Test Bank Chapter 28: Immobility Potter et al.: Fundamentals of Nursing, 9th Edition ,100% CORRECT

Document Content and Description Below

Test Bank Chapter 28: Immobility Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 2. A nurse is providing range of motion to the shoulder and must perform external rotation. Whic... h action will the nurse take? a. Moves patient’s arm in a full circle b. Moves patient’s arm cross the body as far as possible c. Moves patient’s arm behind body, keeping elbow straight d. Moves patient’s arm until thumb is upward and lateral to head with elbow flexed ANS: D 4. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse’s action? a. Prevention of atelectasis b. Prevention of renal calculi c. Prevention of pressure ulcers d. Prevention of joint contractures ANS: D 8. A nurse reviews an immobilized patient’s laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient? a. Hypostatic pneumonia b. Renal calculi c. Pressure ulcers d. Thrombus formation ANS: B 9. A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient? a. Increased appetite b. Increased diarrhea c. Increased metabolic rate d. Altered nutrient metabolism ANS: D 14. A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal? a. When observed laterally, the spinal curves align in a reversed “S” pattern. b. When observed posteriorly, the hips and shoulders form an “S” pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out. ANS: A 15. The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding? a. The edge of the seat is in contact with the popliteal space. b. Both feet are supported on the floor with ankles flexed. c. The body weight is directly on the buttocks only. d. The arms hang comfortably at the sides. ANS: B 16. The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use? a. Supine position b. Lateral position c. Lateral position with positioning supports d. Supine position with no pillow under the patient’s head ANS: B 19. A nurse is assessing the skin of an immobilized patient. What will the nurse do? a. Assess the skin every 4 hours. b. Limit the amount of fluid intake. c. Use a standardized tool such as the Braden Scale. d. Have special times for inspection so as to not interrupt routine care. ANS: C 21. A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess? a. Imbalance b. Hemiplegia c. Muscle sprain d. Lower extremity paralysis ANS: A 22. Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan? a. A patient who is completely immobile b. A patient who is not completely immobile c. A patient at risk for single-system involvement d. A patient who is at risk for multisystem problems ANS: B 23. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take? a. Encourage the patient to do self-care. b. Keep the patient as mobile as possible. c. Encourage the patient to perform ROM. d. Assist the patient with comfort measures. ANS: D 27. Which goal is most appropriate for a patient who has had a total hip replacement? a. The patient will ambulate briskly on the treadmill by the time of discharge. b. The patient will walk 100 feet using a walker by the time of discharge. c. The nurse will assist the patient to ambulate in the hall 2 times a day. d. The patient will ambulate by the time of discharge. ANS: B 29. A nurse is caring for a patient with osteoporosis and lactose intolerance. What will the nurse do? a. Encourage dairy products. b. Monitor intake of vitamin D. c. Increase intake of caffeinated drinks. d. Try to do as much as possible for the patient. ANS: B 31. The patient is immobilized after undergoing hip replacement surgery. Which finding will alert the nurse to monitor for hemorrhage in this patient? a. Thick, tenacious pulmonary secretions c. SCDs wrapped around the legs d. Elastic stockings (TED hose) ANS: B 32. The nurse needs to move a patient up in bed using a drawsheet. The nurse has another nurse helping. In which order will the nurses perform the steps, beginning with the first one? 1. Grasp the drawsheet firmly near the patient.2. Move the patient and drawsheet to the desired position.3. Position one nurse at each side of the bed.4. Place the drawsheet under the patient from shoulder to thigh.5. Place your feet apart with a forward-backward stance.6. Flex knees and hips and on count of three shift weight from the front to back leg. a. 1, 4, 5, 6, 3, 2 b. 4, 1, 3, 5, 6, 2 c. 3, 4, 1, 5, 6, 2 d. 5, 6, 3, 1, 4, 2 ANS: C 33. The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take? a. Place pillow under the patient’s abdomen after turning. b. Turn head toward one side with large, soft pillow. c. Position legs flat against bed. d. Raise head of bed to 45 degrees. ANS: A 36. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient’s toes. Which device will the nurse use? a. Hand rolls b. A foot cradle c. A trapeze bar d. A trochanter roll ANS: B 37. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the NAP to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome? a. Patient is lying on side. b. Patient is lying on back. c. Patient is lying semiprone. d. Patient is lying on abdomen. ANS: A 39. A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care? a. A patient with neck surgery b. A patient with hypostatic pneumonia c. A patient with a total knee replacement d. A patient with a Stage IV pressure ulcer ANS: A 41. The nurse is caring for a patient who has had a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive ROM will be initiated. When should the nurse begin this therapy? a. After the acute phase of the disease has passed b. As soon as the ability to move is lost c. Once the patient enters the rehab unit d. When the patient requests it ANS: B 43. A nurse is assessing pressure points in a patient placed in the Sims’ position. Which areas will the nurse observe? a. Chin, elbow, hips b. Ileum, clavicle, knees c. Shoulder, anterior iliac spine, ankles d. Occipital region of the head, coccyx, heels ANS: B 45. The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the nurse use for logrolling? a. Use at least three people. b. Have the patient reach for the opposite side rail when turning. c. Move the top part of the patient’s torso and then the bottom part. d. Do not use pillows after