, TESTBANK FOR
Fundamentals of Nursing, 12th Edition Potter
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, TestBank - Chapter 1
Q1. A nurse is assessing body alignment. What is the nurse monitoring? The relationship of
one body part to another while in different positions The coordinated efforts of the
musculoskeletal and nervous systems The force that occurs in a direction to oppose
movement The inability to move about freely
1) The relationship of one body part to another while in different positions
2) The coordinated efforts of the musculoskeletal and nervous systems
3) The force that occurs in a direction to oppose movement
4) The inability to move about freely
Q2. A nurse is providing range of motion to the shoulder and must perform external rotation.
Which action will the nurse take? Moves patient’s arm in a full circle. Moves patient’s arm
cross the body as far as possible. Moves patient’s arm behind body, keeping elbow straight.
Moves patient’s arm until thumb is upward and lateral to head with elbow flexed.
1) Moves patient’s arm in a full circle.
2) Moves patient’s arm cross the body as far as possible.
3) Moves patient’s arm behind body, keeping elbow straight.
4) Moves patient’s arm until thumb is upward and lateral to head with elbow flexed.
Q3. A nurse is providing passive range of motion (ROM) for a patient with impaired mobility.
Which technique will the nurse use for each movement? Each movement is repeated 5 times
by the patient. Each movement is performed until the patient reports pain. Each movement is
completed quickly and smoothly by the nurse. Each movement is moved just to the point of
resistance by the nurse.
1) Each movement is repeated 5 times by the patient.
2) Each movement is performed until the patient reports pain.
3) Each movement is completed quickly and smoothly by the nurse.
4) Each movement is moved just to the point of resistance by the nurse.
Q4. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient.
The absence of which finding will indicate goal achievement for the nurse’s action?
Atelectasis Renal calculi Pressure ulcers Joint contractures
1) Atelectasis
2) Renal calculi
3) Pressure ulcers
4) Joint contractures
Q5. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the
assistive personnel? Determining the level of comfort Changing the patient’s position
Identifying immobility hazards Assessing circulation
1) Determining the level of comfort
2) Changing the patient’s position
3) Identifying immobility hazards
4) Assessing circulation
,Q6. A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of
equipment will the nurse obtain to assess for this condition? Thermometer Elastic stockings
Blood pressure cuff Sequential compression devices
1) Thermometer
2) Elastic stockings
3) Blood pressure cuff
4) Sequential compression devices
Q7. The patient has been in bed for several days and needs to be ambulated. Which action
will the nurse take first? Maintain a narrow base of support. Dangle the patient at the bedside.
Encourage isometric exercises. Suggest a high-calcium diet.
1) Maintain a narrow base of support.
2) Dangle the patient at the bedside.
3) Encourage isometric exercises.
4) Suggest a high-calcium diet.
Q8. A nurse reviews an immobilized patient’s laboratory results and discovers hypercalcemia.
Which condition will the nurse monitor for most closely in this patient? Hypostatic pneumonia
Renal stones Pressure ulcers Thrombus formation
1) Hypostatic pneumonia
2) Renal stones
3) Pressure ulcers
4) Thrombus formation
Q9. A nurse is caring for an older, immobile patient whose condition requires a supine
position. Which metabolic alteration will the nurse monitor for in this patient? Increased
appetite Increased diarrhea Increased metabolic rate Increased pulse rate
1) Increased appetite
2) Increased diarrhea
3) Increased metabolic rate
4) Increased pulse rate
Q10. A nurse is preparing a care plan for a patient who is immobile. Which psychosocial
aspect will the nurse assess for? Loss of bone mass Loss of strength Loss of weight Loss of
hope
1) Loss of bone mass
2) Loss of strength
3) Loss of weight
4) Loss of hope
Q11. The nurse is preparing to lift and reposition a patient. Which action will the nurse take
first? Position a drawsheet under the patient. Assess weight to determine assistance needs.
Delegate the task to assistive personnel. Attempt to manually lift the patient alone before
asking for assistance.
1) Position a drawsheet under the patient.
2) Assess weight to determine assistance needs.
3) Delegate the task to assistive personnel.
4) Attempt to manually lift the patient alone before asking for assistance.
,Q12. The nurse is caring for an older-adult patient who has been diagnosed with a stroke.
Which intervention will the nurse add to the care plan? Encourage the patient to perform as
many self-care activities as possible. Provide a complete bed bath to promote patient comfort.
Coordinate with occupational therapy for gait training. Place the patient on bed rest to prevent
fatigue.
1) Encourage the patient to perform as many self-care activities as possible.
