A nurse is instructing a patient who has decreased leg strength on the left side on how to use a
cane. Which actions indicate proper cane use by the patient?
a. The patient keeps the cane on the left side of the body.
b. The patient slightly leans to one side while walking.
c. The patient keeps two points of support on the floor at all times.
d. After the patient places the cane forward, he or she then moves the right leg forward to the
cane. - CORRECT ANSWER-Answer: c
A patient has been on bed rest for over 5 days. Which of these findings during the nurse's
assessment may indicate a complication of immobility?
a. Decreased peristalsis
b. Decreased heart rate
c. Increased blood pressure
d. Increased urinary output - CORRECT ANSWER-Answer: a
An older adult patient has been bedridden for 2 weeks. Which of these complaints by the
patient indicates to the nurse that he or she is developing a complication of immobility?
,a. Increase of appetite
b. Gum soreness
c. Difficulty in swallowing
d. Left ankle joint stiffness - CORRECT ANSWER-Answer: d
A nurse is helping a patient perform active assisted range of motion in the right elbow. Which
statement describes the correct technique?
a. Support elbow by holding distal part of extremity.
b. Grasp joint with fingers to provide support.
c. Have patient move joint independently.
d. Move the joint past the point of resistance.
e. Perform the exercise a few times only, and gradually build up to more. - CORRECT ANSWER-
Answer: a
What is the proper position to use for an unresponsive patient during oral care to prevent
aspiration?
a. Prone position
b. Trendelenburg position
c. Semi-Fowler's position with head to side
d. Supine position - CORRECT ANSWER-Answer: c
A nurse is assigned to care for the following patients. Which patient is most at risk for
developing skin problems and thus requiring thorough bathing and skin care?
a. A 44-year-old female patient who has had removal of a breast lesion and is having her
menstrual period
, b. A 56-year-old male patient who is homeless and admitted to the emergency department with
malnutrition and dehydration and who has an intravenous line
c. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an
orthopedic brace applied to the left leg
d. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool -
CORRECT ANSWER-Answer: d
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is
indicated when a reddened area blanches on fingertip touch?
a. A local skin infection requiring antibiotics
b. Sensitive skin that requires special bed linen
c. A stage 3 pressure injury needing the appropriate dressing
d. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode -
CORRECT ANSWER-Answer: d
After surgery the patient with a closed abdominal wound reports a sudden "pop" after
coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces
of small bowel are noted at the bottom of the now-opened wound. Which are the priority
nursing interventions? (Select all that apply)
a. Notify the health care provider.
b. Allow the area to be exposed to air until all drainage has stopped.
c. Place several cold packs over the area, protecting the skin around the wound.
d. Cover the area with sterile, saline-soaked towels immediately.
e. Cover the area with sterile gauze and apply an abdominal binder - CORRECT ANSWER-
Answer: a & d
What is the removal of devitalized tissue from a wound called?
cane. Which actions indicate proper cane use by the patient?
a. The patient keeps the cane on the left side of the body.
b. The patient slightly leans to one side while walking.
c. The patient keeps two points of support on the floor at all times.
d. After the patient places the cane forward, he or she then moves the right leg forward to the
cane. - CORRECT ANSWER-Answer: c
A patient has been on bed rest for over 5 days. Which of these findings during the nurse's
assessment may indicate a complication of immobility?
a. Decreased peristalsis
b. Decreased heart rate
c. Increased blood pressure
d. Increased urinary output - CORRECT ANSWER-Answer: a
An older adult patient has been bedridden for 2 weeks. Which of these complaints by the
patient indicates to the nurse that he or she is developing a complication of immobility?
,a. Increase of appetite
b. Gum soreness
c. Difficulty in swallowing
d. Left ankle joint stiffness - CORRECT ANSWER-Answer: d
A nurse is helping a patient perform active assisted range of motion in the right elbow. Which
statement describes the correct technique?
a. Support elbow by holding distal part of extremity.
b. Grasp joint with fingers to provide support.
c. Have patient move joint independently.
d. Move the joint past the point of resistance.
e. Perform the exercise a few times only, and gradually build up to more. - CORRECT ANSWER-
Answer: a
What is the proper position to use for an unresponsive patient during oral care to prevent
aspiration?
a. Prone position
b. Trendelenburg position
c. Semi-Fowler's position with head to side
d. Supine position - CORRECT ANSWER-Answer: c
A nurse is assigned to care for the following patients. Which patient is most at risk for
developing skin problems and thus requiring thorough bathing and skin care?
a. A 44-year-old female patient who has had removal of a breast lesion and is having her
menstrual period
, b. A 56-year-old male patient who is homeless and admitted to the emergency department with
malnutrition and dehydration and who has an intravenous line
c. A 60-year-old female patient who experienced a stroke with right-sided paralysis and has an
orthopedic brace applied to the left leg
d. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool -
CORRECT ANSWER-Answer: d
When repositioning an immobile patient, the nurse notices redness over the hip bone. What is
indicated when a reddened area blanches on fingertip touch?
a. A local skin infection requiring antibiotics
b. Sensitive skin that requires special bed linen
c. A stage 3 pressure injury needing the appropriate dressing
d. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode -
CORRECT ANSWER-Answer: d
After surgery the patient with a closed abdominal wound reports a sudden "pop" after
coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces
of small bowel are noted at the bottom of the now-opened wound. Which are the priority
nursing interventions? (Select all that apply)
a. Notify the health care provider.
b. Allow the area to be exposed to air until all drainage has stopped.
c. Place several cold packs over the area, protecting the skin around the wound.
d. Cover the area with sterile, saline-soaked towels immediately.
e. Cover the area with sterile gauze and apply an abdominal binder - CORRECT ANSWER-
Answer: a & d
What is the removal of devitalized tissue from a wound called?
