Patient Centered Care 1 Exam 2 with
Complete Solutions
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.)
1. B/P = 128/84
2. Respirations 26/min on room air
3. HR 114
4. Crackles over lower lobes heard on auscultation
5. Pain reported as 3 on scale of 0 to 10 after medication - ANS-2. Respirations
26/min on room air
3. HR 114
4. Crackles over lower lobes heard on auscultation
A patient has been on bed rest for over 4 days. On assessment, the nurse identifies
the following as a sign associated with immobility:
1. Decreased peristalsis
2. Decreased heart rate
3. Increased blood pressure
4. Increased urinary output - ANS-1. Decreased peristalsis
The nurse puts elastic stockings on a patient following major abdominal surgery.
The nurse teaches the patient that the stockings are used after a surgical procedure
to __________________________. - ANS-Promote venous return to the heart
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.)
1. "I usually go swimming with my family at the YMCA 3 times a week."
2. "I need to ask my doctor if I should have a bone mineral density check this
, year."
3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that
I need in my diet."
4. "I'll check the label of my multivitamin. If it has calcium, I can save money by
not taking another pill."
5. "My lactose intolerance should not be a concern when considering my calcium
intake." - ANS-1. "I usually go swimming with my family at the YMCA 3 times a
week."
2. "I need to ask my doctor if I should have a bone mineral density check this
year."
3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that
I need in my diet."
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?
1. Encouraging use of an overhead trapeze for positioning and transfer
2. Frequent family visits
3. Assisting the patient to a wheelchair once per day
4. Ensuring that there is an order for physical therapy - ANS-1. Encouraging use of
an overhead trapeze for positioning and transfer
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?
1. Loss of appetite
2. Gum soreness
3. Difficulty swallowing
4. Left ankle joint stiffness - ANS-4. Left ankle joint stiffness
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.)
Complete Solutions
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.)
1. B/P = 128/84
2. Respirations 26/min on room air
3. HR 114
4. Crackles over lower lobes heard on auscultation
5. Pain reported as 3 on scale of 0 to 10 after medication - ANS-2. Respirations
26/min on room air
3. HR 114
4. Crackles over lower lobes heard on auscultation
A patient has been on bed rest for over 4 days. On assessment, the nurse identifies
the following as a sign associated with immobility:
1. Decreased peristalsis
2. Decreased heart rate
3. Increased blood pressure
4. Increased urinary output - ANS-1. Decreased peristalsis
The nurse puts elastic stockings on a patient following major abdominal surgery.
The nurse teaches the patient that the stockings are used after a surgical procedure
to __________________________. - ANS-Promote venous return to the heart
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.)
1. "I usually go swimming with my family at the YMCA 3 times a week."
2. "I need to ask my doctor if I should have a bone mineral density check this
, year."
3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that
I need in my diet."
4. "I'll check the label of my multivitamin. If it has calcium, I can save money by
not taking another pill."
5. "My lactose intolerance should not be a concern when considering my calcium
intake." - ANS-1. "I usually go swimming with my family at the YMCA 3 times a
week."
2. "I need to ask my doctor if I should have a bone mineral density check this
year."
3. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that
I need in my diet."
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?
1. Encouraging use of an overhead trapeze for positioning and transfer
2. Frequent family visits
3. Assisting the patient to a wheelchair once per day
4. Ensuring that there is an order for physical therapy - ANS-1. Encouraging use of
an overhead trapeze for positioning and transfer
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?
1. Loss of appetite
2. Gum soreness
3. Difficulty swallowing
4. Left ankle joint stiffness - ANS-4. Left ankle joint stiffness
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.)