turning. ANS: A MULTIPLE RESPONSE 1. Upon assessment a nurse discovers that a patient has erythema. Which actions will the nurse take? (Select all that apply.) a. Consult a dietitian. b. Increase fiber in the diet. c. Place on chest physiotherapy. d. Increase frequency of turning. e. Place on pressure-relieving mattress. ANS: A, D, E 2. The nurse is caring for a patient with impaired physical mobility. Which potential complications will the nurse monitor for in this patient? (Select all that apply.) a. Footdrop b. Somnolence c. Hypostatic pneumonia d. Impaired skin integrity e. Increased socialization ANS: A, C, D 3. The nurse is caring for a patient who has had a recent stroke and is paralyzed on the left side. The patient has no respiratory or cardiac issues but cannot walk. The patient cannot button a shirt and cannot feed self due to being left-handed and becomes frustrated very easily. The patient has been eating very little and has lost 2 lbs. The patient asks the nurse, “How can I go home like this? I’m not getting better.” Which health care team members will the nurse need to consult? (Select all that apply.) a. Dietitian b. Physical therapist c. Respiratory therapist d. Cardiac rehabilitation therapist e. Occupational therapist f. Psychologist ANS: A, B, E, F Chapter 29: Infection Prevention and Control Chapter 29: Infection Prevention and ControlPotter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 7. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. A nurse is taking a health history. Which question is the priority? a. “When was the last time you visited your primary health care provider?” b. “Has this condition affected your eating habits in any way?” c. “What medications are you currently taking?” d. “Are you able to sleep at night?” ANS: C 11. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access (IV) device. Which nursing intervention is a priority in this procedure? a. Review the procedure with the patient. b. Position the patient comfortably. c. Maintain surgical aseptic technique. d. Gather available supplies. ANS: C 13. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection? a. Teaching the patient about fall prevention b. Teaching the patient to take a temperature c. Teaching the patient to select nutritious foods d. Teaching the patient about the effects of alcohol ANS: C 15. A patient presents with pneumonia. Which priority intervention should be included in the plan of care for this patient? a. Observe the patient for decreased activity tolerance. b. Assume the patient is in pain and treat accordingly. c. Provide the patient ice chips as requested. ANS: A 16. The nurse is caring for a patient in an intensive care unit who needs a bath. Which priority action will the nurse take to decrease the potential for a health care–associated infection? a. Use local anesthetic on reddened areas. b. Use nonallergenic tape on dressings. c. Use a chlorhexidine wash. d. Use filtered water. ANS: C 17. The infection control nurse is reviewing data for the medical- surgical unit. The nurse notices an increase in postoperative infections from Aspergillus. Which type of health care–associated infection will the nurse report? a. Vector b. Exogenous c. Endogenous d. Suprainfection ANS: B 18. The patient has contracted a urinary tract infection (UTI) while in the hospital. Which action will most likely increase the risk of a patient contracting a UTI? a. Reusing the patient’s graduated receptacle to empty the drainage bag. b. Allowing the drainage bag port to touch the graduated receptacle. c. Emptying the urinary drainage bag at least once a shift. d. Irrigating the catheter infrequently. ANS: B 19. Which nursing action will most likely increase a patient’s risk for developing a health care– associated infection? a. Uses surgical aseptic technique to suction an airway b. Uses a clean technique for inserting a urinary catheter c. Uses a cleaning stroke from the urinary meatus toward the rectum d. Uses a sterile bottled solution more than once within a 24-hour period ANS: B 20. The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient’s cervix, the electronic infusion device being used on the intravenous (IV) infusion alarms. Which sequence of actions is mostappropriate for the nurse to take? a. Complete the assessment, remove gloves, and silence the alarm. b. Discontinue the assessment, silence the alarm, and assess the intravenous site. c. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion. d. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion. ANS: C 21. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break in sterile technique? a. Touching clean protective eyewear b. Standing with hands above waist area c. Accepting sterile supplies from the surgeon d. Staying with the sterile table once it is open ANS: A 22. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change? a. Donning clean goggles, gown, and gloves to dress the wound b. Donning sterile gown and gloves to remove the wound dressing c. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing d. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing ANS: C 23. The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which observation will require the nurse to intervene? a. Washing hands after removing gloves b. Disinfecting endoscopes in the workroom c. Removing gloves to transfer the endoscope d. Placing the endoscope in a container for transfer ANS: C 24. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions? a. Teaches the patient about good nutrition b. Dons gloves when wearing artificial nails c. Disposes an uncapped needle in the designated container d. Wears eyewear when emptying the urinary drainage bag ANS: D 25. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. Which precaution will the nurse use? a. Contact b. Droplet c. Standard d. Protective environment ANS: C 26. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistive personnel (NAP) turning off the handle faucet with bare hands. Which professional practice principle supports the need for follow-up with the NAP? a. The nurse is responsible for providing a safe environment for the patient. b. Different scopes of practice allow modification of procedures. c. Allowing the water to run is a waste of resources and money. d. This is a key step in the procedure for washing hands. ANS: A 27. