N4010 Exam 1
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 immobility?
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
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
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.
A nurse is conducting a primary survey of a client who has sustained life-threatening
injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should
take.
A. Perform a Glasgow Coma Scale assessment.
B. Establish IV access.
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
E. Remove clothing for a thorough assessment.
C, D, B, A, E
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? (Select all that apply.)