1 A nurse is assessing for early signs of compartmentsyndrome for a client who has a short−leg fiberglass

cast. Which of the following findings should the nurse expect?

A. Capillary refill less than 2 seconds

B. Bounding distal pulses

C. Intense pain with movement

D. Erythema of the toes

2 A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following

manifestations indicates a hemolytic transfusion reaction?

A. Chills ? (think fever, you get cold when your body is hot)

B. Hypertension

C. Bradycardia

D. Back pain

3 A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should the

nurse take to prevent hip dislocation?

A. Remove the wedge device when turning

B. Place two bed pillows between the legs when in bed

C. Encourage the clientto lean forward when attempting to stand

D. Elevate the knees higher than the hips when sitting

4 A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should

recognize thatthe client is at risk for an allergic cross−reactivity to which of the following substances

A. Povidone−iodine

B. Adhesive tape

C. Latex

D. Anesthetics

5 A nurse isteaching a client about the use of an incentive spirometer. Which of the following

instructions should the nurse include in the teaching?

A. Place hands on the upper abdomen during inhalation.

B. Position the mouthpiece 2.5 cm (1 in) from the mouth

C. Exhale slowly through pursed lips

D. Hold breaths about 3 to 5 seconds before exhaling