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. Which action is best for the nurse to take next? a. Wash hands with an antimicrobial soap and water. b. Clean hands with wipes from the bedside table. c. Use an alcohol-based waterless hand gel. d. Wipe hands with a dry paper towel. ANS: A 28. The nurse is performing hand hygiene before assisting a health care provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next? a. Inform the health care provider and recruit another nurse to assist. b. Rinse and dry hands, and begin assisting the health care provider. c. Extend the handwashing procedure to 5 minutes. d. Repeat handwashing using antiseptic soap. ANS: D 29. The nurse on the surgical team and the surgeon have completed a surgery. After donning gloves, gathering instruments, and placing in the transport carrier, what is the next step in handling the instruments used during the procedure? a. Sending to central sterile for cleaning and sterilization b. Sending to central sterile for cleaning and disinfection c. Sending to central sterile for cleaning and boiling d. Sending to central sterile for cleaning ANS: A 30. The nurse is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings? a. The family member places the used dressings in a plastic bag. b. The family member saves part of the dressing because it is clean. c. The family member removes gloves and gathers items for disposal. d. The family member wraps the used dressing in toilet tissue before placing in trash. ANS: A 31. The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with Clostridium difficile in droplet precautions b. A patient with tuberculosis in airborne precautions c. A patient with MRSA infection in contact precautions d. A patient with a lung transplant in protective environment precautions ANS: A 32. The home health nurse is teaching a patient and family about hand hygiene in the home. Which situation will cause the nurse to emphasize washing hands before and after? a. Shaking hands b. Performing treatments c. Opening the refrigerator d. Working on a computer ANS: B 33. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next? a. Apply a new mask. b. Reapply the mask after it air-dries. c. Change the mask when relieved by next shift. d. Do not change the mask if the nurse is comfortable. ANS: A 34. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease? a. Place the patient in a room with negative airflow. b. Wear a gown, gloves, face mask, and goggles for interactions with the patient. c. Transport the patient safely and quickly when going to the radiology department. d. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only. ANS: D 35. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which action will the nurse take next? a. Instruct assistive personnel to use soap and water rather than sanitizer. b. Wear an N95 respirator when entering the patient room. c. Place the patient on droplet precautions. d. Teach the patient cough etiquette. ANS: A 36. The nurse is changing linens for a postoperative patient and feels a prick in the left hand. A nonactivated safe needle is noted in the linens. For which condition is the nurse most at risk? a. Diphtheria b. Hepatitis B ANS: B 37. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next? a. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care. b. Immediately wash the site with soap and running water, and seek guidance from the manager. c. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job. d. Delay washing of the site until the nurse is finished providing care to the patient. ANS: B 38. Which process will be required after exposure of a nurse to blood by a cut from a used scalpel in the operative area? a. Placing the scalpel in a needle safe container b. Testing the patient and offering treatment to the nurse c. Removing sterile gloves and disposing of in kick bucket d. Providing a medical evaluation of the nurse to the manager ANS: B 39. The nurse is caring for a patient who needs a protective environment. The nurse has provided the care needed and is now leaving the room. In which order will the nurse remove the personal protective equipment, beginning with the first step? 1. Remove eyewear/face shield and goggles.2. Perform hand hygiene, leave room, and close door. 3. Remove gloves. 4. Untie gown, allow gown to fall from shoulders, and do not touch outside of gown; dispose of properly. 5. Remove mask by strings; do not touch outside of mask.6. Dispose of all contaminated supplies and equipment in designated receptacles. a. 3, 1, 4, 5, 6, 2 b. 1, 4, 5, 3, 6, 2 c. 1, 4, 5, 3, 2, 6 d. 3, 1, 4, 5, 2, 6 ANS: D 40. The nurse manager is evaluating current infection control data for the intensive care unit. The nurse compares past patient data with current data to look for trends. The nurse manager examines the infection chain for possible solutions. In which order will the nurse arrange the items for the infection chain beginning with the first step? 1. A mode of transmission2. An infectious agent or pathogen3. A susceptible host4. A reservoir or source for pathogen growth 5. A portal of entry to a host 6. A portal of exit from the reservoir a. 3, 2, 4, 1, 5, 6 b. 1, 3, 5, 4, 6, 2 c. 4, 2, 1, 6, 3, 5 d. 2, 4, 6, 1, 5, 3 ANS: D MULTIPLE RESPONSE 1. The nurse is caring for a patient in protective environment. Which actions will the nurse take? (Select all that apply.) a. Wear an N95 respirator when entering the patient’s room. b. Maintain airflow rate greater than 12 air exchanges/hr. c. Place in special room with negative-pressure airflow. d. Open drapes during the daytime. e. Listen to the patient’s interests. f. Place dried flowers in a plastic vase. ANS: B, D, E 2. The nurse is assessing a new patient admitted to home health. Which questions willbe most appropriate for the nurse to ask to determine the risk of infection? (Select all that apply.) a. “Can you explain the risk for infection in your home?” b. “Have you traveled outside of the United States?” c. “Will you demonstrate how to wash your hands?” d. “What are the