2) Provide a complete bed bath to promote patient comfort.
3) Coordinate with occupational therapy for gait training.
4) Place the patient on bed rest to prevent fatigue.
Q13. The nurse is observing the way a patient walks. Which aspect is the nurse assessing?
Activity tolerance Body alignment Range of motion Gait
1) Activity tolerance
2) Body alignment
3) Range of motion
4) Gait
Q14. A nurse is assessing the body alignment of a standing patient. Which finding will the
nurse report as normal? When observed laterally, the spinal curves align in a reversed “S”
pattern. When observed posteriorly, the hips and shoulders form an “S” pattern. The arms
should be crossed over the chest or in the lap. The feet should be close together with toes
pointed out.
1) When observed laterally, the spinal curves align in a reversed “S” pattern.
2) When observed posteriorly, the hips and shoulders form an “S” pattern.
3) The arms should be crossed over the chest or in the lap.
4) The feet should be close together with toes pointed out.
Q15. The nurse is evaluating the body alignment of a patient in the sitting position. Which
observation by the nurse will indicate a normal finding? The edge of the seat is in contact with
the popliteal space. Both feet are supported on the floor with ankles flexed. The body weight
is directly on the buttocks only. The arms hang comfortably at the sides.
1) The edge of the seat is in contact with the popliteal space.
2) Both feet are supported on the floor with ankles flexed.
3) The body weight is directly on the buttocks only.
4) The arms hang comfortably at the sides.
Q16. The nurse is assessing body alignment for a patient who is immobilized. Which patient
position will the nurse use? Supine position Lateral position Lateral position with positioning
supports Supine position with no pillow under the patient’s head
1) Supine position
2) Lateral position
3) Lateral position with positioning supports
4) Supine position with no pillow under the patient’s head
Q17. The nurse is assessing the patient for respiratory complications of immobility. Which
action will the nurse take when assessing the respiratory system? Inspect chest wall
movements primarily during the expiratory cycle. Auscultate the entire lung region to assess
,lung sounds. Focus auscultation on the upper lung fields. Assess the patient at least every 4
hours.
1) Inspect chest wall movements primarily during the expiratory cycle.
2) Auscultate the entire lung region to assess lung sounds.
3) Focus auscultation on the upper lung fields.
4) Assess the patient at least every 4 hours.
Q18. The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which
action will the nurse take? Remove elastic stockings every 4 hours. Measure the calf
circumference of both legs. Lightly rub the lower leg for redness and tenderness. Dorsiflex the
foot while assessing for patient discomfort.
1) Remove elastic stockings every 4 hours.
2) Measure the calf circumference of both legs.
3) Lightly rub the lower leg for redness and tenderness.
4) Dorsiflex the foot while assessing for patient discomfort.
Q19. A nurse is assessing the skin of an immobilized patient. What will the nurse do? Assess
the skin every 4 hours. Limit the amount of fluid intake. Use a standardized tool such as the
Braden Scale. Have special times for inspection to not interrupt routine care.
1) Assess the skin every 4 hours.
2) Limit the amount of fluid intake.
3) Use a standardized tool such as the Braden Scale.
4) Have special times for inspection to not interrupt routine care.
Q20. The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection
(UTI). Upon assessment the nurse finds the patient confused and agitated. How will the nurse
interpret these assessment findings? These are normal signs of aging. These are early signs
of dementia. These are purely psychological in origin. These are common manifestation with
UTIs.
1) These are normal signs of aging.
2) These are early signs of dementia.
3) These are purely psychological in origin.
4) These are common manifestation with UTIs.
Q21. A patient has damage to the cerebellum. Which disorder is most important for the nurse
to assess? Impaired balance Hemiplegia Muscle sprain Lower extremity paralysis
1) Impaired balance
2) Hemiplegia
3) Muscle sprain
4) Lower extremity paralysis
Q22. Which patient will cause the nurse to select a nursing diagnosis of Impaired physical
mobility for a care plan? A patient who is completely immobile A patient who is not completely
immobile A patient at risk for single-system involvement A patient who is at risk for
multisystem problems
1) A patient who is completely immobile
2) A patient who is not completely immobile
3) A patient at risk for single-system involvement
, 4) A patient who is at risk for multisystem problems
Q23. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the
left shoulder. Which priority action will the nurse take? Encourage the patient to do self-care.
Keep the patient as mobile as possible. Encourage the patient to perform ROM. Assist the
patient with comfort measures.
1) Encourage the patient to do self-care.
2) Keep the patient as mobile as possible.
