Fundamentals |Exam |1 |(Potter |& |Perry
|Chapter |Practice |Questions)
*Answer: ||A* ||Rationale:
1. *A ||patient ||has ||been ||on ||bed ||rest ||for ||over ||4 ||days. ||On ||assessment, ||Immo- ||bility ||disrupts
||the ||nurse ||identifies ||the ||following ||as ||a ||sign ||associated ||with ||nor- ||mal ||metabolic
||immobility:* ||functioning: ||de-
A. Decreased ||peristalsis ||creasing ||the |meta- ||bolic
B. Decreased ||heart ||rate ||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 *Answer: ||A* ||Rationale:
||following ||nursing ||measures ||will ||best ||facilitate ||the ||resumption ||of ||The ||trapeze ||bar ||allows
||activities ||of ||daily ||living ||for ||this ||patient?* ||the ||patient ||to ||pull
A. Encouraging ||use ||of ||an ||overhead ||trapeze ||for ||posi- ||tioning ||and ||with ||the ||upper ||ex-
||transfer. ||tremities ||to ||raise ||the
||trunk ||off ||the ||bed, ||aid
B. Frequent ||family ||visits ||in ||transfer ||from |bed ||to
C. Assisting ||the ||patient ||to ||a ||wheelchair ||once ||per ||day ||wheel- ||chair, ||or
D. Ensuring ||that ||there ||is ||an ||order ||for ||physical ||therapy ||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 ||of *Answer: ||D* ||Rationale:
||the ||following ||complaints ||by ||the ||pa- ||tient ||indicates ||to ||the ||nurse ||that ||Patients ||whose ||mobility
||he ||or ||she ||is ||develop- ||ing ||a ||complication ||of ||immobility?* ||is ||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 *Answer: ||A* ||Rationale:
||increase ||because ||of ||high ||risk ||factors ||for ||osteoporosis. ||Which ||of ||the ||Teach ||patient ||and/or
||following ||menus ||should ||the ||nurse ||recommend?* ||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 ||this *Answer: ||C* ||Rationale:
||common ||complication ||of ||immo- ||bility ||if ||preventive ||measures ||are ||not ||Immo- ||bility ||is ||a ||major
||taken:* ||risk ||factor ||for ||pressure
A. Myoclonus ||ulcers. ||Any ||break ||in
||the ||integrity ||of ||the
B. Pathological ||fractures ||skin ||is ||difficult ||to
C. Pressure ||ulcers ||heal. |Preventing ||a
D. Pruritus ||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 *Answer: ||B* ||Rationale:
||effective ||activity ||on ||the ||first ||postop- ||erative ||day ||for ||a ||patient |Preven- ||tion ||of
||who ||has ||had ||abdominal ||surgery?* ||complica- ||tions ||of
A. Turn, ||cough, ||and ||deep ||breathe ||every ||30 ||minutes ||while ||awake ||immobil- ||ity ||begins
B. Ambulate ||patient ||to ||chair ||in ||the ||hall ||when ||the ||patient ||be-
||comes ||immobi- ||lized.
C. Passive ||range ||of ||motion ||4 ||times ||a ||day ||Every ||30 ||minutes ||is ||not
D. Immobility ||is ||not ||a ||concern ||the ||first ||postoperative ||day ||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
||stasis.
7. *Which ||of ||the ||following ||nursing ||interventions ||should ||be ||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* ||Rationale:
C. 1, ||5, ||7, ||4, ||6, ||3, ||2 ||Physio- ||logic ||outcomes
D. 1, ||5, ||4, ||7, ||6, ||3, ||2 ||of ||immobility ||include
||decreased ||metab- ||olism,
||increased ||cardiac
9. *Which ||of ||the ||following ||are ||physiological ||outcomes ||of ||immobility?* ||workload, ||decreased
