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ORTHOPAEDIC NURSE CERTIFICATION EXAM (ONC)
PRACTICE TEST – 200 QUESTIONS WITH CORRECT
ANSWERS & DETAILED RATIONALES | LATEST 2026
EDITION
Introduction This comprehensive practice test is designed to prepare candidates for the Orthopaedic Nurses Certification (ONC) examination administered by the Orthopaedic Nurses Certification Board (ONCB). The 200 questions reflect the core domains of orthopaedic nursing practice, including musculoskeletal anatomy and physiology, assessment and diagnostic procedures, fracture management, joint replacement, spinal disorders, paediatric orthopaedics, metabolic bone diseases, trauma care, postoperative complications, rehabilitation principles, pharmacological interventions, and patient education. Each question is followed by the correct answer in bold and an italicized rationale explaining the clinical reasoning and evidence base. Use this test to identify knowledge gaps and reinforce critical concepts essential for safe, competent orthopaedic nursing practice.
Orthopaedic Nurse Certification Practice Test
Question 1 A 72-year-old female patient with osteoporosis presents after a fall. She reports severe groin and buttock pain with inability to bear weight on the right leg. The right leg appears shortened and externally rotated. The nurse suspects which condition? A) Hip dislocation B) Femoral neck fracture C) Pelvic ramus fracture D) Lumbar compression fracture Answer: B Rationale: Femoral neck fractures (intracapsular hip fractures) classically present with severe groin pain, inability to bear weight, and external rotation with shortening of the affected leg. This presentation is distinct from hip dislocation (more traumatic, leg typically internally rotated), pelvic fractures (tenderness over pubic symphysis/iliac crests), or lumbar fractures (back pain, no leg deformity). Question 2 A patient underwent total knee arthroplasty 6 hours ago. The nurse notes the patient's surgical leg is pale, cool to touch, and the patient reports new-onset numbness. Dorsalis pedis pulse is weak. What is the priority nursing action? A) Apply warm blankets to the leg B) Elevate the leg on two pillows C) Notify the surgeon immediately D) Continue routine postoperative monitoring
Question 4 A patient is 24 hours post-hip arthroscopy. The nurse should prioritize which patient position? A) Supine with hip flexed to 90 degrees B) Prone with legs extended C) Supine with operative leg in abduction D) Side-lying on the operative side Answer: C Rationale: After hip arthroscopy, patients should maintain the operative leg in abduction (usually with an abduction pillow) to prevent adduction that could cause dislocation or impingement of repaired structures. Supine positioning also protects the hip capsule. Hip flexion beyond 60-70 degrees (A) stresses the repair. Prone (B) is uncomfortable and risks pressure on portals. Side-lying on operative side (D) directly compresses portals and repair sites. Question 5 A nurse is teaching a patient with lumbar spinal stenosis about non-surgical management. Which instruction is most appropriate? A) "Avoid all forms of exercise to prevent further injury" B) "Flexion-based exercises, such as cycling, may reduce your pain" C) "Walking downhill is preferred over walking on flat surfaces" D) "Prolonged standing will help decompress your spine" Answer: B Rationale: Lumbar spinal stenosis symptoms (neurogenic claudication) improve with lumbar flexion, which increases spinal canal diameter and reduces nerve compression. Flexion-based exercises including cycling and recumbent exercise are
beneficial. Extension activities (standing, walking downhill, standing) worsen symptoms. Complete rest (A) leads to deconditioning and worse long-term outcomes. Walking uphill (not flat or downhill) is better as it encourages flexion. Question 6 A patient with a new below-knee amputation reports phantom limb sensation. What is the nurse's best response? A) "The sensation is not real, so try to ignore it" B) "This is a normal neurological phenomenon that many patients experience" C) "That means your nerves are healing improperly and we need to evaluate you" D) "Only patients with traumatic amputations experience phantom sensations" Answer: B Rationale: Phantom limb sensation (feeling that the amputated limb is still present) occurs in 80-100% of amputees and is a normal phenomenon caused by cortical reorganization and persistent peripheral nerve signals. It differs from phantom pain (which requires treatment). Normalizing this experience reduces anxiety. Dismissing it as "not real" (A) invalidates the patient's experience. It is not a sign of improper healing (C) and occurs across all amputation etiologies (D). Question 7 Which laboratory finding would the nurse anticipate in a patient with acute gouty arthritis? A) Elevated rheumatoid factor B) Elevated serum uric acid