3) Encourage the patient to perform ROM.
4) Assist the patient with comfort measures.
Q24. A nurse is developing an individualized plan of care for a patient. Which action is
important for the nurse to take? Establish goals that are measurable and realistic. Set goals
that are a little beyond the capabilities of the patient. Use the nurse’s own judgment and not
be swayed by family desires. Explain that without taking alignment risks, there can be no
progress.
1) Establish goals that are measurable and realistic.
2) Set goals that are a little beyond the capabilities of the patient.
3) Use the nurse’s own judgment and not be swayed by family desires.
4) Explain that without taking alignment risks, there can be no progress.
Q25. Which behavior indicates the nurse is using a team approach when caring for a patient
who is experiencing alterations in mobility? Delegates assessment of lung sounds to assistive
personnel. Becomes solely responsible for modifying activities of daily living. Consults
physical therapy for strengthening exercises in the extremities. Involves respiratory therapy
for altered breathing from severe anxiety levels.
1) Delegates assessment of lung sounds to assistive personnel.
2) Becomes solely responsible for modifying activities of daily living.
3) Consults physical therapy for strengthening exercises in the extremities.
4) Involves respiratory therapy for altered breathing from severe anxiety levels.
Q26. The patient is being admitted to the neurological unit with a diagnosis of stroke. When
will the nurse begin discharge planning? At the time of admission The day before the patient
is to be discharged When outpatient therapy will no longer be needed As soon as the patient’s
discharge destination is known
1) At the time of admission
2) The day before the patient is to be discharged
3) When outpatient therapy will no longer be needed
4) As soon as the patient’s discharge destination is known
Q27. Which goal is most appropriate for a patient who has had a total hip replacement? The
patient will ambulate briskly on the treadmill by the time of discharge. The patient will walk 100
feet using a walker by the time of discharge. The nurse will assist the patient to ambulate in
the hall 2 times a day. The patient will ambulate by the time of discharge.
1) The patient will ambulate briskly on the treadmill by the time of discharge.
2) The patient will walk 100 feet using a walker by the time of discharge.
3) The nurse will assist the patient to ambulate in the hall 2 times a day.
4) The patient will ambulate by the time of discharge.
,Q28. The nurse is working on an orthopedic rehabilitation unit that requires lifting and
positioning of patients. Which personal injury will the nurse most likely try to prevent? Arm Hip
Back Ankle
1) Arm
2) Hip
3) Back
4) Ankle
Q29. A nurse is caring for a patient diagnosed with osteoporosis and lactose intolerance.
What intervention will the nurse implement? Encourage dairy products. Monitor intake of
calcium. Increase intake of caffeinated drinks. Try to do as much as possible for the patient.
1) Encourage dairy products.
2) Monitor intake of calcium.
3) Increase intake of caffeinated drinks.
4) Try to do as much as possible for the patient.
Q30. A nurse is providing care to a group of patients. Which patient will the nurse see first? A
patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea A
bedridden patient who has a reddened area on the buttocks who needs to be turned every 2
hours A patient on bed rest who has renal calculi and needs to go to the bathroom so urine
can be strained A patient after knee surgery who needs range of motion exercises
1) A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
2) A bedridden patient who has a reddened area on the buttocks who needs to be turned every 2
hours
3) A patient on bed rest who has renal calculi and needs to go to the bathroom so urine can be
strained
4) A patient after knee surgery who needs range of motion exercises
Q31. 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 the count of three shift weight from the front to back leg. 1, 4, 5, 6,
3, 2 4, 1, 3, 5, 6, 2 3, 4, 1, 5, 6, 2 5, 6, 3, 1, 4, 2
1) 1, 4, 5, 6, 3, 2
2) 4, 1, 3, 5, 6, 2
3) 3, 4, 1, 5, 6, 2
4) 5, 6, 3, 1, 4, 2
Q32. The nurse is caring for a patient who needs to be placed in the prone position. Which
action will the nurse take? Place pillow under the patient’s lower legs. Turn head toward one
side with large, soft pillow. Position legs flat against bed. Raise head of bed to 45 degrees.
1) Place pillow under the patient’s lower legs.
2) Turn head toward one side with large, soft pillow.
3) Position legs flat against bed.
4) Raise head of bed to 45 degrees.
