Fundamentals ||Exam ||1 ||(Potter ||& ||Perry
||Chapter ||Practice ||Questions)
*Answer: |||A* |||Rationale:
1. *A |||patient |||has |||been |||on |||bed |||rest |||for |||over |||4 |||days. |||On |||Immo- |||bility |||disrupts
|||assessment, |||the |||nurse |||identifies |||the |||following |||as |||a |||sign |||nor- |||mal |||metabolic
|||associated |||with |||immobility:* |||functioning: |||de-
A. Decreased |||peristalsis |||creasing |||the |||meta-
B. Decreased |||heart |||rate |||bolic |||rate; |||altering
|||the |||metabolism
C. Increased |||blood |||pressure of |||carbohydrates, |||fats,
D. Increased |||urinary |||output |||and |||proteins; |||causing
|||fluid, |||elec- |||trolyte,
|||and |||cal- |||cium
|||imbalances; |||and
|||causing |||gas-
|||trointestinal |||dis-
|||turbances |||such | | | as
|||decreased |||ap- |||petite
|||and |||slowing |||of
|||peristalsis.
2. *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 *Answer: |||A*
|||the |||resumption |||of |||activities |||of |||daily |||living |||for |||this |||patient?* |||Rationale: |||The |||trapeze
A. Encouraging |||use |||of |||an |||overhead |||trapeze |||for |||posi- |||tioning |||and |||bar |||allows |||the |||patient
|||transfer. |||to |||pull |||with |||the
|||upper |||ex- |||tremities
B. Frequent |||family |||visits |||to |||raise |||the |||trunk
C. Assisting |||the |||patient |||to |||a |||wheelchair |||once |||per |||day |||off |||the |||bed, |||aid |||in
D. Ensuring |||that |||there |||is |||an |||order |||for |||physical |||therapy |||transfer |||from |||bed |||to
|||wheel- |||chair, |||or
|||perform |||upper-arm
|||exer- |||cises. |||It
|||increas- |||es
|||independence |||and
|||maintains |||up- |||per
|||body |||strength |||to
|||help |||in |||per- |||forming
|||activities |||of |||daily
|||living.
1 |||/ |||235
,3. *An |||older-adult |||patient |||has |||been |||bedridden |||for |||2 |||weeks. ||Which *Answer: |||D*
|||of |||the |||following |||complaints |||by |||the |||pa- |||tient |||indicates |||to |||the |||Rationale: |||Patients
|||nurse |||that |||he |||or |||she |||is |||develop- |||ing |||a |||complication |||of |||whose |||mobility |||is
|||immobility?* |||restricted |||require
|||range-of-motion |||(ROM)
A. Loss |||of |||appetite |||exercises |||daily |||to
B. Gum |||soreness |||reduce |||the |||hazards |||of
C. Difficulty |||swallowing |||immobility.
D. Left-ankle |||joint |||stiffness 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.
4. *The |||nurse |||is |||caring |||for |||a |||patient |||whose |||calcium |||in- |||take
|||must |||increase |||because |||of |||high |||risk |||factors |||for |||osteoporosis. *Answer: |||A*
|||Which |||of |||the |||following |||menus |||should |||the |||nurse |||recommend?* |||Rationale: |||Teach
|||patient |||and/or
|||caregiver ||the |||cured
|||dietary |||al- |||lowances
|||for |||cal- |||cium |||and
|||review |||foods |||high |||in
|||calci- |||um |||(e.g., |||milk
|||for- |||tified |||with
|||vitamin |||D, |||leafy |||green
|||veg- |||etables
A. Cream |||of |||broccoli |||soup |||with |||whole |||wheat |||crackers, |||rent ||recommend-
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
5.
