MDC 2356
KEY NURSING ASSESSMENT INTERVENTIONS
[RASMUSSEN UNIVERSITY]
Exam 2
STUDY GUIDE
, 1. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause
for concern?
a. The nurse cannot insert one finger between the cast and the skin
b. The nurse finds 2+ pulses distal from the cast
c. The nurse assesses capillary refill of 2 seconds
d. The nurse does not observe any drainage.
2. What non-pharmacological intervention does not help reduce edema?
a. Cold therapy
b. passive range of motion (PROM)
c. Heat therapy
d. Elevation
3. What intervention by the nurse would be best to prevent deep vein thrombosis after a fracture of
the hip?
a. Encouraging bedrest
b. applying anti-embolism stockings
c. Teaching about smoking cessation
d. Tell the client to take anticoagulants
4. What is correct health promotion education for vision? (Select all that apply)
a. Wear sunglasses to filter ultraviolet (UV) light
b. Avoid nonsteroidal anti-inflammatory drug (NSAID) use
c. Older adults should have an eye exam every 3-5 years
d. wear eye protection when working with fluids
e. Wash your hands before touching your eyelids
5. What is the most common method of reducing and immobilizing a fracture?
a. Open reduction with external fixation
b. open reduction with internal fixation
c. External reduction and internal fixation
d. External fixation with closed reduction
6. The client reports a ringing in the ears. What is this called?
a. Rinne
b. Tinnitus
c. Pinna
d. Weber
7. The provider orders the client to be placed in a high fowler's position. At what angle will the nurse
position the client?
a. 0 degrees
b. 15 degrees
c. 30 degrees
d. 90 degrees
8. What is the priority nursing diagnosis for a client with immobility?
a. Constipation related to immobility
b. risk for disuse syndrome as evidenced by immobility
c. Risk of impaired skin integrity as evidenced by pressure over bony prominences
KEY NURSING ASSESSMENT INTERVENTIONS
[RASMUSSEN UNIVERSITY]
Exam 2
STUDY GUIDE
, 1. The nurse is assessing a client who had a cast placed 4 hours ago. What assessment finding is cause
for concern?
a. The nurse cannot insert one finger between the cast and the skin
b. The nurse finds 2+ pulses distal from the cast
c. The nurse assesses capillary refill of 2 seconds
d. The nurse does not observe any drainage.
2. What non-pharmacological intervention does not help reduce edema?
a. Cold therapy
b. passive range of motion (PROM)
c. Heat therapy
d. Elevation
3. What intervention by the nurse would be best to prevent deep vein thrombosis after a fracture of
the hip?
a. Encouraging bedrest
b. applying anti-embolism stockings
c. Teaching about smoking cessation
d. Tell the client to take anticoagulants
4. What is correct health promotion education for vision? (Select all that apply)
a. Wear sunglasses to filter ultraviolet (UV) light
b. Avoid nonsteroidal anti-inflammatory drug (NSAID) use
c. Older adults should have an eye exam every 3-5 years
d. wear eye protection when working with fluids
e. Wash your hands before touching your eyelids
5. What is the most common method of reducing and immobilizing a fracture?
a. Open reduction with external fixation
b. open reduction with internal fixation
c. External reduction and internal fixation
d. External fixation with closed reduction
6. The client reports a ringing in the ears. What is this called?
a. Rinne
b. Tinnitus
c. Pinna
d. Weber
7. The provider orders the client to be placed in a high fowler's position. At what angle will the nurse
position the client?
a. 0 degrees
b. 15 degrees
c. 30 degrees
d. 90 degrees
8. What is the priority nursing diagnosis for a client with immobility?
a. Constipation related to immobility
b. risk for disuse syndrome as evidenced by immobility
c. Risk of impaired skin integrity as evidenced by pressure over bony prominences