,Q33. The nurse is caring for a patient with a spinal cord injury and notices that the patient’s
hips tend to rotate externally when the patient is supine. Which device will the nurse use to
help prevent injury secondary to this rotation? Hand rolls A trapeze bar A trochanter roll
Hand-wrist splints
1) Hand rolls
2) A trapeze bar
3) A trochanter roll
4) Hand-wrist splints
Q34. The patient is unable to move self and needs to be pulled up in bed. What will the nurse
do to make this procedure safe? Place the pillow under the patient’s head and shoulders. Do
by self if the bed is in the flat position. Place the side rails in the up position. Use a
friction-reducing device.
1) Place the pillow under the patient’s head and shoulders.
2) Do by self if the bed is in the flat position.
3) Place the side rails in the up position.
4) Use a friction-reducing device.
Q35. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours.
Which device will the nurse use to help maintain foot function? Hand rolls A foot boot A
trapeze bar A trochanter roll
1) Hand rolls
2) A foot boot
3) A trapeze bar
4) A trochanter roll
Q36. A nurse delegates a position change to nursing assistive personnel. The nurse instructs
the assistive personnel (AP) to place the patient in the lateral position. Which finding by the
nurse indicates a correct outcome? Patient is lying on side. Patient is lying on back. Patient is
lying semi-prone. Patient is lying on abdomen.
1) Patient is lying on side.
2) Patient is lying on back.
3) Patient is lying semi-prone.
4) Patient is lying on abdomen.
Q37. A nurse is evaluating care of an immobilized patient. Which action will the nurse take?
Focus on whether the interdisciplinary team is satisfied with the care. Compare the patient’s
actual outcomes with the outcomes in the care plan. Involve primarily the patient’s family and
health care team to determine goal achievement. Use objective data solely in determining
whether interventions have been successful.
1) Focus on whether the interdisciplinary team is satisfied with the care.
2) Compare the patient’s actual outcomes with the outcomes in the care plan.
3) Involve primarily the patient’s family and health care team to determine goal achievement.
4) Use objective data solely in determining whether interventions have been successful.
Q38. A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely
providing care? A patient with neck surgery A patient with hypostatic pneumonia A patient
with a total knee replacement A patient with a stage IV pressure ulcer
, 1) A patient with neck surgery
2) A patient with hypostatic pneumonia
3) A patient with a total knee replacement
4) A patient with a stage IV pressure ulcer
Q39. The nurse is providing teaching to an immobilized patient with impaired skin integrity
about diet. Which diet will the nurse recommend? High protein, high calorie High
carbohydrate, low fat High vitamin A, high vitamin E Fluid restricted, bland
1) High protein, high calorie
2) High carbohydrate, low fat
3) High vitamin A, high vitamin E
4) Fluid restricted, bland
Q40. The nurse is caring for a patient who has experienced a stroke causing total paralysis of
the right side. To help maintain joint function and minimize the disability from contractures,
passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?
After the acute phase of the disease has passed As soon as the ability to move is lost Once
the patient enters the rehab unit When the patient requests it
1) After the acute phase of the disease has passed
2) As soon as the ability to move is lost
3) Once the patient enters the rehab unit
4) When the patient requests it
Q41. The nurse is admitting a patient who has been diagnosed as having had a stroke. The
health care provider writes orders for “ROM as needed.” What should the nurse do next?
Restrict patient’s mobility as much as possible. Realize the patient is unable to move
extremities. Move all the patient’s extremities. Further assess the patient.
1) Restrict patient’s mobility as much as possible.
2) Realize the patient is unable to move extremities.
3) Move all the patient’s extremities.
4) Further assess the patient.
Q42. A nurse is assessing pressure points in a patient placed in the Sims’ position. Which
areas will the nurse observe? Chin, elbow, hips Ileum, clavicle, humerus Shoulder, anterior
iliac spine, ankles Occipital region of the head, coccyx, heels
1) Chin, elbow, hips
2) Ileum, clavicle, humerus
3) Shoulder, anterior iliac spine, ankles
4) Occipital region of the head, coccyx, heels
Q43. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure
of fixation of a fractured left hip. The patient’s nursing diagnosis is Impaired physical mobility
related to musculoskeletal impairment from surgery and pain with movement. The patient is
able to use a walker but needs assistance ambulating and transferring from the bed to the
chair. Which nursing intervention is most appropriate for this patient? Obtain assistance and
physically transfer the patient to the chair. Assist with ambulation and measure how far the
patient walks. Give pain medication after ambulation so the patient will have a clear mind.
Bring the patient to the cafeteria for group instruction on ambulation.
Fundamentals of Nursing, 12th Edition Potter
Important Notes
The file includes the complete test bank, organized chapter by chapter.
A sample of selected pages has been provided for preview.
All available appendices and Excel files (if included in the original resources) are
provided.
