NUR204 exam 2 Questions With Complete Solutions
The nurse is providing ancillary personnel with instructions
regarding the performance of
passive range-of-motion (ROM) exercises for a client
experiencing paralysis from the
waist down (paraplegia) as a result of an automobile accident.
Which of the following
statements made by the ancillary personnel reflects the greatest
insight regarding the
frequency with which the intervention should be provided for
this client?
1. "I will do a whole body range of motion as I complete her
daily bath."
2. "Bath time, bedtime, after lunch, and at least once more; she
can pick when."
3. "It works well with her bath and when she is being prepared
for bed at night."
4. "I'll ask her when she wants me to exercise her joints in
addition to bath time."
ANS: 2
If the client is unable to move part or all of the body, perform
passive ROM exercises for
all immobilized joints while bathing the client and at least 2 or 3
more times a day
,The nurse is discussing joint mobility exercises with a client
who experienced a stroke
and now has left-sided weakness. Which of the following
statements made by the client
reflects the greatest insight regarding the best method for him to
maintain mobility of the
joints on his left side?
1. "My wife knows how to do those exercises for the joints on
my left side."
2. "Physical therapy really exercises my left side when I go there
every afternoon."
3. "I'll remind the staff to exercise my left side when they come
to help me with my
bath and getting dressed."
4. "I will do those passive range of motion exercises you taught
me to my left side at
least 3 times a day."
ANS: 4
If one extremity is paralyzed, teach the client to put each joint
independently through its
ROM.
,The nurse caring for a 38-year-old female client with multiple
fractures in the trauma
intensive care unit knows that this client is at high risk for
pulmonary complications such
as atelectasis from her immobility. One of the interventions that
the nurse can do to help
prevent this from occurring is to:
1. Keep the PaO2 level at or above 94%
2. Instruct the client to deep breathe and cough every hour while
awake
3. Turn the client every 2 hours
4. Keep the client on the ventilator as long as possible
ANS: 2
In atelectasis, secretions block a bronchiole or a bronchus, and
the distal lung tissue
(alveoli) collapses as the existing air is absorbed, producing
hypoventilation. The site of
the blockage affects the severity of atelectasis. Sometimes an
entire lung lobe or a whole
lung collapses. At some point in the development of these
complications, there is a
proportional decline in the client's ability to cough productively.
Turning the client is an
excellent way to help prevent the accumulation of mucus in the
dependent regions of the
airways causing hypostatic pneumonia. Mucus is an excellent
place for bacteria to grow.
Keeping a client on a ventilator longer than necessary has the
, potential to cause multiple
other complications and is not the best choice.
The nurse is caring for a 48-year-old male client who was
involved in a motor vehicle
accident and had a fractured pelvis, a ruptured spleen, and
multiple contusions. The client
has been in the hospital for 5 days on bed rest. The nurse knows
that this client is at risk
for venous thrombus formation because of prolonged bed rest,
potential damage to vessel
walls during surgery, and the platelets he received in the trauma
unit. These three factors
are also known as:
1. Trigeminy
2. Virchow's triad
3. Trigone
4. Hutchinson's triad
ANS: 2
There are three factors that contribute to venous thrombus
formation: (1) damage to the
vessel wall (e.g., injury during surgical procedures), (2)
alterations of blood flow (e.g.,
slow blood flow in calf veins associated with bed rest), and (3)
alterations in blood
constituents (e.g., a change in clotting factors or increased
platelet activity. These three
factors are sometimes referred to as Virchow's triad
The nurse is providing ancillary personnel with instructions
regarding the performance of
passive range-of-motion (ROM) exercises for a client
experiencing paralysis from the
waist down (paraplegia) as a result of an automobile accident.
Which of the following
statements made by the ancillary personnel reflects the greatest
insight regarding the
frequency with which the intervention should be provided for
this client?
1. "I will do a whole body range of motion as I complete her
daily bath."
2. "Bath time, bedtime, after lunch, and at least once more; she
can pick when."
3. "It works well with her bath and when she is being prepared
for bed at night."
4. "I'll ask her when she wants me to exercise her joints in
addition to bath time."
ANS: 2
If the client is unable to move part or all of the body, perform
passive ROM exercises for
all immobilized joints while bathing the client and at least 2 or 3
more times a day
,The nurse is discussing joint mobility exercises with a client
who experienced a stroke
and now has left-sided weakness. Which of the following
statements made by the client
reflects the greatest insight regarding the best method for him to
maintain mobility of the
joints on his left side?
1. "My wife knows how to do those exercises for the joints on
my left side."
2. "Physical therapy really exercises my left side when I go there
every afternoon."
3. "I'll remind the staff to exercise my left side when they come
to help me with my
bath and getting dressed."
4. "I will do those passive range of motion exercises you taught
me to my left side at
least 3 times a day."
ANS: 4
If one extremity is paralyzed, teach the client to put each joint
independently through its
ROM.
,The nurse caring for a 38-year-old female client with multiple
fractures in the trauma
intensive care unit knows that this client is at high risk for
pulmonary complications such
as atelectasis from her immobility. One of the interventions that
the nurse can do to help
prevent this from occurring is to:
1. Keep the PaO2 level at or above 94%
2. Instruct the client to deep breathe and cough every hour while
awake
3. Turn the client every 2 hours
4. Keep the client on the ventilator as long as possible
ANS: 2
In atelectasis, secretions block a bronchiole or a bronchus, and
the distal lung tissue
(alveoli) collapses as the existing air is absorbed, producing
hypoventilation. The site of
the blockage affects the severity of atelectasis. Sometimes an
entire lung lobe or a whole
lung collapses. At some point in the development of these
complications, there is a
proportional decline in the client's ability to cough productively.
Turning the client is an
excellent way to help prevent the accumulation of mucus in the
dependent regions of the
airways causing hypostatic pneumonia. Mucus is an excellent
place for bacteria to grow.
Keeping a client on a ventilator longer than necessary has the
, potential to cause multiple
other complications and is not the best choice.
The nurse is caring for a 48-year-old male client who was
involved in a motor vehicle
accident and had a fractured pelvis, a ruptured spleen, and
multiple contusions. The client
has been in the hospital for 5 days on bed rest. The nurse knows
that this client is at risk
for venous thrombus formation because of prolonged bed rest,
potential damage to vessel
walls during surgery, and the platelets he received in the trauma
unit. These three factors
are also known as:
1. Trigeminy
2. Virchow's triad
3. Trigone
4. Hutchinson's triad
ANS: 2
There are three factors that contribute to venous thrombus
formation: (1) damage to the
vessel wall (e.g., injury during surgical procedures), (2)
alterations of blood flow (e.g.,
slow blood flow in calf veins associated with bed rest), and (3)
alterations in blood
constituents (e.g., a change in clotting factors or increased
platelet activity. These three
factors are sometimes referred to as Virchow's triad
