Portage Learning
2 MAXE · 132 RUN
★ ★
NUR 231 — Exam 2: Mobility, Elimination, Wound Care &
P Medications
EST. 1972 TO TRANSFORM LIVES AND COMMUNITIES BY PROVIDING LEARNING
OPPORTUNITIES FOR ALL WHO ASPIRE TO THRIVE.
Portage Learning NUR 231 Exam 2 — Mobility,
Elimination, Wound Care & Medications
CO M P L E T E Q U E ST I O N S & CO R R E CT D E TA I L E D A N S W E RS
INSTITUTION Portage Learning PROGRAM Bachelor of Science in Nursing
COURSE CODE NUR 231 COURSE TITLE Fundamentals of Nursing
ACADEMIC YEAR EXAM TITLE Portage Learning NUR 231 Exam 2
TOTAL QUESTIONS 74 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Mobility, body mechanics, urinary elimination, wound care, medication administration, and sterile
technique are all testable content.
▸ Pressure ulcer staging, wound assessment, catheter care, and medication rights are emphasized.
▸ Correct answers and clinical rationales appear below each question.
▸ All content reflects current nursing practice standards.
, SECTION I — MOBILITY, ELIMINATION, WOUND CARE &
Questions 1 – 74
MEDICATIONS
1. What is the first step in the nursing process?
A. Diagnose
B. Assessment
C. Plan
D. Implement
CORRECT ANSWER B — Assessment
RATIONALE The first step in the nursing process is assessment. The nurse collects
comprehensive data about the patient's health status, which forms the
foundation for all subsequent steps including diagnosis, planning,
implementation, and evaluation.
2. What are interventions for the immobilized patient?
A. Maintain proper body alignment, turn at least every 2 hours, ROM, CPM machine,
positioning aides, special mattresses, elastic stockings/SCD
B. Only turn every 4 hours
C. Only use ROM exercises
D. Only apply elastic stockings
CORRECT ANSWER A — Maintain proper body alignment, turn at least every 2 hours, ROM, CPM
machine, positioning aides, special mattresses, elastic stockings/SCD
RATIONALE Interventions for the immobilized patient include: maintaining proper body
alignment, turning at least every 2 hours, range of motion exercises, CPM
machine, positioning aides, special mattresses, and elastic stockings or
sequential compression devices to prevent complications.
,3. Why do we want to get patients up as soon as possible?
A. To reduce or eliminate the effects of immobility such as orthostatic hypotension and
thrombus formation
B. To make patients more comfortable
C. To reduce staffing needs
D. To discharge patients sooner
CORRECT ANSWER A — To reduce or eliminate the effects of immobility such as orthostatic
hypotension and thrombus formation
RATIONALE Early mobilization helps reduce or eliminate the effects of immobility such as
orthostatic hypotension and thrombus formation. Patients should be mobilized
as soon as their physical condition allows, even if this only involves dangling at
the bedside or moving to a chair.
4. What is orthostatic hypotension?
A. A form of low blood pressure that happens when you stand up from sitting or lying down
B. High blood pressure when standing
C. Normal blood pressure response to standing
D. A form of hypertension
CORRECT ANSWER A — A form of low blood pressure that happens when you stand up from
sitting or lying down
RATIONALE Orthostatic hypotension is a form of low blood pressure that occurs when
standing up from sitting or lying down. It is a common complication of immobility
and can lead to falls if not properly managed.
, 5. What is thrombus formation (thrombosis)?
A. Formation of a blood clot inside a blood vessel, obstructing blood flow
B. A blood clot that travels to the lungs
C. A blood clot that dissolves on its own
D. A blood clot in the heart
CORRECT ANSWER A — Formation of a blood clot inside a blood vessel, obstructing blood flow
RATIONALE Thrombus formation (thrombosis) is the formation of a blood clot inside a blood
vessel, obstructing the flow of blood through the circulatory system. Immobility is
a major risk factor for thrombosis.
6. What should nurses consider before lifting a patient?
A. Assess the weight to be lifted, determine assistance needed, use safe patient handling
equipment, use manual lifting only as a last resort, use proper body mechanics
B. Only assess the weight to be lifted
C. Only use proper body mechanics
D. Only use manual lifting
CORRECT ANSWER A — Assess the weight to be lifted, determine assistance needed, use safe
patient handling equipment, use manual lifting only as a last resort, use
proper body mechanics
RATIONALE Before lifting, nurses should assess the weight to be lifted, determine the
assistance needed, use safe patient handling equipment when the patient is
unable to assist, use manual lifting only as a last resort, and use proper body
mechanics if lifting is required.