We continuously update our files to ensure you receive the latest and most accurate
editions.
New editions are added regularly – stay connected for updates!
Purchase Guarantee
If you believe you have purchased the wrong file, don’t worry. Contact us anytime and we
will gladly replace it with the correct version.
Contact Email:
, TestBank - Chapter 1
Q1. A nurse is assessing body alignment. What is the nurse monitoring? The relationship of
one body part to another while in different positions The coordinated efforts of the
musculoskeletal and nervous systems The force that occurs in a direction to oppose
movement The inability to move about freely
1) The relationship of one body part to another while in different positions
2) The coordinated efforts of the musculoskeletal and nervous systems
3) The force that occurs in a direction to oppose movement
4) The inability to move about freely
Q2. A nurse is providing range of motion to the shoulder and must perform external rotation.
Which action will the nurse take? Moves patient’s arm in a full circle. Moves patient’s arm
cross the body as far as possible. Moves patient’s arm behind body, keeping elbow straight.
Moves patient’s arm until thumb is upward and lateral to head with elbow flexed.
1) Moves patient’s arm in a full circle.
2) Moves patient’s arm cross the body as far as possible.
3) Moves patient’s arm behind body, keeping elbow straight.
4) Moves patient’s arm until thumb is upward and lateral to head with elbow flexed.
Q3. A nurse is providing passive range of motion (ROM) for a patient with impaired mobility.
Which technique will the nurse use for each movement? Each movement is repeated 5 times
by the patient. Each movement is performed until the patient reports pain. Each movement is
completed quickly and smoothly by the nurse. Each movement is moved just to the point of
resistance by the nurse.
1) Each movement is repeated 5 times by the patient.
2) Each movement is performed until the patient reports pain.
3) Each movement is completed quickly and smoothly by the nurse.
4) Each movement is moved just to the point of resistance by the nurse.
Q4. A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient.
The absence of which finding will indicate goal achievement for the nurse’s action?
Atelectasis Renal calculi Pressure ulcers Joint contractures
1) Atelectasis
2) Renal calculi
3) Pressure ulcers
4) Joint contractures
Q5. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the
assistive personnel? Determining the level of comfort Changing the patient’s position
Identifying immobility hazards Assessing circulation
1) Determining the level of comfort
2) Changing the patient’s position
3) Identifying immobility hazards
4) Assessing circulation
,Q6. A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of
equipment will the nurse obtain to assess for this condition? Thermometer Elastic stockings
Blood pressure cuff Sequential compression devices
1) Thermometer
2) Elastic stockings
3) Blood pressure cuff
4) Sequential compression devices
Q7. The patient has been in bed for several days and needs to be ambulated. Which action
will the nurse take first? Maintain a narrow base of support. Dangle the patient at the bedside.
Encourage isometric exercises. Suggest a high-calcium diet.
1) Maintain a narrow base of support.
2) Dangle the patient at the bedside.
3) Encourage isometric exercises.
4) Suggest a high-calcium diet.
Q8. A nurse reviews an immobilized patient’s laboratory results and discovers hypercalcemia.
Which condition will the nurse monitor for most closely in this patient? Hypostatic pneumonia
Renal stones Pressure ulcers Thrombus formation
1) Hypostatic pneumonia
2) Renal stones
3) Pressure ulcers
4) Thrombus formation
Q9. A nurse is caring for an older, immobile patient whose condition requires a supine
position. Which metabolic alteration will the nurse monitor for in this patient? Increased
appetite Increased diarrhea Increased metabolic rate Increased pulse rate
1) Increased appetite
2) Increased diarrhea
3) Increased metabolic rate
4) Increased pulse rate
Q10. A nurse is preparing a care plan for a patient who is immobile. Which psychosocial
aspect will the nurse assess for? Loss of bone mass Loss of strength Loss of weight Loss of
hope
1) Loss of bone mass
2) Loss of strength
3) Loss of weight
4) Loss of hope
Q11. The nurse is preparing to lift and reposition a patient. Which action will the nurse take
first? Position a drawsheet under the patient. Assess weight to determine assistance needs.
Delegate the task to assistive personnel. Attempt to manually lift the patient alone before
asking for assistance.
1) Position a drawsheet under the patient.
2) Assess weight to determine assistance needs.
3) Delegate the task to assistive personnel.
4) Attempt to manually lift the patient alone before asking for assistance.
,Q12. The nurse is caring for an older-adult patient who has been diagnosed with a stroke.
Which intervention will the nurse add to the care plan? Encourage the patient to perform as
many self-care activities as possible. Provide a complete bed bath to promote patient comfort.
