NR224 EXAM 1 PRACTICE
QUESTIONS WITH CORRECT
ANSWERS VERIFIED AND GRADED
A+
An older adult who was in a car accident and fractured his femur has been
immobilized for 5 days. Which nursing diagnosis is related to patient safety
when the nurse assists this patient out of bed for the first time?
A. Chronic pain
B. Impaired skin integrity
C. Risk for ineffective cerebral tissue perfusion
D. Risk for activity intolerance
D
A patient had a left-sided cerebrovascular accident 3 days ago and is
receiving 5000 units of heparin subcutaneously every 12 hours to prevent
thrombophlebitis. The patient is receiving enteral feedings through a small-
bore nasogastric (NG) tube because of dysphagia. Which of the following
symptoms requires the nurse to call the health care provider immediately?
A. Pale yellow urine
B. Unilateral neglect
C. Slight movement noted on the R side
D. Coffee ground-like aspirate from the feeding tube
D
,A home care nurse is preparing the home for a patient who is discharged to
home following a left-sided stroke. The patient is cooperative and can
ambulate with a quad-cane. Which of the following must be corrected or
removed for the patient's safety? (Select all that apply.)
A. The rubber mat in the walk-in shower
B. The three-legged stool on wheels in the kitchen
C. The braided throw rugs in the entry hallway and between the bedroom
and bathroom
D. The night-lights in the hallways, bedroom, and bathroom
E. The cordless phone next to the patient's bed
B&C
The nurse is caring for a patient whose calcium intake must increase
because of high risk factors for osteoporosis. The nurse would recommend
which of the following menus?
A. Cream of broccoli soup with whole wheat crackers and tapioca for dessert
B. Hamburger on soft roll with a side salad and an apple for dessert
C. Low-fat turkey chili with sour cream and fresh pears for dessert
D. Chicken salad on toast with tomato and lettuce and honey bun for dessert
A
Before transferring a patient from the bed to a stretcher, which assessment
data does the nurse need to gather? (Select all that apply.)
,A. Patient's weight
B. Patient's level of cooperation
C. Patient's ability to assist
D. Presence of medical equipment
E. 24-hour calorie intake
A, B, C, D
A patient of any age can develop a contracture of a joint when:
A. The adductors muscles are weakened as a result of immobility.
B. The muscle fibers become shortened because of disuse.
C. The calcium-to-phosphorus ratio becomes disrupted.
D. There is a deficiency in vitamin D.
B
Immobilized patients are at risk for impaired skin integrity. Which of the
following interventions would reduce this risk? (Select all that apply.)
A. Repositioning patient every 1 to 2 hours while awake
B. Using an objective, valid scale to assess patient's risk for pressure ulcer
development
C. Using a device to relieve pressure when patient is seated in chair
D. Teaching patient how to shift weight at regular intervals while sitting in a
chair
, E. A good rule is: the higher the risk for skin breakdown, the shorter the
interval between position changes
B, C, D, E
Which of the following indicates that additional assistance is needed to
transfer the patient from the bed to the stretcher?
A. The patient is 5 feet 6 inches and weighs 120 lbs.
B. The patient speaks and understands English.
C. The patient received an injection of morphine 30 minutes ago for pain.
D. You feel comfortable handling a patient of his size and with his level of
cooperation.
C
A patient with left-sided weakness asks his nurse, "Why are you walking on
my left side? I can hold on to you better with my right hand." What would be
your best therapeutic response?
A. "Walking on your left side lets me use my right hand to hold on to your
arm. In case you start to fall, I can still hold you."
B. "Would you like me to walk on your right side so you feel more secure?"
C. "Either side is appropriate, but I prefer the left side. If you like, I can have
another nurse walk with you who will hold you on the right side."
D. "By walking on your left side I can support you and help keep you from
injury if you should start to fall. By holding your waist I would protect your
shoulder if you should start to fall or faint.
D
QUESTIONS WITH CORRECT
ANSWERS VERIFIED AND GRADED
A+
An older adult who was in a car accident and fractured his femur has been
immobilized for 5 days. Which nursing diagnosis is related to patient safety
when the nurse assists this patient out of bed for the first time?
A. Chronic pain
B. Impaired skin integrity
C. Risk for ineffective cerebral tissue perfusion
D. Risk for activity intolerance
D
A patient had a left-sided cerebrovascular accident 3 days ago and is
receiving 5000 units of heparin subcutaneously every 12 hours to prevent
thrombophlebitis. The patient is receiving enteral feedings through a small-
bore nasogastric (NG) tube because of dysphagia. Which of the following
symptoms requires the nurse to call the health care provider immediately?
A. Pale yellow urine
B. Unilateral neglect
C. Slight movement noted on the R side
D. Coffee ground-like aspirate from the feeding tube
D
,A home care nurse is preparing the home for a patient who is discharged to
home following a left-sided stroke. The patient is cooperative and can
ambulate with a quad-cane. Which of the following must be corrected or
removed for the patient's safety? (Select all that apply.)
A. The rubber mat in the walk-in shower
B. The three-legged stool on wheels in the kitchen
C. The braided throw rugs in the entry hallway and between the bedroom
and bathroom
D. The night-lights in the hallways, bedroom, and bathroom
E. The cordless phone next to the patient's bed
B&C
The nurse is caring for a patient whose calcium intake must increase
because of high risk factors for osteoporosis. The nurse would recommend
which of the following menus?
A. Cream of broccoli soup with whole wheat crackers and tapioca for dessert
B. Hamburger on soft roll with a side salad and an apple for dessert
C. Low-fat turkey chili with sour cream and fresh pears for dessert
D. Chicken salad on toast with tomato and lettuce and honey bun for dessert
A
Before transferring a patient from the bed to a stretcher, which assessment
data does the nurse need to gather? (Select all that apply.)
,A. Patient's weight
B. Patient's level of cooperation
C. Patient's ability to assist
D. Presence of medical equipment
E. 24-hour calorie intake
A, B, C, D
A patient of any age can develop a contracture of a joint when:
A. The adductors muscles are weakened as a result of immobility.
B. The muscle fibers become shortened because of disuse.
C. The calcium-to-phosphorus ratio becomes disrupted.
D. There is a deficiency in vitamin D.
B
Immobilized patients are at risk for impaired skin integrity. Which of the
following interventions would reduce this risk? (Select all that apply.)
A. Repositioning patient every 1 to 2 hours while awake
B. Using an objective, valid scale to assess patient's risk for pressure ulcer
development
C. Using a device to relieve pressure when patient is seated in chair
D. Teaching patient how to shift weight at regular intervals while sitting in a
chair
, E. A good rule is: the higher the risk for skin breakdown, the shorter the
interval between position changes
B, C, D, E
Which of the following indicates that additional assistance is needed to
transfer the patient from the bed to the stretcher?
A. The patient is 5 feet 6 inches and weighs 120 lbs.
B. The patient speaks and understands English.
C. The patient received an injection of morphine 30 minutes ago for pain.
D. You feel comfortable handling a patient of his size and with his level of
cooperation.
C
A patient with left-sided weakness asks his nurse, "Why are you walking on
my left side? I can hold on to you better with my right hand." What would be
your best therapeutic response?
A. "Walking on your left side lets me use my right hand to hold on to your
arm. In case you start to fall, I can still hold you."
B. "Would you like me to walk on your right side so you feel more secure?"
C. "Either side is appropriate, but I prefer the left side. If you like, I can have
another nurse walk with you who will hold you on the right side."
D. "By walking on your left side I can support you and help keep you from
injury if you should start to fall. By holding your waist I would protect your
shoulder if you should start to fall or faint.
D