2 MAXE · 132 RUN
★ ★
NUR 231 — Exam 2: Mobility, Elimination, Wound Care &
P Medications
EST. 1972 TO TRANSFORM LIVES AND COMMUNITIES BY PROVIDING LEARNING
OPPORTUNITIES FOR ALL WHO ASPIRE TO THRIVE.
Portage Learning NUR 231 Exam 2 — Mobility,
Elimination, Wound Care & Medications
CO M P L E T E Q U E ST I O N S & CO R R E CT D E TA I L E D A N S W E RS
INSTITUTION Portage Learning PROGRAM Bachelor of Science in Nursing
COURSE CODE NUR 231 COURSE TITLE Fundamentals of Nursing
ACADEMIC YEAR EXAM TITLE Portage Learning NUR 231 Exam 2
TOTAL QUESTIONS 74 Questions FORMAT Multiple Choice — Select the
Single Best Answer
EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Mobility, body mechanics, urinary elimination, wound care, medication administration, and sterile
technique are all testable content.
▸ Pressure ulcer staging, wound assessment, catheter care, and medication rights are emphasized.
▸ Correct answers and clinical rationales appear below each question.
▸ All content reflects current nursing practice standards.
, SECTION I — MOBILITY, ELIMINATION, WOUND CARE &
Questions 1 – 74
MEDICATIONS
1. What is the first step in the nursing process?
A. Diagnose
B. Assessment
C. Plan
D. Implement
CORRECT ANSWER B — Assessment
RATIONALE The first step in the nursing process is assessment. The nurse collects
comprehensive data about the patient's health status, which forms the
foundation for all subsequent steps including diagnosis, planning,
implementation, and evaluation.
2. What are interventions for the immobilized patient?
A. Maintain proper body alignment, turn at least every 2 hours, ROM, CPM machine,
positioning aides, special mattresses, elastic stockings/SCD
B. Only turn every 4 hours
C. Only use ROM exercises
D. Only apply elastic stockings
CORRECT ANSWER A — Maintain proper body alignment, turn at least every 2 hours, ROM, CPM
machine, positioning aides, special mattresses, elastic stockings/SCD
RATIONALE Interventions for the immobilized patient include: maintaining proper body
alignment, turning at least every 2 hours, range of motion exercises, CPM
machine, positioning aides, special mattresses, and elastic stockings or
sequential compression devices to prevent complications.
,3. Why do we want to get patients up as soon as possible?
A. To reduce or eliminate the effects of immobility such as orthostatic hypotension and
thrombus formation
B. To make patients more comfortable
C. To reduce staffing needs
D. To discharge patients sooner
CORRECT ANSWER A — To reduce or eliminate the effects of immobility such as orthostatic
hypotension and thrombus formation
RATIONALE Early mobilization helps reduce or eliminate the effects of immobility such as
orthostatic hypotension and thrombus formation. Patients should be mobilized
as soon as their physical condition allows, even if this only involves dangling at
the bedside or moving to a chair.
4. What is orthostatic hypotension?
A. A form of low blood pressure that happens when you stand up from sitting or lying down
B. High blood pressure when standing
C. Normal blood pressure response to standing
D. A form of hypertension
CORRECT ANSWER A — A form of low blood pressure that happens when you stand up from
sitting or lying down
RATIONALE Orthostatic hypotension is a form of low blood pressure that occurs when
standing up from sitting or lying down. It is a common complication of immobility
and can lead to falls if not properly managed.
, 5. What is thrombus formation (thrombosis)?
A. Formation of a blood clot inside a blood vessel, obstructing blood flow
B. A blood clot that travels to the lungs
C. A blood clot that dissolves on its own
D. A blood clot in the heart
CORRECT ANSWER A — Formation of a blood clot inside a blood vessel, obstructing blood flow
RATIONALE Thrombus formation (thrombosis) is the formation of a blood clot inside a blood
vessel, obstructing the flow of blood through the circulatory system. Immobility is
a major risk factor for thrombosis.
6. What should nurses consider before lifting a patient?
A. Assess the weight to be lifted, determine assistance needed, use safe patient handling
equipment, use manual lifting only as a last resort, use proper body mechanics
B. Only assess the weight to be lifted
C. Only use proper body mechanics
D. Only use manual lifting
CORRECT ANSWER A — Assess the weight to be lifted, determine assistance needed, use safe
patient handling equipment, use manual lifting only as a last resort, use
proper body mechanics
RATIONALE Before lifting, nurses should assess the weight to be lifted, determine the
assistance needed, use safe patient handling equipment when the patient is
unable to assist, use manual lifting only as a last resort, and use proper body
mechanics if lifting is required.