signs and symptoms of infection?” e. “Are you able to walk to the mailbox?” f. “Who runs errands for you?” ANS: A, B, C, D 3. The circulating nurse in the operating room is observing the surgical technologist while applying a sterile gown and gloves to care for a patient having an appendectomy. Which behaviors indicate to the nurse that the procedure by the surgical technologist is correct? (Select all that apply.) a. Ties the back of own gown b. Touches only the inside of gown c. Slips arms into arm holes simultaneously d. Extended fingers fully into both of the gloves e. Uses hands covered by sleeves to open gloves f. Applies surgical cap and face mask in the operating suite ANS: B, C, D, E 4. The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.) a. While putting on the first glove, touch only the outside surface of the glove. b. With gloved dominant hand, slip fingers underneath second glove cuff. c. Remove outer glove package by tearing the package open. d. Lay glove package on clean flat surface above waistline. e. Glove the dominant hand of the nurse first. f. After second glove is on, interlock hands. ANS: B, D, E, F 5. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient? (Select all that apply.) a. Private room b. Negative-pressure airflow in room c. Surgical mask, gown, gloves, eyewear d. N95 respirator, gown, gloves, eyewear e. Communication signs for droplet precautions f. Communication signs for airborne precautions ANS: A, B, D, F 6. The nurse and the student nurse are caring for two different patients on the medical-surgical unit. One patient is in airborne precautions, and one is in contact precautions. The nurse explains to the student different interventions for care. Which information will the nurse include in the teaching session? (Select all that apply.) a. Dispose of supplies to prevent the spread of microorganisms. b. Wash hands before entering and leaving both of the patients’ rooms. c. Be consistent in nursing interventions since there is only one difference in the precautions. d. Apply the knowledge the nurse has of the disease process to prevent the spread of microorganisms. e. Have patients in airborne precautions wear a mask during transportation to other departments. Check the working order of the negative-pressure room for the airborne precaution patient on admission a f. discharge. ANS: A, B, D, E Chapter 30: Vital Signs Chapter 30: Vital SignsPotter et al.: Fundamentals of Nursing, 9th EditionMULTIPLE CHOICE 1. A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure ANS: C 2. A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation ANS: C 3. The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature? a. Radiation b. Conduction c. Convection d. Evaporation ANS: B 4. A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a. Apply just a diaper. b. Double the clothing. c. Place a cap on their heads. d. Increase room temperature to 90 degrees. ANS: C 5. The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the health care provider immediately to report a possible infection. b. Administer medication to lower the temperature further. c. Provide another blanket to conserve body temperature. d. Realize that this is a normal temperature variation. ANS: D 6. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a. Wait 30 minutes and recheck the patient’s temperature. b. Assume that the patient has an infection and order blood cultures. c. Encourage the patient to move around to increase muscular activity. d. Be aware that temperatures this high are harmful and affect patient safety. ANS: A 7. A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? a. Stethoscope b. Thermometer c. Blood pressure cuff d. Sphygmomanometer ANS: B 8. The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a. Hyperthermia and fever are the same thing. b. Hyperthermia is an upward shift in the set point. c. Hyperthermia occurs when the body cannot reduce heat production. d. Hyperthermia results from a reduction in thermoregulatory mechanisms. ANS: C 9. The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? a. Place the patient on oxygen. b. Encourage the patient to cough. c. Restrict the patient’s fluid intake. d. Increase the patient’s metabolic rate. ANS: A 10. The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a. Using appropriate route and device b. Assessing changes in body temperature c. Being aware of the usual values for the patient d. Obtaining temperature measurement at ordered frequency ANS: B 11. The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient’s temperature? a. Oral b. Rectal c. Axillary d. Tympanic ANS: D 12. The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? a. Oral b. Axillary c. Tympanic d. Temporal ANS: C 13. The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to bestobtain the infant’s pulse? a. Radial b. Brachial c. Femoral d. Popliteal ANS: B 14. The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a. Radial b. Apical c. Carotid d. Brachial ANS: C 15. The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a. Place the tips of the first two fingers over the groove along the thumb side of the patient’s wrist. b. Place the tips of the first two fingers over the groove along the little finger side of the patient’s wrist. c. Place the thumb over the groove along the little finger side of the patient’s wrist. d. Place the thumb over the groove along the thumb side of the patient’s wrist. ANS: A 16. The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate? a. Inform the patient that she is counting respirations. b. Do not touch the patient until completed. c. Obtain without the patient knowing. d. Estimate respirations. ANS: C 17. The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 60 b. 80 c. 140 d. 200 ANS: B 18. The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a. Arterial blood gas b. Blood culture c. Hematocrit d. Potassium ANS: C 19. The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a. Allow the patient to breathe into a paper bag. b. Use oxygen cautiously in this patient. c. Administer high levels of oxygen. d. ANS: B 20. A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg b. 40 mm Hg c. 45 mm Hg d. 50 mm Hg ANS: D 21. