NUR 4271 Midterm Exam Questions And Correct Answers
A nurse assess a client recovering from coronary artery bypass graft surgery in an
inpatient rehabilitation unit. Which assessment would the nurse complete to evaluate
the client's activity tolerance?
A. Vital signs before, during, and after activity
B. Body image and self-care abilities
C. Ability to use assistive or adaptive devices
D. Client's
A. Vital signs before, during, and after activity
Alterations in the cardiac system can affect a client’s ability to tolerate activity. Signs of
this include changes in blood pressure and pulse since they are directly affected by
cardiac output. A body image assessment is not necessary before basic activities are
performed. Self-care abilities and ability to use assistive or adaptive devices is an
important assessment when planning rehabilitation activities but will not provide
essential information about the client’s activity tolerance. Electrocardiography is not
used to monitor clients in a rehabilitation setting.
A nurse teaches a client about performing intermittent self-catheterization. The client
states, "I am not sure if I will be able to afford these catheters." How would the nurse
respond?
A. "I will try to find out whether you qualify for money to purchase these necessary
supplies."
B. "Even though it is expensive, the cost of taking care of urinary tract infections would
be even higher."
C. "Instead of purchasing new catheters, you can boil the catheters and reuse them up
to 10 times each."
D. "I will contact the social worker who will discuss potential resources with you."
D. “I will contact the social worker who will discuss potential resources with you.”
,Social workers help patients identify support services and resources, including financial
assistance. The nurse would refer the client to the social worker to explore financial
concerns. The nurse would not threaten the client, nor would the client be instructed to
boil the catheters.
A nurse delegates the ambulation of an older adult client to a nursing assistant. Which
statement would the nurse include when delegating this task?
A. The client has skid-proof socks, so there is no need to use your gait belt."
B. "Teach the client how to use the walker while you are ambulating up the hall."
C. "Sit the client on the edge of the bed with legs dangling before ambulating."
D. "Ask the client if pain medication is needed before you walk the client."
C. “Sit the client on the edge of the bed with legs dangling before ambulating.”
Before the client gets out of bed, have the client sit on the bed with legs dangling on the
side. This will enhance safety for the client because it gives the body time to adjust after
changing position and can prevent safety concerns from orthostatic hypotension. A gait
belt would be used for all clients. The nursing assistant cannot teach the client to use a
walker or assess the client’s pain.
The nurse is assessing a patient's functional ability. Which patient best demonstrates
the definition of functional ability?
A. Considers self as a healthy individual; uses cane for stability
B. College educated; travels frequently; can balance a checkbook
C. Exercises daily, reads well, cooks, and cleans house on the weekends
D. Healthy individual, volunteers at church, works part time, takes care of family and
house
D. Healthy individual, volunteers at church, works part time, takes care of family and
house
Functional ability refers to the individual’s ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community;
, and maintain health and well-being. The other options are good; however, healthy
individual, church volunteer, part time worker, and the patient who takes care of the
family and house fully meets the criteria for functional ability.
A 85-year-old female patient has been admitted to the medical/surgical unit. The nurse is
assessing the patient's risk for falls so that falls prevention can be implemented if
necessary. Select all the risk factors that apply from this patient's history and physical.
(Select all that apply.)
A. Being a woman
B. Taking more than six medications
C. Having hypertension
D. Having cataracts
E. Muscle strength 3/5 bilaterally
F. Incontinence
B. Taking more than six medications
D. Having cataracts
E. Muscle strength 3/5 bilaterally
F. Incontinence
Adverse effects of medications can contribute to falls. Cataracts impair vision, which is
a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine
or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does
not contribute to falls. Taking medications to treat hypertension that may lead to
hypotension and dizziness is a fall risk. Dizziness does contribute to falls.
A nurse wants to establish a program to decrease the death rate among adolescents.
A nurse assess a client recovering from coronary artery bypass graft surgery in an
inpatient rehabilitation unit. Which assessment would the nurse complete to evaluate
the client's activity tolerance?
A. Vital signs before, during, and after activity
B. Body image and self-care abilities
C. Ability to use assistive or adaptive devices
D. Client's
A. Vital signs before, during, and after activity
Alterations in the cardiac system can affect a client’s ability to tolerate activity. Signs of
this include changes in blood pressure and pulse since they are directly affected by
cardiac output. A body image assessment is not necessary before basic activities are
performed. Self-care abilities and ability to use assistive or adaptive devices is an
important assessment when planning rehabilitation activities but will not provide
essential information about the client’s activity tolerance. Electrocardiography is not
used to monitor clients in a rehabilitation setting.
A nurse teaches a client about performing intermittent self-catheterization. The client
states, "I am not sure if I will be able to afford these catheters." How would the nurse
respond?
A. "I will try to find out whether you qualify for money to purchase these necessary
supplies."
B. "Even though it is expensive, the cost of taking care of urinary tract infections would
be even higher."
C. "Instead of purchasing new catheters, you can boil the catheters and reuse them up
to 10 times each."
D. "I will contact the social worker who will discuss potential resources with you."
D. “I will contact the social worker who will discuss potential resources with you.”
,Social workers help patients identify support services and resources, including financial
assistance. The nurse would refer the client to the social worker to explore financial
concerns. The nurse would not threaten the client, nor would the client be instructed to
boil the catheters.
A nurse delegates the ambulation of an older adult client to a nursing assistant. Which
statement would the nurse include when delegating this task?
A. The client has skid-proof socks, so there is no need to use your gait belt."
B. "Teach the client how to use the walker while you are ambulating up the hall."
C. "Sit the client on the edge of the bed with legs dangling before ambulating."
D. "Ask the client if pain medication is needed before you walk the client."
C. “Sit the client on the edge of the bed with legs dangling before ambulating.”
Before the client gets out of bed, have the client sit on the bed with legs dangling on the
side. This will enhance safety for the client because it gives the body time to adjust after
changing position and can prevent safety concerns from orthostatic hypotension. A gait
belt would be used for all clients. The nursing assistant cannot teach the client to use a
walker or assess the client’s pain.
The nurse is assessing a patient's functional ability. Which patient best demonstrates
the definition of functional ability?
A. Considers self as a healthy individual; uses cane for stability
B. College educated; travels frequently; can balance a checkbook
C. Exercises daily, reads well, cooks, and cleans house on the weekends
D. Healthy individual, volunteers at church, works part time, takes care of family and
house
D. Healthy individual, volunteers at church, works part time, takes care of family and
house
Functional ability refers to the individual’s ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community;
, and maintain health and well-being. The other options are good; however, healthy
individual, church volunteer, part time worker, and the patient who takes care of the
family and house fully meets the criteria for functional ability.
A 85-year-old female patient has been admitted to the medical/surgical unit. The nurse is
assessing the patient's risk for falls so that falls prevention can be implemented if
necessary. Select all the risk factors that apply from this patient's history and physical.
(Select all that apply.)
A. Being a woman
B. Taking more than six medications
C. Having hypertension
D. Having cataracts
E. Muscle strength 3/5 bilaterally
F. Incontinence
B. Taking more than six medications
D. Having cataracts
E. Muscle strength 3/5 bilaterally
F. Incontinence
Adverse effects of medications can contribute to falls. Cataracts impair vision, which is
a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine
or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does
not contribute to falls. Taking medications to treat hypertension that may lead to
hypotension and dizziness is a fall risk. Dizziness does contribute to falls.
A nurse wants to establish a program to decrease the death rate among adolescents.