2 |||/ |||235
,*A |||patient |||on |||prolonged |||bed |||rest |||is |||at |||an |||increased |||risk |||to |||develop *Answer: |||C* |||Rationale:
|||this |||common |||complication |||of |||immo- |||bility |||if |||preventive |||measures |||are |||Immo- |||bility |||is |||a
|||not |||taken:* |||major ||risk |||factor |||for
A. Myoclonus |||pressure |||ulcers. |||Any
|||break |||in |||the |||integrity
B. Pathological |||fractures |||of |||the |||skin |||is
C. Pressure |||ulcers |||difficult |||to |||heal.
D. Pruritus |Preventing |||a |||pressure
|||ulcer |||is |||much |||less
|||expen- |||sive |||than
|||treating |||one; ||therefore
|||pre- |||ventive |||nursing |||in-
|||terventions |||are |||im-
|||perative.
6. *To |||prevent |||complications |||of |||immobility, |||what |||would |||be |||the |||most
|||effective |||activity |||on |||the |||first |||postop- |||erative |||day |||for |||a *Answer: |||B* |||Rationale:
|||patient |||who |||has |||had |||abdominal |||surgery?* |Preven- |||tion |||of
A. Turn, |||cough, |||and |||deep |||breathe |||every |||30 |||minutes |||while |||awake |||complica- |||tions |||of
B. Ambulate |||patient |||to |||chair |||in |||the |||hall |||immobil- |||ity |||begins
|||when |||the |||patient |||be-
C. Passive |||range |||of |||motion |||4 |||times |||a |||day |||comes |||immobi- |||lized.
D. Immobility |||is |||not |||a |||concern |||the |||first |||postoperative |||day |||Every |||30 |||minutes |||is
|||not ||nec- |||essary |||and
|||disrup- |||tive |||to |||the
|||heal- |||ing |||process.
|||Ac- |||tive |||patient
|||partic- |||ipation |||in
|||exercis- |||es |||is |||more
|||bene- |||ficial |||to
|||preventing |||venous
7. *Which |||of |||the |||following |||nursing |||interventions |||should |||be |||stasis.
|||implemented |||to |||maintain |||a |||patent |||airway |||in |||a |||pa- |||tient |||on
|||bed |||rest?*
A. Isometric |||exercises
B. Administration |||of |||low-dose |||heparin
*Answer: |||D*
|||Rationale: |||Incen- |||tive
|||spirometry |||opens |||the
|||airway,
3 |||/ |||235
, C. Suctioning |||every |||4 |||hours preventing |||atelec- |||tasis.
D. Use |||of |||incentive |||spirometer |||every |||2 |||hours |||while |||awake
*Answer: ||C*
8. *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 |||pa- |||tient'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 |||cir- |||culation |||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 *Answer: |||C*
C. 1, |||5, |||7, |||4, |||6, |||3, |||2 |||Rationale: |||Physio-
D. 1, |||5, |||4, |||7, |||6, |||3, |||2 |||logic |||outcomes |||of
|||immobility |||include
|||decreased |||metab-
9. *Which |||of |||the |||following |||are |||physiological |||outcomes |||of |||olism, |||increased
