Fundamentals Exam 1 (Potter & Perry
Chapter Practice Questions)
Get a hint
*A patient has been on bed rest for over 4 days. On assessment, the nurse identifies
the following as a sign associated with immobility:*
A. Decreased peristalsis
B. Decreased heart rate
C. Increased blood pressure
D. Increased urinary output - ans *Answer: A*
Rationale: Immobility disrupts normal metabolic functioning: decreasing the metabolic
rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid,
electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as
decreased appetite and slowing of peristalsis.
*A nurse is caring for an older adult who has had a fractured hip repaired. In the first few
postoperative days, which of the following nursing measures will best facilitate the
resumption of activities of daily living for this patient?*
A. Encouraging use of an overhead trapeze for positioning and transfer.
B. Frequent family visits
C. Assisting the patient to a wheelchair once per day
D. Ensuring that there is an order for physical therapy - ans *Answer: A*
Rationale: The trapeze bar allows the patient to pull with the upper extremities to raise
the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper-arm
exercises. It increases independence and maintains upper body strength to help in
performing activities of daily living.
*An older-adult patient has been bedridden for 2 weeks. Which of the following
complaints by the patient indicates to the nurse that he or she is developing a
complication of immobility?*
A. Loss of appetite
B. Gum soreness
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,C. Difficulty swallowing
D. Left-ankle joint stiffness - ans *Answer: D*
Rationale: Patients whose mobility is restricted require range-of-motion (ROM)
exercises daily to reduce the hazards of immobility. Temporary immobilization results in
some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint
immobilization without ROM can quickly result in contractures.
*The nurse is caring for a patient whose calcium intake must increase because of high
risk factors for osteoporosis. Which of the following menus should the nurse
recommend?*
A. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert
B. Hot dog on whole wheat bun with a side salad and an apple for dessert
C. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert
D. Turkey salad on toast with tomato and lettuce and honey bun for dessert - ans
*Answer: A*
Rationale: Teach patient and/or caregiver the current recommended dietary allowances
for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy
green vegetables, yogurt, and cheese).
*A patient on prolonged bed rest is at an increased risk to develop this common
complication of immobility if preventive measures are not taken:*
A. Myoclonus
B. Pathological fractures
C. Pressure ulcers
D. Pruritus - ans *Answer: C*
Rationale: Immobility is a major risk factor for pressure ulcers. Any break in the integrity
of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than
treating one; therefore preventive nursing interventions are imperative.
*To prevent complications of immobility, what would be the most effective activity on the
first postoperative day for a patient who has had abdominal surgery?*
A. Turn, cough, and deep breathe every 30 minutes while awake
B. Ambulate patient to chair in the hall
C. Passive range of motion 4 times a day
D. Immobility is not a concern the first postoperative day - ans *Answer: B*
Rationale: Prevention of complications of immobility begins when the patient becomes
immobilized. Every 30 minutes is not necessary and disruptive to the healing process.
Active patient participation in exercises is more beneficial to preventing venous stasis.
*Which of the following nursing interventions should be implemented to maintain a
patent airway in a patient on bed rest?*
A. Isometric exercises
B. Administration of low-dose heparin
C. Suctioning every 4 hours
D. Use of incentive spirometer every 2 hours while awake - ans *Answer: D*
Rationale: Incentive spirometry opens the airway, preventing atelectasis.
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,*What is the correct order in which elastic stockings should be applied?
1. Identify patient using two identifiers.
2. Smooth any creases or wrinkles.
3. Slide the remainder of the stocking over the patient's heel and up the leg
4. Turn the stocking inside out until heel is reached.
5. Assess the condition of the patient's skin and circulation of the legs.
6. Place toes into foot of the stocking.
7. Use tape measure to measure patient's legs to determine proper stocking size.*
A. 1, 5, 7, 4, 6, 2, 3
B. 1, 7, 5, 4, 6, 2, 3
C. 1, 5, 7, 4, 6, 3, 2
D. 1, 5, 4, 7, 6, 3, 2 - ans *Answer: C*
*Which of the following are physiological outcomes of immobility?*
A. Increased metabolism
B. Reduced cardiac workload
C. Decreased lung expansion
D. Decreased oxygen demand - ans *Answer: C*
Rationale: Physiologic outcomes of immobility include decreased metabolism, increased
cardiac workload, decreased lung expansion, and increased oxygen demand.
*An older adult has limited mobility as a result of a total knee replacement. During
assessment you note that the patient has difficulty breathing while lying flat. Which of
the following assessment data support a possible pulmonary problem related to
impaired mobility? (Select all that apply.)*
A. B/P = 128/84
B. Respirations 26/min on room air
C. HR 114
D. Crackles over lower lobes heard on auscultation
E. Pain reported as 3 on scale of 0 to 10 after medication - ans *Answer: B, C, D*
Rationale: Patients who are immobile are at high risk for developing pulmonary
complications. The most common respiratory complications are atelectasis (collapse of
alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of
secretions). Ultimately the distribution of mucus in the bronchi increases, particularly
when the patient is in the supine, prone, or lateral position.
