NURA 303 Exam 2 Questions with
Complete Solutions
A nurse is caring for a patient who is on bed rest following a spinal injury. In which
position would the nurse place the patient's feet to prevent footdrop?
A. Supination
B. Dorsiflexion
C. Hyperextension
D. Abduction - Answer-b. For a patient who has footdrop, the nurse should support the
feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot.
Supination involves lying patients on their back or facing a body part upward, and
hyperextension is a state of exaggerated extension. Abduction involves lateral
movement of a body part away from the midline of the body. These positions would not
be used to prevent footdrop.
A nurse is instructing a patient who is recovering from a stroke how to use a cane.
Which step would the nurse include in the teaching plan for this patient?
A. Support weight on stronger leg and cane and advance weaker foot forward.
B. Hold the cane in the same hand of the leg with the most severe deficit.
C. Stand with as much weight distributed on the cane as possible.
D. Do not use the cane to rise from a sitting position, as this is unsafe. - Answer-a. The
proper procedure for using a cane is to (1) stand with weight distributed evenly between
the feet and cane; (2) support weight on the stronger leg and the cane and advance the
weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and
cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg
forward until even with the stronger leg and advance the cane again as in step 2. The
patient should keep the cane within easy reach and use it for support to rise safely from
a sitting position.
A patient has a fractured left leg, which has been casted. Following teaching from the
physical therapist for using crutches, the nurse reinforces which teaching point with the
patient?
A. Use the axillae to bear body weight.
B. Keep elbows close to the sides of the body.
C. When rising, extend the uninjured leg to prevent weight bearing.
D. To climb stairs, place weight on affected leg first. - Answer-b. The patient should
keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves
and circulation, extend the injured leg to prevent weight bearing when rising from a
chair, and advance the unaffected leg first when climbing stairs.
,A nurse working in a long-term care facility uses proper patient care ergonomics when
handling and transferring patients to avoid back injury. Which action should be the focus
of these preventive measures?
A. Carefully assessing the patient care environment
B. Using two nurses to lift a patient who cannot assist
C. Wearing a back belt to perform routine duties
D. Properly documenting the patient lift - Answer-a. Preventive measures should focus
on careful assessment of the patient care environment so that patients can be moved
safely and effectively. Using lifting teams and assistive patient handling equipment
rather than two nurses to lift increases safety. The use of a back belt does not prevent
back injury. The methods used for safe patient handling and movement should be
documented but are not the primary focus of interventions related to injury prevention.
A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit
in a chair. After assisting the patient to the side of the bed and to stand up, the patient's
knees buckle and she tells the nurse she feels faint. What is the appropriate nursing
action?
A. Wait a few minutes and then continue the move to the chair.
B. Call for assistance and continue the move with the help of another nurse.
C. Lower the patient back to the side of the bed and pivot her back into bed.
D. Have the patient sit down on the bed and dangle her feet before moving. - Answer-c.
If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse
should not continue the move to the chair. The nurse should lower the patient back to
the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess
the patient's vital signs and for the presence of other symptoms. Another attempt should
be made with the assistance of another staff member if vital signs are stable. Instruct
the patient to remain in the sitting position on the side of the bed for several minutes to
allow the circulatory system to adjust to a change in position, and avoid hypotension
related to a sudden change in position.
A patient who injured the spine in a motorcycle accident is receiving rehabilitation
services in a short-term rehabilitation center. The nurse caring for the patient correctly
tells the aide not to place the patient in which position?
A. Side-lying
B. Fowler's
C. Sims'
D. Prone - Answer-d. The prone position is contraindicated in patients who have spinal
problems because the pull of gravity on the trunk when the patient lies prone produces
a marked lordosis or forward curvature of the lumbar spine.
A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to
assess the mobility of a hospitalized patient. During the patient interview, the nurse
documents the following patient data: "Patient bathes self completely but needs help
with dressing. Patient toilets independently and is continent. Patient needs help moving
from bed to chair. Patient follows directions and can feed self." Based on this data,
which score would the patient receive on the Katz index?
,A. 2
B. 4
C. 5
D. 6 - Answer-b. The total score for this patient is 4. On the Katz Index of Independence
in ADLs, one point is awarded for independence in each of the following activities:
bathing, dressing, toileting, transferring, continence, and feeding.