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate? a. The patient has a fever. b. The patient has possible hemorrhage or bleeding. c. The patient has chronic obstructive pulmonary disease (COPD). d. The patient has calcium channel blockers or digitalis medication prescriptions. ANS: D 22. The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient’s oxygen saturation? a. Attach a finger probe to the patient’s index finger. b. Place a nonadhesive sensor on the patient’s earlobe. c. Attach a disposable adhesive sensor to the bridge of the patient’s nose. d. Place the sensor on the same arm that the electronic blood pressure cuff is on. ANS: B 23. The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms? a. Red blood cell count of 5.0 million/mm3 b. Hemoglobin level of 8.0 g/100 mL c. Hematocrit level of 45% d. Pulse oximetry of 95% ANS: B 24. A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? a. 98/50 in a 7-year-old child b. 115/70 in an infant c. 120/80 in a middle-aged adult d. 146/90 in an older adult ANS: C 25. The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? a. Non-Hispanic Caucasians b. European Americans c. African-Americans d. Asian Americans ANS: C 26. A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP)? a. Smoking increases BP for up to 3 hours. b. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement. ANS: C 27. When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? a. This is normal for an infant. b. This is too fast for an infant. c. This is too slow for an infant. d. This is not a rate for an infant but for a toddler. ANS: A 28. The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding? a. The patient has hyperthermia. b. The patient has a normal temperature. c. The patient is suffering from hypothermia. d. The patient is demonstrating increased metabolism. ANS: B 29. When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse’s action? a. It is not affected by skin moisture. b. It has no risk of injury to patient or nurse. c. It reflects rapid changes in radiant temperature. d. It is accurate even when the forehead is covered with hair. ANS: B 30. The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a. Ulnar site b. Radial site c. Brachial site d. Femoral site ANS: C 31. The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a. 30 to 60 b. 22 to 28 c. 16 to 20 d. 10 to 15 ANS: A 32. The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a. Secure the sensor to the toddler’s earlobe. b. Determine whether the toddler has a latex allergy. c. Place the sensor on the bridge of the toddler’s nose. d. Overlook variations between an oximeter pulse rate and the toddler’s pulse rate. ANS: B 33. The nurse is preparing to assess the blood pressure of a 3-year- old. How should the nurse proceed? a. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. b. Obtain the reading before the child has a chance to “settle down.” c. Choose the cuff that says “Child” instead of “Infant.” d. Explain the procedure to the child. ANS: D 34. A nurse is caring for a group of patients. Which patient will the nurse see first? a. A crying infant with P-165 and R-54 b. A sleeping toddler with P-88 and R-23 c. A calm adolescent with P-95 and R-26 d. An exercising adult with P-108 and R-24 ANS: C 35. The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient? a. You can apply the cuff in any manner. b. You will need to recalibrate the machine. c. You can move your arm during the reading. d. You will need to use a stethoscope properly. ANS: B 36. The nurse is caring for a patient who reports feeling light- headed and “woozy.” The nurse checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a. Apply more pressure to the radial artery to feel pulse. b. Perform an apical/radial pulse assessment. c. Call the health care provider immediately. d. Obtain arterial blood gases. ANS: B 37. A nurse is caring for a group of patients. Which patient will the nurse see first? a. A 17-year-old male who has just returned from outside “for a smoke” who needs a temperature taken b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74 d. An 87-year-old male suspected of hypothermia whose temperature is below normal ANS: B 38. The health care provider prescription reads “Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.” The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? a. Documents that the medication was not given because of low blood pressure b. Does not inform the health care provider that the medication was held c. Does not tell the patient what the blood pressure is d. Documents only what the blood pressure was. ANS: A 39. After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action? a. Temperatures vary depending on the route used. b. Temperatures are readings of core measurements. c. Rectal temperatures are cooler than when taken orally. d. Axillary temperatures are higher than oral temperatures. ANS: A 40. When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? a. 68 b. 76 c. 138/62 d. 138/70 ANS: C 41. The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next? a. Ask the NAP retake the blood pressure. b. Instruct the NAP to assess the patient’s other vital signs. c. Disregard the report and have it rechecked at the next scheduled time. d. Retake the blood pressure personally and assess the patient’s condition. ANS: D MULTIPLE RESPONSE 1. A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a. Rectal b. Tympanic c. Esophagus d. Temporal artery e. Pulmonary artery ANS: B, C, E 2. The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a. O2 saturations (SaO2) > 70% b. Carbon monoxide inhalation c. Hypothermic fingers d. Intravascular dyes e. Nail polish f. Jaundice ANS: B, C, D, E, F 3. The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.) a. Obesity b. Cigarette smoking c. Recent weight loss d. Heavy alcohol intake e. Regular exercise sessions ANS: A, B, D 4. The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. c. The risk of obtaining an inaccurate reading is decreased. d. Blood pressures can be obtained if pulse rates become irregular. e. Patients can provide information about patterns to health care providers. ANS: A, B, E 5. A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul’s—abnormally deep, regular, fast respirations d. Hyperventilation—labored, increased in depth and rate respirations e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations f. Biot’s—irregular with alternating periods of apnea and hyperventilation respirations ANS: A, B, C MATCHING A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing. a. Patient’s temperature is 113° F (45° C) with hot, dry skin. b. Patient’s blood pressure sitting is 130/60 and 110/40 standing. c. Patient’s pulse is 110 beats/min. d. Patient’s temperature is 93.2° F (34° C). e. Patient’s blood pressure went from 126/76 to 90/50. 