Coordinate with occupational therapy for gait training. Place the patient on bed rest to prevent
fatigue.
1) Encourage the patient to perform as many self-care activities as possible.
2) Provide a complete bed bath to promote patient comfort.
3) Coordinate with occupational therapy for gait training.
4) Place the patient on bed rest to prevent fatigue.
Q13. The nurse is observing the way a patient walks. Which aspect is the nurse assessing?
Activity tolerance Body alignment Range of motion Gait
1) Activity tolerance
2) Body alignment
3) Range of motion
4) Gait
Q14. A nurse is assessing the body alignment of a standing patient. Which finding will the
nurse report as normal? When observed laterally, the spinal curves align in a reversed “S”
pattern. When observed posteriorly, the hips and shoulders form an “S” pattern. The arms
should be crossed over the chest or in the lap. The feet should be close together with toes
pointed out.
1) When observed laterally, the spinal curves align in a reversed “S” pattern.
2) When observed posteriorly, the hips and shoulders form an “S” pattern.
3) The arms should be crossed over the chest or in the lap.
4) The feet should be close together with toes pointed out.
Q15. The nurse is evaluating the body alignment of a patient in the sitting position. Which
observation by the nurse will indicate a normal finding? The edge of the seat is in contact with
the popliteal space. Both feet are supported on the floor with ankles flexed. The body weight
is directly on the buttocks only. The arms hang comfortably at the sides.
1) The edge of the seat is in contact with the popliteal space.
2) Both feet are supported on the floor with ankles flexed.
3) The body weight is directly on the buttocks only.
4) The arms hang comfortably at the sides.
Q16. The nurse is assessing body alignment for a patient who is immobilized. Which patient
position will the nurse use? Supine position Lateral position Lateral position with positioning
supports Supine position with no pillow under the patient’s head
1) Supine position
2) Lateral position
3) Lateral position with positioning supports
4) Supine position with no pillow under the patient’s head
Q17. The nurse is assessing the patient for respiratory complications of immobility. Which
action will the nurse take when assessing the respiratory system? Inspect chest wall
movements primarily during the expiratory cycle. Auscultate the entire lung region to assess
,lung sounds. Focus auscultation on the upper lung fields. Assess the patient at least every 4
hours.
1) Inspect chest wall movements primarily during the expiratory cycle.
2) Auscultate the entire lung region to assess lung sounds.
3) Focus auscultation on the upper lung fields.
4) Assess the patient at least every 4 hours.
Q18. The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which
action will the nurse take? Remove elastic stockings every 4 hours. Measure the calf
circumference of both legs. Lightly rub the lower leg for redness and tenderness. Dorsiflex the
foot while assessing for patient discomfort.
1) Remove elastic stockings every 4 hours.
2) Measure the calf circumference of both legs.
3) Lightly rub the lower leg for redness and tenderness.
4) Dorsiflex the foot while assessing for patient discomfort.
Q19. A nurse is assessing the skin of an immobilized patient. What will the nurse do? Assess
the skin every 4 hours. Limit the amount of fluid intake. Use a standardized tool such as the
Braden Scale. Have special times for inspection to not interrupt routine care.
1) Assess the skin every 4 hours.
2) Limit the amount of fluid intake.
3) Use a standardized tool such as the Braden Scale.
4) Have special times for inspection to not interrupt routine care.
Q20. The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection
(UTI). Upon assessment the nurse finds the patient confused and agitated. How will the nurse
interpret these assessment findings? These are normal signs of aging. These are early signs
of dementia. These are purely psychological in origin. These are common manifestation with
UTIs.
1) These are normal signs of aging.
2) These are early signs of dementia.
3) These are purely psychological in origin.
4) These are common manifestation with UTIs.
Q21. A patient has damage to the cerebellum. Which disorder is most important for the nurse
to assess? Impaired balance Hemiplegia Muscle sprain Lower extremity paralysis
1) Impaired balance
2) Hemiplegia
3) Muscle sprain
4) Lower extremity paralysis
Q22. Which patient will cause the nurse to select a nursing diagnosis of Impaired physical
mobility for a care plan? A patient who is completely immobile A patient who is not completely
immobile A patient at risk for single-system involvement A patient who is at risk for
multisystem problems
1) A patient who is completely immobile
2) A patient who is not completely immobile
3) A patient at risk for single-system involvement
, 4) A patient who is at risk for multisystem problems
Q23. The patient has the nursing diagnosis of Impaired physical mobility related to pain in the
left shoulder. Which priority action will the nurse take? Encourage the patient to do self-care.