Question 9 A nurse is caring for a patient 2 days after anterior cervical discectomy and fusion (ACDF). Which finding requires immediate intervention? A) Difficulty swallowing soft foods B) Hoarse voice that is unchanged since surgery C) Stridor and oxygen saturation of 88% D) Anterior neck swelling that is soft to palpation Answer: C Rationale: Stridor (high-pitched breathing sound) with hypoxemia after ACDF indicates potential airway compromise from hematoma or soft tissue edema. This is a surgical emergency requiring immediate airway management and possible return to operating room. Mild dysphagia (A) and hoarseness (B) are common post-ACDF due to retraction on esophagus and recurrent laryngeal nerve. Soft neck swelling (D) is expected postoperative edema. Question 10 Which instruction should the nurse include when teaching a patient about crutch walking using a three-point gait? A) "Move the affected leg and both crutches forward together, then bring the unaffected leg forward" B) "Move the right crutch and left foot forward together, alternating sides" C) "Place both crutches forward first, then swing both legs forward together" D) "Move one crutch forward, then the opposite leg, then the other crutch, then the other leg" Answer: A Rationale: Three-point gait is used when one leg is non-weight-bearing. The
patient advances both crutches and the affected leg simultaneously, then bears weight through the crutches while advancing the unaffected leg. Option B describes two-point gait (partial weight-bearing). Option C describes swing- through gait. Option D describes four-point gait (max stability). Question 11 A patient with rheumatoid arthritis is prescribed methotrexate. What critical patient education should the nurse provide? A) "Take this medication with a full glass of grapefruit juice" B) "You should take folic acid supplementation as prescribed" C) "Monthly white blood cell counts are unnecessary after the first year" D) "Avoid all vaccinations while taking this medication" Answer: B Rationale: Folic acid supplementation is essential with methotrexate to reduce adverse effects including gastrointestinal symptoms, stomatitis, and hepatotoxicity without reducing therapeutic efficacy. Grapefruit juice (A) interacts with many medications but not methotrexate specifically. Regular monitoring (C) of CBC, LFTs, and creatinine is lifelong. Live vaccines are contraindicated, but inactivated vaccines (flu, pneumonia) are recommended (D is too absolute). Question 12 A patient has a hip spica cast applied after a femoral fracture. The nurse notes the cast edges are pressing into the patient's skin. What is the appropriate action?
Question 14 A patient with osteomyelitis of the tibia is receiving IV vancomycin. Which laboratory value requires the most immediate nursing action? A) WBC count of 8,500/mm³ B) Serum creatinine increase from 0.9 to 1.8 mg/dL C) Hemoglobin of 12.5 g/dL D) Platelet count of 250,000/mm³ Answer: B Rationale: Vancomycin is nephrotoxic; a doubling of serum creatinine indicates acute kidney injury requiring dose adjustment, potential discontinuation, and notification of provider. Vancomycin trough monitoring is essential. WBC (A) is normal. Hemoglobin (C) is acceptable. Platelets (D) are normal. Question 15 A patient is learning to walk with a walker after hip fracture surgery. What observation indicates correct use? A) Patient pushes the walker forward, then steps into it with the affected leg first B) Patient lifts the walker completely off the ground with each step C) Patient keeps elbows fully extended and wrists flexed backward D) Patient positions the walker too far ahead, requiring leaning forward Answer: A *Rationale: Proper walker technique: advance walker, then step forward with affected leg, followed by unaffected leg. Walkers have glides/wheels and should be slid (not lifted completely, B). Correct arm positioning: elbows slightly flexed (15-30°) and wrists