1. Hypothermia 2. Shock/Hypotension 3. Heatstroke4. Orthostatic hypotension 5. Tachycardia Chapter 15: Critical Thinking in Nursing Practice Chapter 15: Critical Thinking in Nursing PracticePotter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. Which action should the nurse take when using critical thinking to make clinical decisions? a. Make decisions based on intuition. b. Accept one established way to provide care. c. Consider what is important in a given situation. d. Read and follow the heath care provider’s orders. ANS: C A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Patient care can be provided in many ways. The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Following health care provider’s orders is not considered a critical thinking skill. If your knowledge causes you to question a health care provider’s order, do so. DIF:Understand (comprehension)REF:196 | 205 OBJ iscuss a nurse’s responsibility in making clinical decisions. TOP:ImplementationMSC:Management of Care 2. Which patient scenario of a surgical patient in pain is most indicative of critical thinking? e. Administering pain-relief medication according to what was given last shift f. Offering pain-relief medication based on the health care provider’s orders c. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in t d. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that d. performed ANS: C 3. Which action indicates a registered nurse is being responsible for making clinical decisions? a. Applies clear textbook solutions to patients’ problems b. Takes immediate action when a patient’s condition worsens c. Uses only traditional methods of providing care to patients d. Formulates standardized care plans solely for groups of patients ANS: B 4. A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? e. Making an ethical clinical decision f. Making an informed clinical decision g. Making a clinical decision in the patient’s best interest h. Making a clinical decision based on previous shift assessments ANS: D 5. Which action demonstrates a nurse utilizing reflection to improve clinical decision making? a. Obtains data in an orderly fashion b. Uses an objective approach in patient situations c. Improves a plan of care while thinking back on interventions effectiveness d. Provides evidence-based explanations and research for care of assigned patients ANS: C 6. A nursing instructor needs to evaluate students’ abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor’s needs? a. Concept mapping b. Reflective journaling c. Lecture and discussion d. Reading assignment with a written summary ANS: A 7. A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions? a. Attitude b. Experience c. Nursing process d. Specific knowledge base ANS: D 8. Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? e. Drawing on past clinical experiences to formulate standardized care plans f. Relying on recall of information from past lectures and textbooks g. Depending on the charge nurse to determine priorities of care d. Using the nursing process ANS: D 9. A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? d. Examine the meaning of data. e. Support findings and conclusions. f. Review the effectiveness of nursing actions. g. Search for links between the data and the nurse’s assumptions. ANS: C 10. The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill? a. Evaluation b. Explanation c. Interpretation d. Self-regulation ANS: C 11. A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explore other options for pain relief. b. Discuss the surgical procedure and reason for the pain. c. Explain to the patient that nothing else has been ordered. d. Offer to notify the health care provider after morning rounds are completed. ANS: A 12. Which action should the nurse take to best develop critical thinking skills? a. Study 3 hours more each night. b. Attend all inservice opportunities. c. Actively participate in clinical experiences. d. Interview staff nurses about their nursing experiences. ANS: C 13. While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? a. Postpone catheter insertion until the next shift. b. Adapt the positioning technique to the situation. c. Notify the health care provider for a urologist consult. d. Follow textbook procedure with contraindicated position. ANS: B 14. The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? e. Provide privacy and check on the patient 30 minutes later. f. Set a box of tissues at the patient’s bedside before leaving the room. g. Limit visitors while the patient is upset. h. Ask the patient about the crying. ANS: D 15. A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation? e. Humility f. Creativity g. Risk taking h. Confidence ANS: B 16. A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility? e. Refusing the assignment f. Asking for an orientation to the unit g. Admitting lack of knowledge and going home h. Assuming that patient care will be the same as on the other units ANS: B 17. A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse’s actions? a. Establishes minimal passing standards for testing b. Utilizes evidence-based practice based on nurses’ needs c. Bypasses the patient’s feelings to promote ethical standards d. Uses critical thinking for the highest level of quality nursing care ANS: D 18. A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following? a. Fairness b. Intellectual standards c. Independent reasoning d. Institutional practice guidelines ANS: D 19. A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? e. Patient’s outcomes for learning f. Nurse’s assumptions about hospital discharge g. Identification of several actual health problems h. Documentation of patient’s ability to meet the goal ANS: B 20. In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals2. Assessing patient needs3. Planning priorities of care4. Determining nursing diagnoses5. Implementing nursing interventions a. 2, 4, 3, 5, 1 b. 4, 3, 2, 1, 5 c. 1, 2, 4, 5, 3 d. 5, 1, 2, 3, 4 ANS: A MULTIPLE RESPONSE 1. Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) e. Tense muscles f. Reactive responses g. Trouble concentrating h. Very tired feelings i. Managed emotions ANS: A, B, C, D Chapter 39: Activity and Exercise Chapter 39: Activity and ExercisePotter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. A nurse observes a patient rising from a chair slowly by pushing on the chair arms. Which type of tension and contraction did the nurse observe? e. Eccentric tension and isotonic contraction f. Eccentric tension and isometric contraction g. Concentric tension and isotonic contraction h. Concentric tension and isometric contraction ANS: A 2. A nurse notices that a patient has a structural curvature of the spine associated with vertebral rotation. Which condition will the nurse most likely find documented in the patient’s medical record? g. Scoliosis h. Arthritis i. Osteomalacia j. Osteogenesis ANS: A 3. A nurse is caring for a patient who has some immobility from noninflammatory joint degeneration. The nurse is teaching the patient about this process. Which information will the nurse include in the teaching session? e. This will affect synovial fluid. f. This will affect the body systemically. g. This involves mostly non–weight-bearing joints. h. This involves overgrowth of bone at the articular ends. ANS: D 4. The nurse is providing care to a patient who is bedridden. The nurse raises the height of the bed. What is the rationale for the nurse’s action? i. Narrows the nurse’s base of support. j. Allows the nurse to bring feet closer together. k. Prevents a shift in the nurse’s base of support. l. Shifts the nurse’s center of gravity farther away from the base of support. ANS: C 5. A nurse is following the no-lift policy when working to prevent personal injury. Which type of personal back injury is the nurse most likely trying to prevent? e. Thoracic f. Cervical g. Lumbar h. Sacral ANS: C 6. The nurse is caring for a patient in the emergency department with an injured shoulder. Which type of joint will the nurse assess? e. Fibrous f. Synovial g. Synergistic h. Cartilaginous ANS: B 7. The nurse is caring for a patient with inner ear problems. Which goal is the priority? e. Maintain balance. f. Maintain proprioception. g. Maintain muscle strength. h. Maintain body alignment. ANS: A 8. A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples? h. Swimming, jogging, and bicycling i. Tightening or tensing of muscles without moving body parts c. Quadriceps set exercises and contraction of the gluteal muscles d. Push-ups, hip lifting, pushing feet against a footboard on the bed ANS: A 9. An adolescent tells the nurse that a health professional said the fibrous tissue that connects bone and cartilage was strained in a sporting accident. On which structure will the nurse focus an assessment? h. Tendon i. Ligament j. Synergistic muscle k. Antagonistic muscle ANS: B 10. A nurse is developing an exercise plan for a middle-aged patient. In which order will the nurse instruct the patient to execute the plan, beginning with the first step? 1. Design the fitness program. 2. Assemble equipment.3. Assess fitness level.4. Monitor progress. 5. Get started. e. 5, 1, 3, 2, 4 f. 1, 2, 3, 5, 4 g. 2, 5, 3, 1, 4 h. 3, 1, 2, 5, 4 ANS: D 11. The nurse gives instructions to a nursing assistive personnel (NAP) regarding exercise for a patient. Which action by the NAP indicates a correct understanding of the directions? d. Determines the patient’s ability to exercise e. Teaches the patient how to do the exercises f. Reports the patient got dizzy after exercising g. Advises the patient to work through the pain ANS: C 12. The nurse is starting an exercise program in a local community as a health promotion project. Which information will the nurse include in the teaching session? e. A cool-down period lasts about 5 to 10 minutes. f. The purpose of weight training is to bulk up muscles. g. Resistance training is appropriate for warm-up and cool-down periods. h. Aerobic exercise should be done 3 to 5 times per week for about 20 minutes. ANS: A 13. The patient is eager to begin an exercise program with a 2-mile jog. The nurse instructs the patient to warm up. The patient does not want to waste time with a “warm-up.” Which information will the nurse share with the patient? e. The warm-up in this case can be done after the 2-mile jog. f. The warm-up prepares the body and decreases the potential for injury. g. The warm-up allows the body to readjust gradually to baseline functioning. h. The warm-up should be performed with high intensity to prepare for the coming challenge. ANS: B 14. The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse decides to use a transportable hydraulic lift. What will the nurse do? i. Place a horseshoe-shaped base on the opposite side from the chair. j. Remove straps before lowering the patient to the chair. k. Hook longer straps to the bottom of the sling. l. Attach short straps to the bottom of the sling. ANS: C 15. The nurse is preparing to move a patient to a wheelchair. Which action indicates the nurse is following recommendations for safe patient handling? i. Mentally reviews the transfer steps before beginning j. Uses own strength to transfer the patient k. Focuses solely on body mechanics l. Bases decisions on intuition ANS: A 16. A nurse is working in a facility that follows a comprehensive safe patient-handling program. Which finding will alert the nurse to intervene? i. Mechanical lifts are in a locked closet. j. Algorithms for patient handling are available. k. Ergonomic assessment protocols are being followed. l. A no-lift policy is in place with adherence by all staff. ANS: A 17. The patient is brought to the emergency department with possible