Keep the patient as mobile as possible. Encourage the patient to perform ROM. Assist the
patient with comfort measures.
1) Encourage the patient to do self-care.
2) Keep the patient as mobile as possible.
3) Encourage the patient to perform ROM.
4) Assist the patient with comfort measures.
Q24. A nurse is developing an individualized plan of care for a patient. Which action is
important for the nurse to take? Establish goals that are measurable and realistic. Set goals
that are a little beyond the capabilities of the patient. Use the nurse’s own judgment and not
be swayed by family desires. Explain that without taking alignment risks, there can be no
progress.
1) Establish goals that are measurable and realistic.
2) Set goals that are a little beyond the capabilities of the patient.
3) Use the nurse’s own judgment and not be swayed by family desires.
4) Explain that without taking alignment risks, there can be no progress.
Q25. Which behavior indicates the nurse is using a team approach when caring for a patient
who is experiencing alterations in mobility? Delegates assessment of lung sounds to assistive
personnel. Becomes solely responsible for modifying activities of daily living. Consults
physical therapy for strengthening exercises in the extremities. Involves respiratory therapy
for altered breathing from severe anxiety levels.
1) Delegates assessment of lung sounds to assistive personnel.
2) Becomes solely responsible for modifying activities of daily living.
3) Consults physical therapy for strengthening exercises in the extremities.
4) Involves respiratory therapy for altered breathing from severe anxiety levels.
Q26. The patient is being admitted to the neurological unit with a diagnosis of stroke. When
will the nurse begin discharge planning? At the time of admission The day before the patient
is to be discharged When outpatient therapy will no longer be needed As soon as the patient’s
discharge destination is known
1) At the time of admission
2) The day before the patient is to be discharged
3) When outpatient therapy will no longer be needed
4) As soon as the patient’s discharge destination is known
Q27. Which goal is most appropriate for a patient who has had a total hip replacement? The
patient will ambulate briskly on the treadmill by the time of discharge. The patient will walk 100
feet using a walker by the time of discharge. The nurse will assist the patient to ambulate in
the hall 2 times a day. The patient will ambulate by the time of discharge.
1) The patient will ambulate briskly on the treadmill by the time of discharge.
2) The patient will walk 100 feet using a walker by the time of discharge.
3) The nurse will assist the patient to ambulate in the hall 2 times a day.
4) The patient will ambulate by the time of discharge.
,Q28. The nurse is working on an orthopedic rehabilitation unit that requires lifting and
positioning of patients. Which personal injury will the nurse most likely try to prevent? Arm Hip
Back Ankle
1) Arm
2) Hip
3) Back
4) Ankle
Q29. A nurse is caring for a patient diagnosed with osteoporosis and lactose intolerance.
What intervention will the nurse implement? Encourage dairy products. Monitor intake of
calcium. Increase intake of caffeinated drinks. Try to do as much as possible for the patient.
1) Encourage dairy products.
2) Monitor intake of calcium.
3) Increase intake of caffeinated drinks.
4) Try to do as much as possible for the patient.
Q30. A nurse is providing care to a group of patients. Which patient will the nurse see first? A
patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea A
bedridden patient who has a reddened area on the buttocks who needs to be turned every 2
hours A patient on bed rest who has renal calculi and needs to go to the bathroom so urine
can be strained A patient after knee surgery who needs range of motion exercises
1) A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
2) A bedridden patient who has a reddened area on the buttocks who needs to be turned every 2
hours
3) A patient on bed rest who has renal calculi and needs to go to the bathroom so urine can be
strained
4) A patient after knee surgery who needs range of motion exercises
Q31. 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 the count of three shift weight from the front to back leg. 1, 4, 5, 6,
3, 2 4, 1, 3, 5, 6, 2 3, 4, 1, 5, 6, 2 5, 6, 3, 1, 4, 2
1) 1, 4, 5, 6, 3, 2
2) 4, 1, 3, 5, 6, 2
3) 3, 4, 1, 5, 6, 2
4) 5, 6, 3, 1, 4, 2
Q32. The nurse is caring for a patient who needs to be placed in the prone position. Which
action will the nurse take? Place pillow under the patient’s lower legs. Turn head toward one
side with large, soft pillow. Position legs flat against bed. Raise head of bed to 45 degrees.
1) Place pillow under the patient’s lower legs.
2) Turn head toward one side with large, soft pillow.
3) Position legs flat against bed.
4) Raise head of bed to 45 degrees.