|||immobility?* |||cardiac |||workload,
A. Increased |||metabolism |||decreased |||lung
|||expansion, |||and |||in-
B. Reduced |||cardiac |||workload |||creased |||oxygen
C. Decreased |||lung |||expansion |||demand.
D. Decreased |||oxygen |||demand
10. *An |||older |||adult |||has |||limited |||mobility |||as |||a |||result |||of |||a |||total
*Answer: |||B, |||C, |||D*
|||knee |||replacement. |||During |||assessment |||you |||note |||that |||the |||patient
|||Rationale: |||Pa- |||tients
|||has |||difficulty |||breathing |||while |||lying |||flat. ||Which |||of |||the |||following
|||who |||are |||im- |||mobile
|||assessment |||data |||support |||a |||possible |||pulmonary |||problem |||related
|||are |||at |||high |||risk |||for
|||to |||impaired |||mobility? |||(Select |||all |||that |||apply.)*
|||developing |||pulmonary
|||compli-
4 |||/ |||235
||Chapter ||Practice ||Questions)
*Answer: |||A* |||Rationale:
1. *A |||patient |||has |||been |||on |||bed |||rest |||for |||over |||4 |||days. |||On |||Immo- |||bility |||disrupts
|||assessment, |||the |||nurse |||identifies |||the |||following |||as |||a |||sign |||nor- |||mal |||metabolic
|||associated |||with |||immobility:* |||functioning: |||de-
A. Decreased |||peristalsis |||creasing |||the |||meta-
B. Decreased |||heart |||rate |||bolic |||rate; |||altering
|||the |||metabolism
C. Increased |||blood |||pressure of |||carbohydrates, |||fats,
D. Increased |||urinary |||output |||and |||proteins; |||causing
|||fluid, |||elec- |||trolyte,
|||and |||cal- |||cium
|||imbalances; |||and
|||causing |||gas-
|||trointestinal |||dis-
|||turbances |||such | | | as
|||decreased |||ap- |||petite
|||and |||slowing |||of
|||peristalsis.
2. *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 *Answer: |||A*
|||the |||resumption |||of |||activities |||of |||daily |||living |||for |||this |||patient?* |||Rationale: |||The |||trapeze
A. Encouraging |||use |||of |||an |||overhead |||trapeze |||for |||posi- |||tioning |||and |||bar |||allows |||the |||patient
|||transfer. |||to |||pull |||with |||the
|||upper |||ex- |||tremities
B. Frequent |||family |||visits |||to |||raise |||the |||trunk
C. Assisting |||the |||patient |||to |||a |||wheelchair |||once |||per |||day |||off |||the |||bed, |||aid |||in
D. Ensuring |||that |||there |||is |||an |||order |||for |||physical |||therapy |||transfer |||from |||bed |||to
|||wheel- |||chair, |||or
|||perform |||upper-arm
|||exer- |||cises. |||It
|||increas- |||es
|||independence |||and
|||maintains |||up- |||per
|||body |||strength |||to
|||help |||in |||per- |||forming
|||activities |||of |||daily
|||living.
1 |||/ |||235
,3. *An |||older-adult |||patient |||has |||been |||bedridden |||for |||2 |||weeks. ||Which *Answer: |||D*
|||of |||the |||following |||complaints |||by |||the |||pa- |||tient |||indicates |||to |||the |||Rationale: |||Patients
|||nurse |||that |||he |||or |||she |||is |||develop- |||ing |||a |||complication |||of |||whose |||mobility |||is
|||immobility?* |||restricted |||require
|||range-of-motion |||(ROM)
A. Loss |||of |||appetite |||exercises |||daily |||to
B. Gum |||soreness |||reduce |||the |||hazards |||of
C. Difficulty |||swallowing |||immobility.
D. Left-ankle |||joint |||stiffness 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.
4. *The |||nurse |||is |||caring |||for |||a |||patient |||whose |||calcium |||in- |||take
|||must |||increase |||because |||of |||high |||risk |||factors |||for |||osteoporosis. *Answer: |||A*
|||Which |||of |||the |||following |||menus |||should |||the |||nurse |||recommend?* |||Rationale: |||Teach
|||patient |||and/or
|||caregiver ||the |||cured
|||dietary |||al- |||lowances
|||for |||cal- |||cium |||and
|||review |||foods |||high |||in
|||calci- |||um |||(e.g., |||milk
|||for- |||tified |||with
|||vitamin |||D, |||leafy |||green
|||veg- |||etables
A. Cream |||of |||broccoli |||soup |||with |||whole |||wheat |||crackers, |||rent ||recommend-
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
5.
