Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
1. *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.
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 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 upper-arm
exercises. It increases independence and maintains upper body strength to help
in performing activities of daily living.
3. *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.
4. *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?*
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
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).
5. *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.
6. *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.
7. *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
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
D. Use of incentive spirometer every 2 hours while awake: *Answer: D*
Rationale: Incentive spirometry opens the airway, preventing atelectasis.
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 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*
9. *Which of the following are physiological outcomes of immobility?*
A. Increased metabolism
B. Reduced cardiac workload
C. Decreased lung expansion
D. Decreased oxygen demand: *Answer: C*
Rationale: Physiologic outcomes of immobility include decreased metabolism,
increased cardiac workload, decreased lung expansion, and increased oxygen
demand.
10. *An older adult has limited mobility as a result of a total knee replacement.
During assessment you note that the patient has difficulty breathing while
lying flat. Which of the following assessment data support a possible
pulmonary
problem related to impaired mobility? (Select all that apply.)*
A. B/P = 128/84
B. Respirations 26/min on room air
C. HR 114
D. Crackles over lower lobes heard on auscultation
E. Pain reported as 3 on scale of 0 to 10 after medication: *Answer: B, C, D*
Rationale: Patients who are immobile are at high risk for developing pulmonary
complications. The most common respiratory complications are atelectasis
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
(collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from
stasis or pooling of secretions). Ultimately the distribution of mucus in the bronchi
increases, particularly when the patient is in the supine, prone, or lateral position.
11. *A nurse is teaching a community group about ways to minimize the
risk of developing osteoporosis. Which of the following statements reflect
understanding of what was taught? (Select all that apply.)*
A. "I usually go swimming with my family at the YMCA 3 times a week."
B. "I need to ask my doctor if I should have a bone mineral density check this
year."
C. "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium
that I need in my diet."
D. "I'll check the label of my multivitamin. If it has calcium, I can save money
by not taking another pill."
E. "My lactose intolerance should not be a concern when considering my
calcium intake.": *Answer: A, B, C*
Rationale: Patients at risk for or diagnosed with osteoporosis have special health
promotion needs. Encourage patients at risk to be screened for osteoporosis and
assess their diets for calcium and vitamin D intake. Multivitamins do not always
have the needed amount of calcium for every individual. A patient needs to know
his or her requirement and make a decision based on that.
12. *A patient is receiving 5000 units of heparin subcutaneously every 12
hours while on prolonged bed rest to prevent thrombophlebitis. Because
bleeding is a potential side effect of this medication, the nurse should
continually assess the patient for the following signs of bleeding: (Select all
that apply.)* A. Bruising
B. Pale yellow urine
C. Bleeding gums
D. Coffee ground-like vomitus
E. Light brown stool: *Answer: A, C, D*
Rationale: Because bleeding is a potential side effect of these medications,
continually assess the patient for signs of bleeding such as hematuria, bruising,
coffee ground-like vomitus or gastrointestinal aspirate, guaiac-positive stools, and
bleeding gums.
13. *The nurse evaluates that the NAP has applied a patient's sequential
compression device (SCD) appropriately when which of the following is
observed?