,Q33. The nurse is caring for a patient with a spinal cord injury and notices that the patient’s
hips tend to rotate externally when the patient is supine. Which device will the nurse use to
help prevent injury secondary to this rotation? Hand rolls A trapeze bar A trochanter roll
Hand-wrist splints
1) Hand rolls
2) A trapeze bar
3) A trochanter roll
4) Hand-wrist splints
Q34. The patient is unable to move self and needs to be pulled up in bed. What will the nurse
do to make this procedure safe? Place the pillow under the patient’s head and shoulders. Do
by self if the bed is in the flat position. Place the side rails in the up position. Use a
friction-reducing device.
1) Place the pillow under the patient’s head and shoulders.
2) Do by self if the bed is in the flat position.
3) Place the side rails in the up position.
4) Use a friction-reducing device.
Q35. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours.
Which device will the nurse use to help maintain foot function? Hand rolls A foot boot A
trapeze bar A trochanter roll
1) Hand rolls
2) A foot boot
3) A trapeze bar
4) A trochanter roll
Q36. A nurse delegates a position change to nursing assistive personnel. The nurse instructs
the assistive personnel (AP) to place the patient in the lateral position. Which finding by the
nurse indicates a correct outcome? Patient is lying on side. Patient is lying on back. Patient is
lying semi-prone. Patient is lying on abdomen.
1) Patient is lying on side.
2) Patient is lying on back.
3) Patient is lying semi-prone.
4) Patient is lying on abdomen.
Q37. A nurse is evaluating care of an immobilized patient. Which action will the nurse take?
Focus on whether the interdisciplinary team is satisfied with the care. Compare the patient’s
actual outcomes with the outcomes in the care plan. Involve primarily the patient’s family and
health care team to determine goal achievement. Use objective data solely in determining
whether interventions have been successful.
1) Focus on whether the interdisciplinary team is satisfied with the care.
2) Compare the patient’s actual outcomes with the outcomes in the care plan.
3) Involve primarily the patient’s family and health care team to determine goal achievement.
4) Use objective data solely in determining whether interventions have been successful.
Q38. A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely
providing care? A patient with neck surgery A patient with hypostatic pneumonia A patient
with a total knee replacement A patient with a stage IV pressure ulcer
, 1) A patient with neck surgery
2) A patient with hypostatic pneumonia
3) A patient with a total knee replacement
4) A patient with a stage IV pressure ulcer
Q39. The nurse is providing teaching to an immobilized patient with impaired skin integrity
about diet. Which diet will the nurse recommend? High protein, high calorie High
carbohydrate, low fat High vitamin A, high vitamin E Fluid restricted, bland
1) High protein, high calorie
2) High carbohydrate, low fat
3) High vitamin A, high vitamin E
4) Fluid restricted, bland
Q40. The nurse is caring for a patient who has experienced a stroke causing total paralysis of
the right side. To help maintain joint function and minimize the disability from contractures,
passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?
After the acute phase of the disease has passed As soon as the ability to move is lost Once
the patient enters the rehab unit When the patient requests it
1) After the acute phase of the disease has passed
2) As soon as the ability to move is lost
3) Once the patient enters the rehab unit
4) When the patient requests it
Q41. The nurse is admitting a patient who has been diagnosed as having had a stroke. The
health care provider writes orders for “ROM as needed.” What should the nurse do next?
Restrict patient’s mobility as much as possible. Realize the patient is unable to move
extremities. Move all the patient’s extremities. Further assess the patient.
1) Restrict patient’s mobility as much as possible.
2) Realize the patient is unable to move extremities.
3) Move all the patient’s extremities.
4) Further assess the patient.
Q42. A nurse is assessing pressure points in a patient placed in the Sims’ position. Which
areas will the nurse observe? Chin, elbow, hips Ileum, clavicle, humerus Shoulder, anterior
iliac spine, ankles Occipital region of the head, coccyx, heels
1) Chin, elbow, hips
2) Ileum, clavicle, humerus
3) Shoulder, anterior iliac spine, ankles
4) Occipital region of the head, coccyx, heels
Q43. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure
of fixation of a fractured left hip. The patient’s nursing diagnosis is Impaired physical mobility
related to musculoskeletal impairment from surgery and pain with movement. The patient is
able to use a walker but needs assistance ambulating and transferring from the bed to the
chair. Which nursing intervention is most appropriate for this patient? Obtain assistance and
physically transfer the patient to the chair. Assist with ambulation and measure how far the
patient walks. Give pain medication after ambulation so the patient will have a clear mind.
Bring the patient to the cafeteria for group instruction on ambulation.