neutral (not fully extended or flexed, C). Walker should be positioned close to patient to prevent excessive forward lean (D increases fall risk).* Question 16 The nurse is assessing a patient with a suspected rotator cuff tear. Which finding is most consistent with this diagnosis? A) Positive Phalen's test B) Positive drop arm test C) Positive straight leg raise test D) Positive McMurray's test Answer: B Rationale: Drop arm test (patient cannot slowly lower abducted arm to side without dropping it) indicates full-thickness rotator cuff tear, typically supraspinatus. Phalen's test (A) assesses carpal tunnel syndrome. Straight leg raise (C) assesses lumbar radiculopathy. McMurray's test (D) assesses meniscal tear of the knee. Question 17 A patient has a newly applied long arm cast. The nurse should prioritize assessment of which neurovascular structure? A) Ulnar nerve and radial artery B) Median nerve and brachial artery C) Musculocutaneous nerve and ulnar artery D) Axillary nerve and profunda brachii artery
A) Patient's heel is resting firmly against the footplate B) Traction weights are 15 pounds and hanging 2 inches above floor C) Patient complains of mild muscle spasms in the affected leg D) Skin straps are tight with mild erythema around the malleoli Answer: B Rationale: Effective traction requires weights to hang freely (not touching floor or bed frame) to provide continuous counter-traction. For Buck's traction, typical weight is 5- 10 lbs (15 lbs may be excessive - check order). The heel should NOT rest against footplate (A) as this counteracts traction. Mild muscle spasms (C) are expected initially but should decrease with effective traction. Skin straps should not be tight; erythema suggests skin breakdown risk (D). Question 20 A patient with systemic lupus erythematosus (SLE) reports new bilateral hip pain. The nurse understands this is most likely due to: A) Avascular necrosis of the femoral head B) Trochanteric bursitis C) Lumbar radiculopathy D) Fibromyalgia Answer: A Rationale: Patients with SLE (and other autoimmune diseases requiring chronic corticosteroid therapy) are at high risk for avascular necrosis (osteonecrosis) of the femoral head. Bilateral involvement is common. Presenting symptom is groin or hip pain with weight-bearing. Bursitis (B) and fibromyalgia (D) are also possible but AVN is specifically associated with SLE/steroid use and requires prompt MRI diagnosis to prevent collapse.
Question 21 During a neurovascular assessment of a patient with a humeral fracture, the nurse asks the patient to spread all fingers apart. Which nerve is being tested? A) Median nerve B) Ulnar nerve C) Radial nerve D) Musculocutaneous nerve Answer: B Rationale: Finger abduction (spreading fingers) tests the ulnar nerve's innervation of the interossei muscles of the hand. Ulnar nerve dysfunction also affects thumb adduction and little finger abduction. Median nerve (A) is tested by thumb opposition/OK sign. Radial nerve (C) tests thumb extension and wrist extension. Musculocutaneous nerve (D) is sensory to lateral forearm only (no hand motor function). Question 22 A patient with a fractured tibia has a pulse oximeter on the affected foot with a reading of 92%. The nurse cannot palpate the dorsalis pedis pulse but sees capillary refill of < seconds in the toes. What is the most appropriate action? A) Notify the surgeon immediately for possible arterial injury B) Document findings and reassess in 1 hour C) Use a Doppler ultrasound to assess for pulse D) Elevate the leg to improve venous return
