately notify the health care provider.
1
A client being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse should respond knowing that which can
occur if the crutches rest underneath the arm?
1.A fall and further injury
2.Injury to the brachial plexus nerves
3.Skin breakdown in the area of the axilla
4.Impaired range of motion while the client ambulates
2
The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse
monitors for which priority finding specifically related to this injury?
1.Leakage of clear fluid from the nose
2.Inability to breathe through one nare
3.Hematoma formation around the eyes
4.Edema noted around the nose and eyes
1
This morning a client sustained a right proximal fibula and tibia fracture that was casted
in a long leg plaster cast. During evening rounds, the nurse notes that the right lower
extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky.
,The client states that the pain medication is not working anymore and that the right foot
feels like it is asleep. The nurse analyzes the data and determines that the client's symptoms
are indicative of which complication?
1.Fat embolism
2.Venous thrombosis
3.Volkmann's thrombosis
4.Compartment syndrome
4
The nurse has a prescription to place a client with a herniated lumbar intervertebral disk
on bed rest to minimize the pain. The nurse plans to put the bed in which position?
1.Flat with the knee gatch raised
2.In semi-Fowler's position with the foot of the bed flat
3.In high-Fowler's position with the foot of the bed flat
4.In semi-Fowler's position with the knee gatch slightly raised
4
A client has undergone total hip replacement of the right hip, which was damaged by
osteoarthritis. Which action should be included in the postoperative plan of care?
1.Assist the client in keeping her legs as close together as possible.
2.Ensure the client receives her daily tablet of enoxaparin (Lovenox).
3.Remind the client to use a handrail if she is lowering her hips into a 120-degree flexion.
4.Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively.
4
During admission data collection, the nurse asks the client to run the heel of one foot down
the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg
being tested and concludes that the client has interference in which area?
, 1.Sensation and reflexes
2.Balance and coordination
3.Bowel and bladder control
4.Muscle strength and flexibility
2
A client has sustained a closed fracture and has just had a cast applied to the affected arm.
The client is complaining of intense pain. The nurse has elevated the limb, applied an ice
bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse
interprets that this pain may be caused by which condition?
1.Infection under the cast
2.The anxiety of the client
3.Impaired tissue perfusion
4.The newness of the fracture
3
The nurse is caring for the client who has skeletal traction applied to the left leg. The client
complains of severe left leg pain. The nurse checks the client's alignment in bed and notes
that proper alignment is maintained. Which action should the nurse take next?
1.Provide pin care.
2.Medicate the client.
3.Notify the registered nurse.
4.Remove 2 pounds of weight from the traction.
3
A postoperative client received a spinal anesthetic. The client has not experienced pain
because the anesthetic has not yet worn off. The nurse will monitor the client closely for
pain and provide the client with which instruction?
1."I will be bringing your pain medication at 10:00 pm."
CORRECT ANSWERS.
The nurse is monitoring a confused older client admitted to the hospital with a hip fracture.
Which data obtained by the nurse could place the client at increased risk for disturbed
thought processes?
1.Relatives at the bedside
2.Eyeglasses left at home
3.Familiar hospital setting
4.Hearing aid available and in working order
2
The nurse is reinforcing instructions to a client with osteoporosis regarding appropriate
food items to include in the diet. The nurse tells the client that which food item would
provide the least amount of calcium?
1.Pork
2.Seafood
3.Sardines
4.Plain yogurt
1
The nurse is caring for a client who has had spinal fusion with insertion of hardware. The
nurse should be especially concerned with which finding?
1.An oral temperature of 101° F orally
2.Complaints of discomfort during repositioning
3.Old bloody drainage outlined on the surgical dressing
4.Discomfort during coughing and deep breathing eercises
1
,The nurse is caring for a client following total hip replacement who has a wound suction
drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the
wound-suction device. Based on this amount of drainage, which action is appropriate?
1.Document the findings.
2.Place the leg in a flat position.
3.Check the client's blood pressure.
4.Immediately notify the health care provider.
1
A client being measured for crutches asks the nurse why the crutches cannot rest up
underneath the arm for extra support. The nurse should respond knowing that which can
occur if the crutches rest underneath the arm?
1.A fall and further injury
2.Injury to the brachial plexus nerves
3.Skin breakdown in the area of the axilla
4.Impaired range of motion while the client ambulates
2
The nurse is assisting with care for a client who has sustained a nasal fracture. The nurse
monitors for which priority finding specifically related to this injury?
1.Leakage of clear fluid from the nose
2.Inability to breathe through one nare
3.Hematoma formation around the eyes
4.Edema noted around the nose and eyes
1
This morning a client sustained a right proximal fibula and tibia fracture that was casted
in a long leg plaster cast. During evening rounds, the nurse notes that the right lower
extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky.
,The client states that the pain medication is not working anymore and that the right foot
feels like it is asleep. The nurse analyzes the data and determines that the client's symptoms
are indicative of which complication?
1.Fat embolism
2.Venous thrombosis
3.Volkmann's thrombosis
4.Compartment syndrome
4
The nurse has a prescription to place a client with a herniated lumbar intervertebral disk
on bed rest to minimize the pain. The nurse plans to put the bed in which position?
1.Flat with the knee gatch raised
2.In semi-Fowler's position with the foot of the bed flat
3.In high-Fowler's position with the foot of the bed flat
4.In semi-Fowler's position with the knee gatch slightly raised
4
A client has undergone total hip replacement of the right hip, which was damaged by
osteoarthritis. Which action should be included in the postoperative plan of care?
1.Assist the client in keeping her legs as close together as possible.
2.Ensure the client receives her daily tablet of enoxaparin (Lovenox).
3.Remind the client to use a handrail if she is lowering her hips into a 120-degree flexion.
4.Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively.
4
During admission data collection, the nurse asks the client to run the heel of one foot down
the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg
being tested and concludes that the client has interference in which area?
, 1.Sensation and reflexes
2.Balance and coordination
3.Bowel and bladder control
4.Muscle strength and flexibility
2
A client has sustained a closed fracture and has just had a cast applied to the affected arm.
The client is complaining of intense pain. The nurse has elevated the limb, applied an ice
bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse
interprets that this pain may be caused by which condition?
1.Infection under the cast
2.The anxiety of the client
3.Impaired tissue perfusion
4.The newness of the fracture
3
The nurse is caring for the client who has skeletal traction applied to the left leg. The client
complains of severe left leg pain. The nurse checks the client's alignment in bed and notes
that proper alignment is maintained. Which action should the nurse take next?
1.Provide pin care.
2.Medicate the client.
3.Notify the registered nurse.
4.Remove 2 pounds of weight from the traction.
3
A postoperative client received a spinal anesthetic. The client has not experienced pain
because the anesthetic has not yet worn off. The nurse will monitor the client closely for
pain and provide the client with which instruction?
1."I will be bringing your pain medication at 10:00 pm."
