JOYCE UNIVERSITY OF NURSING EXAM 2 (NUR125 -
NURSING FUNDAMENTALS ) QUESTIONS WITH
COMPLETE SOLUTIONS
A client has a Braden score of 9. What is the nurse's priority?
A. Encourage ambulation B. Initiate aggressive pressure injury prevention
C. Document only D. Increase linens - CORRECT ANSWE✅✅ - B. Initiate
aggressive pressure injury prevention
.A client reports dizziness upon standing. Which intervention is priority?
A. Encourage rapid ambulation B. Assess orthostatic BP C. Apply restraints
D. Elevate HOB to 90° - CORRECT ANSWE✅✅ - B. Assess orthostatic
BP
.A client with immobility is at risk for which complications? (Select all that
apply.)
A. Atelectasis B. Constipation C. DVT D. Osteoporosis E. Hypercalcemia -
CORRECT ANSWE✅✅ - A. Atelectasis
B. Constipation
C. DVT
D. Osteoporosis
.A medical bed should always be locked and in the lowest position T/F? -
CORRECT ANSWE✅✅ - True - this is the safest way to use a med bed.
.A nurse is applying restraints. Which actions are appropriate? (Select all
that apply.)
A. Obtain provider order B. Tie restraints to bed rails C. Use quick-release
knot D. Perform frequent skin checks E. Attempt alternatives first -
CORRECT ANSWE✅✅ - A. Obtain provider order
C. Use quick-release knot
D. Perform frequent skin checks
E. Attempt alternatives first
Tie to bed frame, not rails that move
,.A nurse is caring for a client on bedrest for 5 days. Which assessment
finding requires immediate intervention?
A. Diminished bowel sounds B. Orthostatic hypotension C. Unilateral calf
warmth and swelling D. Mild anxiety - CORRECT ANSWE✅✅ - C.
Unilateral calf warmth and swelling
(Diminished bowel sounds is concerning but doesn't require immediate
intervention compared to the above choice)
.A nurse notes thick, yellow, foul-smelling drainage. This indicates:
A. Serous drainage B. Sanguineous drainage C. Purulent drainage D.
Normal inflammatory response - CORRECT ANSWE✅✅ - C. Purulent
drainage (infection!!!)
.A nurse should encourage a patient who is a high fall risk or experiencing
immobility to avoid doing any of their ADLs? - CORRECT ANSWE✅✅ -
False- having patients perform any part of their ADLs helps improve their
condition as well as supports their mental health.
.A nurse should have a gait belt available near the bed of a patient who is a
high fall risk? T/F - CORRECT ANSWE✅✅ - True, these help keep the PT
and the nurse safe when moving a patient.
.A patient at risk of a pressure wound on their sacrum and heels should be
placed in which position? - CORRECT ANSWE✅✅ - Lateral (called side or
Sims) position. This relieves bony prominences - redistributes pressure to
prevent skin breakdown.
.A patient is using an IV pole to help them walk, and he falls- was the cause
intrinsic or extrinsic? - CORRECT ANSWE✅✅ - Extrinsic
.A patient misjudges their own ability to walk (extrinsic/intrinsix) -
CORRECT ANSWE✅✅ - intrinsic
.A patient refusing to use a walker to move around the hospital is an
extrinsic factor impacting mobility T/F - CORRECT ANSWE✅✅ - False, it
is intrinsic as it is derived by the self
, .A patient with a suspected blood clot should ambulate to help lessen the
symptoms T/F? - CORRECT ANSWE✅✅ - FAlse- this could dislodge the
clot. Have them rest.
.A postoperative client suddenly reports chest pain and shortness of breath.
The nurse suspects a pulmonary embolism. What is the priority action?
A. Elevate legs B. Administer oxygen C. Massage the calf D. Ambulate the
client - CORRECT ANSWE✅✅ - B. Administer oxygen
DO NOT ambulate, elevate legs or massage - all of these can further
dislodge a DVT
.A surgical incision closed with staples heals by:
A. Secondary intention B. Tertiary intention C. Primary intention D. Delayed
intention - CORRECT ANSWE✅✅ - C. Primary intention
.A wound with visible adipose tissue is classified as:
A. Stage 2 B. Stage 3 C. Stage 4 D. Unstageable - CORRECT
ANSWE✅✅ - B. Stage 3
.Bed rails are considered a restraint when used to restrict voluntary
movement. T/F - CORRECT ANSWE✅✅ - True
.Chronic wounds typically heal within 2 weeks. T/F - CORRECT
ANSWE✅✅ - False (chronic > 3 months)
.Clients who are immobile can haveslower and shallower ____ putting them
at risk for _____ and _____? - CORRECT ANSWE✅✅ - Breaths
Pneumonia and atelectasis (lungs don't expand)
.Define a pressure injury - CORRECT ANSWE✅✅ - Damage to skin or
underlying tissue, usually over a bony prominence due to prolonged
pressure.