Question 24 A patient with a L4-L5 disc herniation reports new-onset bowel incontinence. What is the priority nursing action? A) Administer prescribed stool softener B) Document finding and continue monitoring C) Prepare patient for emergent surgical consultation D) Encourage increased fluid intake Answer: C Rationale: Bowel or bladder incontinence in a patient with lumbar disc disease suggests cauda equina syndrome, a surgical emergency requiring decompression within 24- 48 hours to prevent permanent paraplegia and loss of bowel/bladder function. This finding cannot be managed expectantly. Stool softeners (A), fluids (D), and monitoring (B) delay critical intervention. Question 25 A patient is 6 weeks post-ACL reconstruction. Which activity is most appropriate for this stage of recovery? A) Full return to competitive soccer B) Stationary cycling with low resistance C) Open-chain quadriceps exercises with 20 lb weight D) Deep squats with barbell Answer: B *Rationale: At 6 weeks post-ACL reconstruction, patients are typically in the intermediate phase (weeks 6-12) focusing on closed-chain exercises, proprioception, and low- resistance cycling. Full return to cutting sports (A) is not until 6-12 months. Open-chain
quadriceps exercises (C) stress the graft and are avoided early. Deep squats (D) risk graft impingement and patellofemoral complications.* Question 26 Which laboratory value is most concerning in a patient with a pelvic fracture? A) Hemoglobin 11.5 g/dL B) Hemoglobin 7.2 g/dL C) White blood cell count 12,000/mm³ D) Platelet count 180,000/mm³ Answer: B Rationale: Pelvic fractures can cause massive retroperitoneal bleeding with significant blood loss hidden from external view. Hemoglobin of 7.2 g/dL indicates severe hemorrhage requiring transfusion and possible pelvic binding/angiography. Hgb 11. (A) is mildly low but not critical. Elevated WBC (C) may reflect stress response or injury. Normal platelets (D) are not acutely concerning in hemorrhage (though function may be impaired by transfusion). Question 27 A nurse is providing discharge teaching to a patient after lumbar laminectomy. Which instruction is correct? A) "You can bend at the waist to pick up objects from the floor" B) "Avoid sitting for prolonged periods; use a chair with armrests" C) "Twisting your spine during exercise is encouraged to improve flexibility" D) "You may lift up to 30 pounds as tolerated"
A) Night pain with tingling relieved by shaking the hand B) Weakness of the abductor digiti minimi C) Numbness over the dorsal aspect of the thumb D) Positive Tinel's sign over the cubital tunnel Answer: A Rationale: Carpal tunnel syndrome (median nerve compression) classically presents with nocturnal paresthesias in thumb, index, and middle fingers relieved by "flicking" or shaking the hand. Weakness of abductor digiti minimi (B) is ulnar nerve (hypothenar muscles). Dorsal thumb numbness (C) is radial nerve (superficial radial sensory). Cubital tunnel Tinel's (D) suggests ulnar neuropathy at elbow. Question 30 A patient with a hip fracture is being positioned for surgery. The nurse should avoid which position to prevent displacement? A) Supine with operative leg neutral B) Side-lying on the unaffected side with pillow between legs C) Sitting with the operative leg crossed over the opposite knee D) Supine with slight hip flexion using a wedge Answer: C Rationale: Crossing the operative leg over the opposite knee (Figure-4 position) places extreme stress on the fractured femoral neck, potentially converting a nondisplaced fracture into a displaced fracture with vascular compromise. Supine neutral (A) and side- lying with abduction pillow (B) are safe. Slight flexion with wedge (D) is acceptable for comfort.
Question 31 A patient is receiving continuous passive motion (CPM) after total knee arthroplasty. What is the primary goal of this therapy? A) Strengthen the quadriceps muscle B) Prevent venous thromboembolism C) Improve range of motion and prevent stiffness D) Reduce the need for outpatient physical therapy Answer: C Rationale: CPM's evidence-based primary indication is to improve early range of motion and prevent postoperative stiffness/adhesions after TKA. It does not significantly improve strength (A) - active exercises are needed for strength. CPM may slightly reduce DVT risk (B) through venous return but is not prescribed primarily for this purpose. CPM does not replace (and may not reduce need for) outpatient PT (D). Question 32 A child with suspected slipped capital femoral epiphysis (SCFE) presents with hip pain and a limp. The nurse expects which finding on physical examination? A) Internal rotation of the hip with flexion B) External rotation of the hip with flexion C) Abduction contracture of the hip D) Hyperextension of the affected hip Answer: B Rationale: In SCFE, the femoral head slips posteriorly and medially relative to the