2 |||/ |||235
,*A |||patient |||on |||prolonged |||bed |||rest |||is |||at |||an |||increased |||risk |||to |||develop *Answer: |||C* |||Rationale:
|||this |||common |||complication |||of |||immo- |||bility |||if |||preventive |||measures |||are |||Immo- |||bility |||is |||a
|||not |||taken:* |||major ||risk |||factor |||for
A. Myoclonus |||pressure |||ulcers. |||Any
|||break |||in |||the |||integrity
B. Pathological |||fractures |||of |||the |||skin |||is
C. Pressure |||ulcers |||difficult |||to |||heal.
D. Pruritus |Preventing |||a |||pressure
|||ulcer |||is |||much |||less
|||expen- |||sive |||than
|||treating |||one; ||therefore
|||pre- |||ventive |||nursing |||in-
|||terventions |||are |||im-
|||perative.
6. *To |||prevent |||complications |||of |||immobility, |||what |||would |||be |||the |||most
|||effective |||activity |||on |||the |||first |||postop- |||erative |||day |||for |||a *Answer: |||B* |||Rationale:
|||patient |||who |||has |||had |||abdominal |||surgery?* |Preven- |||tion |||of
A. Turn, |||cough, |||and |||deep |||breathe |||every |||30 |||minutes |||while |||awake |||complica- |||tions |||of
B. Ambulate |||patient |||to |||chair |||in |||the |||hall |||immobil- |||ity |||begins
|||when |||the |||patient |||be-
C. Passive |||range |||of |||motion |||4 |||times |||a |||day |||comes |||immobi- |||lized.
D. Immobility |||is |||not |||a |||concern |||the |||first |||postoperative |||day |||Every |||30 |||minutes |||is
|||not ||nec- |||essary |||and
|||disrup- |||tive |||to |||the
|||heal- |||ing |||process.
|||Ac- |||tive |||patient
|||partic- |||ipation |||in
|||exercis- |||es |||is |||more
|||bene- |||ficial |||to
|||preventing |||venous
7. *Which |||of |||the |||following |||nursing |||interventions |||should |||be |||stasis.
|||implemented |||to |||maintain |||a |||patent |||airway |||in |||a |||pa- |||tient |||on
|||bed |||rest?*
A. Isometric |||exercises
B. Administration |||of |||low-dose |||heparin
*Answer: |||D*
|||Rationale: |||Incen- |||tive
|||spirometry |||opens |||the
|||airway,
3 |||/ |||235
, C. Suctioning |||every |||4 |||hours preventing |||atelec- |||tasis.
D. Use |||of |||incentive |||spirometer |||every |||2 |||hours |||while |||awake
*Answer: ||C*
8. *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 |||pa- |||tient'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 |||cir- |||culation |||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 *Answer: |||C*
C. 1, |||5, |||7, |||4, |||6, |||3, |||2 |||Rationale: |||Physio-
D. 1, |||5, |||4, |||7, |||6, |||3, |||2 |||logic |||outcomes |||of
|||immobility |||include
|||decreased |||metab-
9. *Which |||of |||the |||following |||are |||physiological |||outcomes |||of |||olism, |||increased
|||immobility?* |||cardiac |||workload,
A. Increased |||metabolism |||decreased |||lung
|||expansion, |||and |||in-
B. Reduced |||cardiac |||workload |||creased |||oxygen
C. Decreased |||lung |||expansion |||demand.
D. Decreased |||oxygen |||demand
10. *An |||older |||adult |||has |||limited |||mobility |||as |||a |||result |||of |||a |||total
*Answer: |||B, |||C, |||D*
|||knee |||replacement. |||During |||assessment |||you |||note |||that |||the |||patient
|||Rationale: |||Pa- |||tients
|||has |||difficulty |||breathing |||while |||lying |||flat. ||Which |||of |||the |||following
|||who |||are |||im- |||mobile
|||assessment |||data |||support |||a |||possible |||pulmonary |||problem |||related
|||are |||at |||high |||risk |||for
|||to |||impaired |||mobility? |||(Select |||all |||that |||apply.)*
|||developing |||pulmonary
|||compli-
4 |||/ |||235