The nurse caring for patients in a long-term care facility knows that there are factors that
place certain patients at a higher risk for falls. Which patients would the nurse consider
to be in this category? Select all that apply.
A. A patient who is older than 50
B. A patient who has already fallen twice
C. A patient who is taking antibiotics
D. A patient who experiences postural hypotension
E. A patient who is experiencing nausea from chemotherapy
F. A 70-year-old patient who is transferred to long-term care - Answer-b, d, f. Risk
factors for falls include age over 65 years, documented history of falls, postural
hypotension, and unfamiliar environment. A medication regimen that includes diuretics,
tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy
or antibiotics.
While discussing home safety with the nurse, a patient admits that she always smokes
a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the
priority for this patient?
A. Impaired gas exchange related to cigarette smoking
B. Anxiety related to inability to stop smoking
C. Risk for suffocation related to unfamiliarity with fire prevention guidelines
D. Deficient knowledge related to lack of follow-through of recommendation to stop
smoking - Answer-c. Because the patient is not aware that smoking in bed is extremely
dangerous, she is at risk for suffocation from fire. The other three nursing diagnoses are
correctly stated but are not a priority in this situation.
Based on the statistics for the leading cause of hospital admission for trauma in older
adults, what would be the nurse's priority intervention to prevent trauma when caring for
older adults in a nursing home?
A. Checking to make sure fire alarms are working properly.
B. Preventing exposure to temperature extremes.
C. Screening for partner or elder abuse.
D. Making sure patient rooms are decluttered. - Answer-d. Falls among older adults are
the most common cause of hospital admissions for trauma, therefore rooms should be
free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards
for older adults but are not the most common cause of trauma admissions. IPV occurs
more frequently in adults as opposed to older adults.
What consideration should the nurse keep in mind regarding the use of side rails for a
patient who is confused?
, A. They prevent confused patients from wandering.
B. A history of a previous fall from a bed with raised side rails is insignificant.
C. Alternative measures are ineffective to prevent wandering.
D. A person of small stature is at increased risk for injury from entrapment. - Answer-d.
Studies of restraint-related deaths have shown that people of small stature are more
likely to slip through or between the side rails. The desire to prevent a patient from
wandering is not sufficient reason for the use of side rails. Creative use of alternative
measures indicates respect for the patient's dignity and may in fact prevent more
serious fall-related injuries. A history of falls from a bed with raised side rails carries a
significant risk for a future serious incident
A nurse is following the principles of medical asepsis when performing patient care in a
hospital setting. Which nursing action performed by the nurse follows these
recommended guidelines?
A. The nurse carries the patients' soiled bed linens close to the body to prevent
spreading microorganisms into the air
B. The nurse places soiled bed linens and hospital gowns on the floor when making the
bed
C. The nurse moves the patient table away from the nurse's body when wiping it off
after a meal
D. The nurse cleans the most soiled items in the patient's bathroom first and follows
with the cleaner items - Answer-c. According to the principles of medical asepsis, the
nurse should move equipment away from the body when brushing, scrubbing, or
dusting articles to prevent contaminated particles from settling on the hair, face, or
uniform. The nurse should carry soiled items away from the body to prevent them from
touching the clothing. The nurse should not put soiled items on the floor, as it is highly
contaminated. The nurse should also clean the least soiled areas first and then move to
the more soiled ones to prevent having the cleaner areas soiled by the dirtier areas.
A school nurse is performing an assessment of a student who states, "I'm too tired to
keep my head up in class." The student has a low-grade fever. The nurse would
interpret these findings as indicating which stage of infection?
A. Incubation period
B. Prodromal stage
C. Full stage of illness
D. Convalescent period - Answer-b. During the prodromal stage, the person has vague
signs and symptoms, such as fatigue and a low-grade fever. There are no obvious
symptoms of infection during the incubation period, and they are more specific during
the full stage of illness before disappearing by the convalescent period.
A nurse is caring for patients in an isolation ward. In which situations would the nurse
appropriately use an alcohol-based handrub to decontaminate the hands? Select all that
apply.
A. Providing a bed bath for a patient
B. Visibly soiled hands after changing the bedding of a patient
C. Removing gloves when patient care is completed