.Define Low fowler's, fowler's and high fowlers - CORRECT ANSWE✅✅ -
Low Fowlers: HoB 30deg or less
Fowlers: 45-60deg
High: HOB at 90deg - swallowing issues;
NURSING FUNDAMENTALS ) QUESTIONS WITH
COMPLETE SOLUTIONS
A client has a Braden score of 9. What is the nurse's priority?
A. Encourage ambulation B. Initiate aggressive pressure injury prevention
C. Document only D. Increase linens - CORRECT ANSWE✅✅ - B. Initiate
aggressive pressure injury prevention
.A client reports dizziness upon standing. Which intervention is priority?
A. Encourage rapid ambulation B. Assess orthostatic BP C. Apply restraints
D. Elevate HOB to 90° - CORRECT ANSWE✅✅ - B. Assess orthostatic
BP
.A client with immobility is at risk for which complications? (Select all that
apply.)
A. Atelectasis B. Constipation C. DVT D. Osteoporosis E. Hypercalcemia -
CORRECT ANSWE✅✅ - A. Atelectasis
B. Constipation
C. DVT
D. Osteoporosis
.A medical bed should always be locked and in the lowest position T/F? -
CORRECT ANSWE✅✅ - True - this is the safest way to use a med bed.
.A nurse is applying restraints. Which actions are appropriate? (Select all
that apply.)
A. Obtain provider order B. Tie restraints to bed rails C. Use quick-release
knot D. Perform frequent skin checks E. Attempt alternatives first -
CORRECT ANSWE✅✅ - A. Obtain provider order
C. Use quick-release knot
D. Perform frequent skin checks
E. Attempt alternatives first
Tie to bed frame, not rails that move
,.A nurse is caring for a client on bedrest for 5 days. Which assessment
finding requires immediate intervention?
A. Diminished bowel sounds B. Orthostatic hypotension C. Unilateral calf
warmth and swelling D. Mild anxiety - CORRECT ANSWE✅✅ - C.
Unilateral calf warmth and swelling
(Diminished bowel sounds is concerning but doesn't require immediate
intervention compared to the above choice)
.A nurse notes thick, yellow, foul-smelling drainage. This indicates:
A. Serous drainage B. Sanguineous drainage C. Purulent drainage D.
Normal inflammatory response - CORRECT ANSWE✅✅ - C. Purulent
drainage (infection!!!)
.A nurse should encourage a patient who is a high fall risk or experiencing
immobility to avoid doing any of their ADLs? - CORRECT ANSWE✅✅ -
False- having patients perform any part of their ADLs helps improve their
condition as well as supports their mental health.
.A nurse should have a gait belt available near the bed of a patient who is a
high fall risk? T/F - CORRECT ANSWE✅✅ - True, these help keep the PT
and the nurse safe when moving a patient.
.A patient at risk of a pressure wound on their sacrum and heels should be
placed in which position? - CORRECT ANSWE✅✅ - Lateral (called side or
Sims) position. This relieves bony prominences - redistributes pressure to
prevent skin breakdown.
.A patient is using an IV pole to help them walk, and he falls- was the cause
intrinsic or extrinsic? - CORRECT ANSWE✅✅ - Extrinsic
.A patient misjudges their own ability to walk (extrinsic/intrinsix) -
CORRECT ANSWE✅✅ - intrinsic
.A patient refusing to use a walker to move around the hospital is an
extrinsic factor impacting mobility T/F - CORRECT ANSWE✅✅ - False, it
is intrinsic as it is derived by the self
, .A patient with a suspected blood clot should ambulate to help lessen the
symptoms T/F? - CORRECT ANSWE✅✅ - FAlse- this could dislodge the
clot. Have them rest.
.A postoperative client suddenly reports chest pain and shortness of breath.
The nurse suspects a pulmonary embolism. What is the priority action?
A. Elevate legs B. Administer oxygen C. Massage the calf D. Ambulate the
client - CORRECT ANSWE✅✅ - B. Administer oxygen
DO NOT ambulate, elevate legs or massage - all of these can further
dislodge a DVT
.A surgical incision closed with staples heals by:
A. Secondary intention B. Tertiary intention C. Primary intention D. Delayed
intention - CORRECT ANSWE✅✅ - C. Primary intention
.A wound with visible adipose tissue is classified as:
A. Stage 2 B. Stage 3 C. Stage 4 D. Unstageable - CORRECT
ANSWE✅✅ - B. Stage 3
.Bed rails are considered a restraint when used to restrict voluntary
movement. T/F - CORRECT ANSWE✅✅ - True
.Chronic wounds typically heal within 2 weeks. T/F - CORRECT
ANSWE✅✅ - False (chronic > 3 months)
.Clients who are immobile can haveslower and shallower ____ putting them
at risk for _____ and _____? - CORRECT ANSWE✅✅ - Breaths
Pneumonia and atelectasis (lungs don't expand)
.Define a pressure injury - CORRECT ANSWE✅✅ - Damage to skin or
underlying tissue, usually over a bony prominence due to prolonged
pressure.
.Define Low fowler's, fowler's and high fowlers - CORRECT ANSWE✅✅ -
Low Fowlers: HoB 30deg or less
Fowlers: 45-60deg
High: HOB at 90deg - swallowing issues;