A. Increased ||metabolism ||lung ||expansion, ||and ||in-
||creased ||oxygen
B. Reduced ||cardiac ||workload ||demand.
C. Decreased ||lung ||expansion
D. Decreased ||oxygen ||demand
*Answer: ||B, ||C, ||D*
10. *An ||older ||adult ||has ||limited ||mobility ||as ||a ||result ||of ||a ||total ||knee
||Rationale: ||Pa- ||tients
||replacement. ||During ||assessment ||you ||note ||that ||the ||patient ||has
||who ||are ||im- ||mobile
||difficulty ||breathing ||while ||lying ||flat. |Which ||of ||the ||following
||are ||at ||high ||risk ||for
||assessment ||data ||support ||a ||possible ||pulmonary ||problem ||related ||to
||developing ||pulmonary
||impaired ||mobility? ||(Select ||all ||that ||apply.)*
||compli-
4 ||/ ||235
|Chapter |Practice |Questions)
*Answer: ||A* ||Rationale:
1. *A ||patient ||has ||been ||on ||bed ||rest ||for ||over ||4 ||days. ||On ||assessment, ||Immo- ||bility ||disrupts
||the ||nurse ||identifies ||the ||following ||as ||a ||sign ||associated ||with ||nor- ||mal ||metabolic
||immobility:* ||functioning: ||de-
A. Decreased ||peristalsis ||creasing ||the |meta- ||bolic
B. Decreased ||heart ||rate ||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 *Answer: ||A* ||Rationale:
||following ||nursing ||measures ||will ||best ||facilitate ||the ||resumption ||of ||The ||trapeze ||bar ||allows
||activities ||of ||daily ||living ||for ||this ||patient?* ||the ||patient ||to ||pull
A. Encouraging ||use ||of ||an ||overhead ||trapeze ||for ||posi- ||tioning ||and ||with ||the ||upper ||ex-
||transfer. ||tremities ||to ||raise ||the
||trunk ||off ||the ||bed, ||aid
B. Frequent ||family ||visits ||in ||transfer ||from |bed ||to
C. Assisting ||the ||patient ||to ||a ||wheelchair ||once ||per ||day ||wheel- ||chair, ||or
D. Ensuring ||that ||there ||is ||an ||order ||for ||physical ||therapy ||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 ||of *Answer: ||D* ||Rationale:
||the ||following ||complaints ||by ||the ||pa- ||tient ||indicates ||to ||the ||nurse ||that ||Patients ||whose ||mobility
||he ||or ||she ||is ||develop- ||ing ||a ||complication ||of ||immobility?* ||is ||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 *Answer: ||A* ||Rationale:
||increase ||because ||of ||high ||risk ||factors ||for ||osteoporosis. ||Which ||of ||the ||Teach ||patient ||and/or
||following ||menus ||should ||the ||nurse ||recommend?* ||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 ||this *Answer: ||C* ||Rationale:
||common ||complication ||of ||immo- ||bility ||if ||preventive ||measures ||are ||not ||Immo- ||bility ||is ||a ||major
||taken:* ||risk ||factor ||for ||pressure
A. Myoclonus ||ulcers. ||Any ||break ||in
||the ||integrity ||of ||the
B. Pathological ||fractures ||skin ||is ||difficult ||to
C. Pressure ||ulcers ||heal. |Preventing ||a
D. Pruritus ||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 *Answer: ||B* ||Rationale:
||effective ||activity ||on ||the ||first ||postop- ||erative ||day ||for ||a ||patient |Preven- ||tion ||of
||who ||has ||had ||abdominal ||surgery?* ||complica- ||tions ||of
A. Turn, ||cough, ||and ||deep ||breathe ||every ||30 ||minutes ||while ||awake ||immobil- ||ity ||begins
B. Ambulate ||patient ||to ||chair ||in ||the ||hall ||when ||the ||patient ||be-
||comes ||immobi- ||lized.
C. Passive ||range ||of ||motion ||4 ||times ||a ||day ||Every ||30 ||minutes ||is ||not
D. Immobility ||is ||not ||a ||concern ||the ||first ||postoperative ||day ||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
||stasis.
7. *Which ||of ||the ||following ||nursing ||interventions ||should ||be ||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* ||Rationale:
C. 1, ||5, ||7, ||4, ||6, ||3, ||2 ||Physio- ||logic ||outcomes
D. 1, ||5, ||4, ||7, ||6, ||3, ||2 ||of ||immobility ||include
||decreased ||metab- ||olism,
||increased ||cardiac
9. *Which ||of ||the ||following ||are ||physiological ||outcomes ||of ||immobility?* ||workload, ||decreased
A. Increased ||metabolism ||lung ||expansion, ||and ||in-
||creased ||oxygen
B. Reduced ||cardiac ||workload ||demand.
C. Decreased ||lung ||expansion
D. Decreased ||oxygen ||demand
*Answer: ||B, ||C, ||D*
10. *An ||older ||adult ||has ||limited ||mobility ||as ||a ||result ||of ||a ||total ||knee
||Rationale: ||Pa- ||tients
||replacement. ||During ||assessment ||you ||note ||that ||the ||patient ||has
||who ||are ||im- ||mobile
||difficulty ||breathing ||while ||lying ||flat. |Which ||of ||the ||following
||are ||at ||high ||risk ||for
||assessment ||data ||support ||a ||possible ||pulmonary ||problem ||related ||to
||developing ||pulmonary
||impaired ||mobility? ||(Select ||all ||that ||apply.)*
||compli-
4 ||/ ||235
