Potter & Perry Final Review Questions
What is the proper position to use for an unresponsive patient during oral care to prevent
aspiration? (Select all that apply.)
1. Prone position
2. Modified left lateral recumbent position
3. Semi-Fowler's position with head to side
4. Trendelenburg position
5. Supine position - correct answer 2,3
The student nurse is teaching a family member the importance of foot care for their mother,
who has diabetes mellitus. Which safety precautions are important for the family member to
know to prevent infection? (Select all that apply.)
1. Cut nails frequently.
2. Assess skin for redness, abrasions, and open areas daily.
3. Soak feet in water at least 10 minutes before nail care.
4. Apply lotion to feet daily.
5. Clean between toes after bathing. - correct answer 2,4,5
Which of the following factors directly impairs salivary gland secretion? (Select all that apply.)
1. Use of cough drops
2. Immunosuppression
3. Radiation therapy
4. Dehydration
5. Presence of oral airway - correct answer 3,4
A nurse is assigned to care for the following patients. Which patient is most at risk for
developing skin problems that will require thorough bathing and skin care?
1. A 44-year-old female patient who has had removal of a breast lesion and is in pain and
unwilling to ambulate postoperatively.
2. A 56-year-old male patient who is homeless and admitted to the emergency department
with malnutrition and dehydration.
,3. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an
orthopedic brace applied to the left leg
4. A 70-year-old patient who has diabetes and dementia and has been incontinent of urine and
stool - correct answer 4
When the nurse is assigned to a patient who has a reduced level of consciousness and requires
mouth care, which physical assessment techniques should the nurse perform before the
procedure? (Select all that apply.)
1. Oxygen saturation
2. Heart rate
3. Respirations
4. Gag reflex
5. Response to painful stimulus - correct answer 1,3,4
The American Dental Association suggests that patients who are at risk for poor hygiene use the
following interventions for oral care: (Select all that apply.)
1. Use fluoride toothpaste.
2. Brush teeth 4 times a day.
3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses for high-risk patients.
4. Use a soft toothbrush for oral care.
5. Avoid cleaning the gums and tongue. - correct answer 1,3,4
While planning morning care, which of the following patients would have the highest priority to
receive a bath first?
1. A patient who just returned to the nursing unit from a diagnostic test
2. A patient with a fever who just finished a dose of intravenous antibiotics.
3. A patient who is experiencing frequent incontinent diarrheal stools and urine
4. A patient who has been awake all night because of pain 8/10 - correct answer 3
A patient with a malignant brain tumor requires oral care. The patient's level of consciousness
has declined, with the patient only being able to respond to voice commands. Place the
following steps in the correct order for administration of oral care.
1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.
,2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up
to 30 degrees.
3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces
first.
4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral
cavity.
5. Remove partial plate or dentures if present.
6. Gently brush tongue but avoid stimulating gag reflex. - correct answer 2,5,1,3,6,4
The nurse delegates to the assistive personnel hygiene care for an alert older adult patient who
had a stroke. Which intervention(s) would be appropriate for the assistive personnel to
accomplish during the bath? (Select all that apply.)
1. Checking distal pulses
2. Providing range-of-motion (ROM) exercises to extremities
3. Determining type of treatment for Stage 1 pressure injury
4. Changing the dressing over an intravenous site
5. Providing special skin care as indicated by nurse - correct answer 2,5
The nurse will delegate hygiene care for two patients of different cultures to the assistive
personnel (AP). What cultural information does the nurse need to provide to the AP? (Select all
that apply.)
1. Specific hygiene products
2. Timing of hygiene care
3. Socioeconomic status
4. The need for gender congruent caregiver
5. Religious practices - correct answer 1,2,4,5
A nurse is instructing a patient who has decreased leg strength on the left side on how to use a
cane. Which actions indicate proper cane use by the patient? (Select all that apply.)
1. The patient keeps the cane on the left side of the body.
2. The patient slightly leans to one side while walking.
3. The patient keeps two points of support on the floor at all times.
, 4. After the patient places the cane forward, the patient then moves the right leg forward to
the cane.
5. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step. - correct
answer 3,5
A patient is admitted to a rehabilitation facility for cardiac rehabilitation following open heart
surgery. The patient is 72 years old, 4 days postoperative, and reportedly was walking with a
one-person assist in the hospital before transfer. The patient has a history of hypertension. His
wife accompanies him at the time of transfer. Which of the following assessment data would
you collect for this patient? (Select all that apply.)
1. Condition of surgical wound
2. Patient's expectations of rehabilitation
3. Previous hospitalization experience
4. Vital signs
5. Ability to sit on side of bed unassisted
6. Gait and balance
7. History of recent weight changes
8. Social support from wife - correct answer 1,2,4,5,6,8
A patient comes to an urgent care clinic with reports of pain in the right lower calf and ankle
after participating in a 5K run. Which of the following assessment questions will determine the
effects exercise has had on this patient?
1. Tell me specifically when your pain began.
2. Describe for me the pain you are having.
3. In what way has your daily activity changed since you noticed your pain?
4. How long have you been having the pain? - correct answer 3
The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical
record to find that the patient has progressive loss of total bone mass. The patient's history and
tendency to take smaller steps with feet kept closer together will most likely result in which of
the following?
1. Increase the patient's risk for falls and injuries
2. Result in less stress on the patient's joints
3. Decrease the amount of work required for patient movement
What is the proper position to use for an unresponsive patient during oral care to prevent
aspiration? (Select all that apply.)