injury to the left shoulder. Which area will the nurse assess to best determine joint mobility? e. The patient’s gait f. The patient’s range of motion g. The patient’s ethnic influences h. The patient’s fine-motor coordination ANS: B 18. The nurse is evaluating care of a patient for crutches. Which finding indicates a successful outcome? e. The top of the crutch is three to four finger widths from the armpit. f. The elbows are slightly flexed at 30 to 35 degrees when the patient is standing. g. The tip of the crutch is 4 to 6 inches anterior to the front of the patient’s shoes. h. The position of the handgrips allows the axilla to support the patient’s body weight. ANS: C 19. The patient reports being tired and weak and lacks energy. Upon assessment, the nurse finds that patient has gained weight, and blood pressure and pulse are elevated after climbing stairs. Which nursing diagnosis will the nurse add to the care plan? ANS: C… Activity Intolerance 20. The patient weighs 450 lbs (204.5 kg) and reports shortness of breath with any exertion. The health care provider has recommended beginning an exercise program. The patient states that she can hardly get out of bed and just cannot do anything around the house. Which nursing diagnosis will the nurse add to the care plan? ANS: A… Activity Intolerance related to exercise 21. A patient with diabetes mellitus is starting an exercise program. Which types of exercises will the nurse suggest? i. Low intensity j. Low to moderate intensity k. Moderate to high intensity d. High intensity ANS: B 22. A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding indicates successful goal achievement? e. Heart rate decreased. f. Contractures developed. g. Muscle strength improved. h. Joint mobility maintained. ANS: D 23. A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension? j. Blood pressure sitting 120/64; blood pressure 140/70 standing k. Blood pressure sitting 126/64; blood pressure 120/58 standing l. Blood pressure sitting 130/60; blood pressure 110/60 standing m. Blood pressure sitting 140/60; blood pressure 130/54 standing ANS: C 24. The nurse is teaching a patient how to use a cane. Which information will the nurse include in the teaching session? e. Place the cane at the top of the hip bone. f. Place the cane on the stronger side of the body. g. Place the cane in front of the body and then move the good leg. h. Place the cane 10 to 15 inches in front of the body when walking. ANS: B 25. A nurse is assisting the patient to perform isometric exercises. Which action will the nurse take? e. Encourage wearing tight shoes. f. Set the pace for the exercise session. g. Stop the exercise if pain is experienced. h. Force muscles or joints to go just beyond resistance. ANS: C 26. The nurse is developing a plan of care for a patient diagnosed with activity intolerance. Which strategy will the nurse use to provide the best chance of maintaining patient compliance? a. Performing 20 minutes of aerobic exercise 7 days a week with 10- minute warm-up and cool-down period b. Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activ c. Stressing the harm of not exercising by getting the patient to take responsibility for current health status d. Arranging for the patient to join a gym that takes self-pay rather than insurance ANS: B 27. The nurse is preparing to transfer an uncooperative patient who does not have upper body strength. Which piece of equipment will be best for the nurses to obtain? a. Drawsheet b. Full body sling c. Overhead trapeze d. Friction-reducing slide sheet ANS: B 28. The nurse is teaching a patient how to sit with crutches. In which order will the nurse present the instructions starting with the first step? 1. Place both crutches in one hand.2. Grasp arm of chair with free hand.3. Completely lower self into chair.4. Transfer weight to crutches and unaffected leg. a. 4, 1, 2, 3 b. 1, 4, 2, 3 c. 1, 2, 4, 3 d. 4, 2, 1, 3 ANS: B 29. The nurse is caring for a group of patients. Which patient will the nurse see first? e. A patient with chronic obstructive pulmonary disease doing stretching exercises f. A patient with diabetes mellitus carrying hard candy while doing exercises g. A patient with a heart attack doing isometric exercises h. A patient with hypertension doing Tai Chi exercises ANS: C MULTIPLE RESPONSE 1. A nurse is preparing to move a patient who is able to assist. Which principles will the nurse consider when planning for safe patient handling? (Select all that apply.) a. Keep the body’s center of gravity high. b. Face the direction of the movement. c. Keep the base of support narrow. e. Use the under-axilla technique. f. Use proper body mechanics. g. Use arms and legs. ANS: B, E, F 2. A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess? (Select all that apply.) a. Skeletal abnormalities b. Emotional factors c. Pregnancy status d. Race e. Age ANS: A, B, C, E 3. A nurse is working in a facility that uses no-lift policies. Which benefits will the nurse observe in the facility? (Select all that apply.) a. Reduced number of work-related injuries b. Increased musculoskeletal accidents c. Reduced safety of patients d. Improved health of nurses e. Increased indirect costs ANS: A, D 4. A nurse writes the following outcomes for a patient who has chronic obstructive pulmonary disease to improve activity level: Diastolic blood pressure will remain below 70 mm Hg with systolic below 130 mm Hg. Resting heart rate will range between 65 and 75. The last goal is that the patient will exercise 3 times a week. Which evaluative findings indicate successful goal achievement? (Select all that apply.) e. Resting heart rate 70 f. Blood pressure 126/64 g. Blood pressure 140/90 h. Reports doing stretching and flexibility exercises 2 times this week i. Reports doing resistive training 1 time and aerobics 2 times this week ANS: A, B, E COMPLETION 1. A 55-year-old patient is preparing to start an exercise program. The health care provider wants 60% of maximum target heart rate. Calculate the heart rate that the nurse will add to the care plan as the target heart rate. Record answer as a whole number. ANS: 99 [Show More]

Last updated: 2 years ago

Preview 1 out of 49 pages