Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)

Test Bank For Fundamentals of Nursing 11th Edition Potter Perry Chapter 1-50 | Complete Guide Newest Version 2022 *A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility:* A. Decreased peristalsis B. Decreased heart rate C. Increased blood pressure D. Increased urinary output - *Answer: A* Rationale: Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis. *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 the resumption of activities of daily living for this patient?* A. Encouraging use of an overhead trapeze for positioning and transfer. B. Frequent family visits C. Assisting the patient to a wheelchair once per day D. Ensuring that there is an order for physical therapy - *Answer: A* Rationale: The trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed, aid in transfer from bed to wheelchair, or perform upperarm exercises. It increases independence and maintains upper body strength to help in performing activities of daily living. *An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility?* A. Loss of appetite B. Gum soreness C. Difficulty swallowing D. Left-ankle joint stiffness - *Answer: D* Rationale: Patients whose mobility is restricted require range-of-motion (ROM) exercises daily to reduce the hazards of immobility. 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. *The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend?* A. Cream of broccoli soup with whole wheat crackers, 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 - *Answer: A* Rationale: Teach patient and/or caregiver the current recommended dietary allowances for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy green vegetables, yogurt, and cheese). *A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken:* A. Myoclonus B. Pathological fractures C. Pressure ulcers D. Pruritus - *Answer: C* Rationale: Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative. *To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had abdominal surgery?* A. Turn, cough, and deep breathe every 30 minutes while awake B. Ambulate patient to chair in the hall C. Passive range of motion 4 times a day D. Immobility is not a concern the first postoperative day - *Answer: B* Rationale: Prevention of complications of immobility begins when the patient becomes immobilized. Every 30 minutes is not necessary and disruptive to the healing process. Active patient participation in exercises is more beneficial to preventing venous stasis. *Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest?* A. Isometric exercises B. Administration of low-dose heparin C. Suctioning every 4 hours D. Use of incentive spirometer every 2 hours while awake - *Answer: D* Rationale: Incentive spirometry opens the airway, preventing atelectasis. *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 patient'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 circulation 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 C. 1, 5, 7, 4, 6, 3, 2 D. 1, 5, 4, 7, 6, 3, 2 - *Answer: C* *Which of the following are physiological outcomes of immobility?* A. Increased metabolism B. Reduced cardiac workloa