1. Prone position
2. Modified left lateral recumbent position
3. Semi-Fowler's position with head to side
4. Trendelenburg position
5. Supine position - correct answer 2,3
The student nurse is teaching a family member the importance of foot care for their mother,
who has diabetes mellitus. Which safety precautions are important for the family member to
know to prevent infection? (Select all that apply.)
1. Cut nails frequently.
2. Assess skin for redness, abrasions, and open areas daily.
3. Soak feet in water at least 10 minutes before nail care.
4. Apply lotion to feet daily.
5. Clean between toes after bathing. - correct answer 2,4,5
Which of the following factors directly impairs salivary gland secretion? (Select all that apply.)
1. Use of cough drops
2. Immunosuppression
3. Radiation therapy
4. Dehydration
5. Presence of oral airway - correct answer 3,4
A nurse is assigned to care for the following patients. Which patient is most at risk for
developing skin problems that will require thorough bathing and skin care?
1. A 44-year-old female patient who has had removal of a breast lesion and is in pain and
unwilling to ambulate postoperatively.
2. A 56-year-old male patient who is homeless and admitted to the emergency department
with malnutrition and dehydration.
,3. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an
orthopedic brace applied to the left leg
4. A 70-year-old patient who has diabetes and dementia and has been incontinent of urine and
stool - correct answer 4
When the nurse is assigned to a patient who has a reduced level of consciousness and requires
mouth care, which physical assessment techniques should the nurse perform before the
procedure? (Select all that apply.)
1. Oxygen saturation
2. Heart rate
3. Respirations
4. Gag reflex
5. Response to painful stimulus - correct answer 1,3,4
The American Dental Association suggests that patients who are at risk for poor hygiene use the
following interventions for oral care: (Select all that apply.)
1. Use fluoride toothpaste.
2. Brush teeth 4 times a day.
3. Use 0.12% chlorhexidine gluconate (CHG) oral rinses for high-risk patients.
4. Use a soft toothbrush for oral care.
5. Avoid cleaning the gums and tongue. - correct answer 1,3,4
While planning morning care, which of the following patients would have the highest priority to
receive a bath first?
1. A patient who just returned to the nursing unit from a diagnostic test
2. A patient with a fever who just finished a dose of intravenous antibiotics.
3. A patient who is experiencing frequent incontinent diarrheal stools and urine
4. A patient who has been awake all night because of pain 8/10 - correct answer 3
A patient with a malignant brain tumor requires oral care. The patient's level of consciousness
has declined, with the patient only being able to respond to voice commands. Place the
following steps in the correct order for administration of oral care.
1. If patient is uncooperative or having difficulty keeping mouth open, insert an oral airway.
,2. Raise bed, lower side rail, and position patient close to side of bed with head of bed raised up
to 30 degrees.
3. Using a brush moistened with chlorhexidine paste, clean chewing and inner tooth surfaces
first.
4. For patients without teeth, use a toothette moistened in chlorhexidine rinse to clean oral
cavity.
5. Remove partial plate or dentures if present.
6. Gently brush tongue but avoid stimulating gag reflex. - correct answer 2,5,1,3,6,4
The nurse delegates to the assistive personnel hygiene care for an alert older adult patient who
had a stroke. Which intervention(s) would be appropriate for the assistive personnel to
accomplish during the bath? (Select all that apply.)
1. Checking distal pulses
2. Providing range-of-motion (ROM) exercises to extremities
3. Determining type of treatment for Stage 1 pressure injury
4. Changing the dressing over an intravenous site
5. Providing special skin care as indicated by nurse - correct answer 2,5
The nurse will delegate hygiene care for two patients of different cultures to the assistive
personnel (AP). What cultural information does the nurse need to provide to the AP? (Select all
that apply.)
1. Specific hygiene products
2. Timing of hygiene care
3. Socioeconomic status
4. The need for gender congruent caregiver
5. Religious practices - correct answer 1,2,4,5
A nurse is instructing a patient who has decreased leg strength on the left side on how to use a
cane. Which actions indicate proper cane use by the patient? (Select all that apply.)
1. The patient keeps the cane on the left side of the body.
2. The patient slightly leans to one side while walking.
3. The patient keeps two points of support on the floor at all times.
, 4. After the patient places the cane forward, the patient then moves the right leg forward to
the cane.
5. The patient places the cane forward 15 to 25 cm (6 to 10 inches) with each step. - correct
answer 3,5
A patient is admitted to a rehabilitation facility for cardiac rehabilitation following open heart
surgery. The patient is 72 years old, 4 days postoperative, and reportedly was walking with a
one-person assist in the hospital before transfer. The patient has a history of hypertension. His
wife accompanies him at the time of transfer. Which of the following assessment data would
you collect for this patient? (Select all that apply.)
1. Condition of surgical wound
2. Patient's expectations of rehabilitation
3. Previous hospitalization experience
4. Vital signs
5. Ability to sit on side of bed unassisted
6. Gait and balance
7. History of recent weight changes
8. Social support from wife - correct answer 1,2,4,5,6,8
A patient comes to an urgent care clinic with reports of pain in the right lower calf and ankle
after participating in a 5K run. Which of the following assessment questions will determine the
effects exercise has had on this patient?
1. Tell me specifically when your pain began.
2. Describe for me the pain you are having.
3. In what way has your daily activity changed since you noticed your pain?
4. How long have you been having the pain? - correct answer 3
The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical
record to find that the patient has progressive loss of total bone mass. The patient's history and
tendency to take smaller steps with feet kept closer together will most likely result in which of
the following?
1. Increase the patient's risk for falls and injuries
2. Result in less stress on the patient's joints
3. Decrease the amount of work required for patient movement