*A nurse is teaching a community group about ways to minimize the risk of developing
osteoporosis. Which of the following statements reflect understanding of what was
taught? (Select all that apply.)*
A. "I usually go swimming with my family at the YMCA 3 times a week."
B. "I need to ask my doctor if I should have a bone mineral density check this year."
C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I
need in my diet."
D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not
taking another pill."
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, E. "My lactose intolerance should not be a concern when considering my calcium
intake." - ans *Answer: A, B, C*
Rationale: Patients at risk for or diagnosed with osteoporosis have special health
promotion needs. Encourage patients at risk to be screened for osteoporosis and
assess their diets for calcium and vitamin D intake. Multivitamins do not always have
the needed amount of calcium for every individual. A patient needs to know his or her
requirement and make a decision based on that.
*A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on
prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side
effect of this medication, the nurse should continually assess the patient for the
following signs of bleeding: (Select all that apply.)*
A. Bruising
B. Pale yellow urine
C. Bleeding gums
D. Coffee ground-like vomitus
E. Light brown stool - ans *Answer: A, C, D*
Rationale: Because bleeding is a potential side effect of these medications, continually
assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like
vomitus or gastrointestinal aspirate, guaiac-positive stools, and bleeding gums.
*The nurse evaluates that the NAP has applied a patient's sequential compression
device (SCD) appropriately when which of the following is observed? (Select all that
apply.)*
A. Initial patient measurement is made around the calves
B. Inflation pressure averages 40 mm Hg
C. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening
on the sleeve.
D. Stockings are removed every 2 hours during application.
E. Yellow light indicates SCD device is functioning. - ans *Answer: B & C*
Rationale: The most effective way to prevent deep vein thrombosis is through an
aggressive program of prophylaxis. A properly functioning SCD inflates with a pressure
around 40 mm Hg. Inflation pressure averages 40 mm Hg, and the patient's leg should
be placed in the SCD sleeve with the back of knee aligned with the popliteal opening on
the sleeve. Measurement involves length of leg, not calf. A green light indicates the
SCD device is functioning.
*The effects of immobility on the cardiac system include which of the following? (Select
all that apply.)*
A. Thrombus formation
B. Increased cardiac workload
C. Weak peripheral pulses
D. Irregular heartbeat
E. Orthostatic hypotension - ans *Answer: A, B, E*
Rationale: The three major changes are orthostatic hypotension, increased cardiac
workload, and thrombus formation.
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Chapter Practice Questions)
Get a hint
*A patient has been on bed rest for over 4 days. On assessment, the nurse identifies
the following as a sign associated with immobility:*
A. Decreased peristalsis
B. Decreased heart rate
C. Increased blood pressure
D. Increased urinary output - ans *Answer: A*
Rationale: Immobility disrupts normal metabolic functioning: decreasing the metabolic
rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid,
electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as
decreased appetite and slowing of peristalsis.
*A nurse is caring for an older adult who has had a fractured hip repaired. In the first few
postoperative days, which of the following nursing measures will best facilitate the
resumption of activities of daily living for this patient?*
A. Encouraging use of an overhead trapeze for positioning and transfer.
B. Frequent family visits
C. Assisting the patient to a wheelchair once per day
D. Ensuring that there is an order for physical therapy - ans *Answer: A*
Rationale: The trapeze bar allows the patient to pull with the upper extremities to raise
the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper-arm
exercises. It increases independence and maintains upper body strength to help in
performing activities of daily living.
*An older-adult patient has been bedridden for 2 weeks. Which of the following
complaints by the patient indicates to the nurse that he or she is developing a
complication of immobility?*
A. Loss of appetite
B. Gum soreness
jjjjjjjjjjj
,C. Difficulty swallowing
D. Left-ankle joint stiffness - ans *Answer: D*
Rationale: Patients whose mobility is restricted require range-of-motion (ROM)
exercises daily to reduce the hazards of immobility. Temporary immobilization results in
some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint
immobilization without ROM can quickly result in contractures.
*The nurse is caring for a patient whose calcium intake must increase because of high
risk factors for osteoporosis. Which of the following menus should the nurse
recommend?*
A. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert
B. Hot dog on whole wheat bun with a side salad and an apple for dessert
C. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert
D. Turkey salad on toast with tomato and lettuce and honey bun for dessert - ans
*Answer: A*
Rationale: Teach patient and/or caregiver the current recommended dietary allowances
for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy
green vegetables, yogurt, and cheese).
*A patient on prolonged bed rest is at an increased risk to develop this common
complication of immobility if preventive measures are not taken:*
A. Myoclonus
B. Pathological fractures
C. Pressure ulcers
D. Pruritus - ans *Answer: C*
Rationale: Immobility is a major risk factor for pressure ulcers. Any break in the integrity
of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than
treating one; therefore preventive nursing interventions are imperative.
*To prevent complications of immobility, what would be the most effective activity on the
first postoperative day for a patient who has had abdominal surgery?*
A. Turn, cough, and deep breathe every 30 minutes while awake
B. Ambulate patient to chair in the hall
C. Passive range of motion 4 times a day
D. Immobility is not a concern the first postoperative day - ans *Answer: B*
Rationale: Prevention of complications of immobility begins when the patient becomes
immobilized. Every 30 minutes is not necessary and disruptive to the healing process.
Active patient participation in exercises is more beneficial to preventing venous stasis.
*Which of the following nursing interventions should be implemented to maintain a
patent airway in a patient on bed rest?*
A. Isometric exercises
B. Administration of low-dose heparin
C. Suctioning every 4 hours
D. Use of incentive spirometer every 2 hours while awake - ans *Answer: D*
Rationale: Incentive spirometry opens the airway, preventing atelectasis.
jjjjjjjjjjj
,*What is the correct order in which elastic stockings should be applied?
1. Identify patient using two identifiers.
2. Smooth any creases or wrinkles.
3. Slide the remainder of the stocking over the patient's heel and up the leg
4. Turn the stocking inside out until heel is reached.
5. Assess the condition of the patient's skin and circulation of the legs.
6. Place toes into foot of the stocking.
7. Use tape measure to measure patient's legs to determine proper stocking size.*
A. 1, 5, 7, 4, 6, 2, 3
B. 1, 7, 5, 4, 6, 2, 3
C. 1, 5, 7, 4, 6, 3, 2
D. 1, 5, 4, 7, 6, 3, 2 - ans *Answer: C*
*Which of the following are physiological outcomes of immobility?*
A. Increased metabolism
B. Reduced cardiac workload
C. Decreased lung expansion
D. Decreased oxygen demand - ans *Answer: C*
Rationale: Physiologic outcomes of immobility include decreased metabolism, increased
cardiac workload, decreased lung expansion, and increased oxygen demand.
*An older adult has limited mobility as a result of a total knee replacement. During
assessment you note that the patient has difficulty breathing while lying flat. Which of
the following assessment data support a possible pulmonary problem related to
impaired mobility? (Select all that apply.)*
A. B/P = 128/84
B. Respirations 26/min on room air
C. HR 114
D. Crackles over lower lobes heard on auscultation
E. Pain reported as 3 on scale of 0 to 10 after medication - ans *Answer: B, C, D*
Rationale: Patients who are immobile are at high risk for developing pulmonary
complications. The most common respiratory complications are atelectasis (collapse of
alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of
secretions). Ultimately the distribution of mucus in the bronchi increases, particularly
when the patient is in the supine, prone, or lateral position.
*A nurse is teaching a community group about ways to minimize the risk of developing
osteoporosis. Which of the following statements reflect understanding of what was
taught? (Select all that apply.)*
A. "I usually go swimming with my family at the YMCA 3 times a week."
B. "I need to ask my doctor if I should have a bone mineral density check this year."
C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I
need in my diet."
D. "I'll check the label of my multivitamin. If it has calcium, I can save money by not
taking another pill."
jjjjjjjjjjj
, E. "My lactose intolerance should not be a concern when considering my calcium
intake." - ans *Answer: A, B, C*
Rationale: Patients at risk for or diagnosed with osteoporosis have special health
promotion needs. Encourage patients at risk to be screened for osteoporosis and
assess their diets for calcium and vitamin D intake. Multivitamins do not always have
the needed amount of calcium for every individual. A patient needs to know his or her
requirement and make a decision based on that.
*A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on
prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side
effect of this medication, the nurse should continually assess the patient for the
following signs of bleeding: (Select all that apply.)*
A. Bruising
B. Pale yellow urine
C. Bleeding gums
D. Coffee ground-like vomitus
E. Light brown stool - ans *Answer: A, C, D*
Rationale: Because bleeding is a potential side effect of these medications, continually
assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like
vomitus or gastrointestinal aspirate, guaiac-positive stools, and bleeding gums.
*The nurse evaluates that the NAP has applied a patient's sequential compression
device (SCD) appropriately when which of the following is observed? (Select all that
apply.)*
A. Initial patient measurement is made around the calves
B. Inflation pressure averages 40 mm Hg
C. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening
on the sleeve.
D. Stockings are removed every 2 hours during application.
E. Yellow light indicates SCD device is functioning. - ans *Answer: B & C*
Rationale: The most effective way to prevent deep vein thrombosis is through an
aggressive program of prophylaxis. A properly functioning SCD inflates with a pressure
around 40 mm Hg. Inflation pressure averages 40 mm Hg, and the patient's leg should
be placed in the SCD sleeve with the back of knee aligned with the popliteal opening on
the sleeve. Measurement involves length of leg, not calf. A green light indicates the
SCD device is functioning.
*The effects of immobility on the cardiac system include which of the following? (Select
all that apply.)*
A. Thrombus formation
B. Increased cardiac workload
C. Weak peripheral pulses
D. Irregular heartbeat
E. Orthostatic hypotension - ans *Answer: A, B, E*
Rationale: The three major changes are orthostatic hypotension, increased cardiac
workload, and thrombus formation.
jjjjjjjjjjj
