NR 224 Fundamentals Weeks 3-5 Exam Review: Questions 200
with Rationales NR 224 Fundamentals: Complete Weeks 3-5
Test Bank —NR 224 Exam Review: Mobility, Elimination, Pain,
Perioperative, Fluids & Electrolytes, Legal/Ethics
SECTION 1: MOBILITY & IMMOBILITY
Q1. A patient on week-long bed rest is now performing isometric exercises. Which
nursing diagnosis best addresses the safety of this patient?
• A) Disturbed thought processes
• B) Impaired skin integrity
• C) Disturbed body image
• D) Risk for activity intolerance
☑ correct answers: D
Rationale: Isometric exercises involve muscle contraction without joint
movement. The patient on prolonged bed rest is at risk for activity intolerance
when beginning exercises, which requires monitoring for fatigue, dyspnea, and
vital sign changes .
Q2. The nurse puts elastic stockings on a patient following major abdominal
surgery. The nurse teaches the patient that the stockings are used after a surgical
procedure to:
• A) Prevent varicose veins
, • B) Prevent muscular atrophy
• C) Ensure joint mobility and prevent contractures
• D) Promote venous return to the heart
☑ correct answers: D
Rationale: Elastic stockings (anti-embolism stockings) promote venous return by
providing graduated external compression, which prevents venous stasis and
reduces the risk of deep vein thrombosis (DVT) .
Q3. Select the statements that apply to the proper use of a cane. (Select all that
apply)
• A) For maximum support, the patient places the cane forward 15 to 25 cm,
keeping body weight on both legs.
• B) A person's cane length is equal to the distance between the elbow and
the floor.
• C) Canes provide less support than a walker and are less stable.
• D) The patient needs to learn that two points of support need to be present
at all times.
☑ correct answerss: A, C, D
Rationale: Cane length should be measured from the greater trochanter to the
floor, not the elbow. Canes provide less stability than walkers. Patients should
maintain two points of support (both feet or one foot and the cane) at all times .
,Q4. Which of the following activities does the nurse delegate to nursing assistive
personnel in regard to crutch walking? (Select all that apply)
• A) Notify nurse if patient reports pain before, during, or after exercise
• B) Notify nurse of patient complaints of increased fatigue, dizziness, light-
headedness
• C) Notify nurse of vital sign values
• D) Evaluate the patient's ability to use crutches properly
• E) Prepare the patient for exercise by assisting in dressing and putting on
shoes
☑ correct answerss: A, B, C, E
Rationale: Evaluation of a patient's ability to use crutches properly requires
nursing judgment and cannot be delegated to UAP. The other tasks (reporting
symptoms, vital signs, preparation) are appropriate for delegation .
Q5. The patient at greatest risk for developing multiple adverse effects of
immobility is a:
• A) 1-year-old child with a hernia repair
• B) 80-year-old woman who has suffered a hemorrhagic cerebrovascular
accident (CVA)
• C) 51-year-old woman following a thyroidectomy
, • D) 38-year-old woman undergoing a hysterectomy
☑ correct answers: B
Rationale: The elderly patient with CVA (stroke) has multiple risk factors:
advanced age, neurological impairment, limited mobility, and potential for
prolonged immobility. This combination places her at highest risk for
complications including pressure injuries, DVT, pneumonia, and contractures .
Q6. One of your assigned patients has been restrained. Which nursing action is
most important when caring for a patient in restraints?
• A) Offer fluids every 2 hours
• B) Offer assistance with eating every 4 hours
• C) Assess the patient's comfort level every 4 hours
• D) Remove the restraint and assess skin condition at least every 2 hours
☑ correct answers: D
Rationale: Restraints require frequent monitoring. Skin should be assessed and
restraints removed at least every 2 hours to check circulation, skin integrity, and
provide range of motion and basic needs .
Q7. A patient has her call bell on and looks frightened when you enter the room.
She has been on bed rest for 3 days following a fractured femur. She says, "It
hurts when I try to breathe, and I can't catch my breath." Your first action is to:
with Rationales NR 224 Fundamentals: Complete Weeks 3-5
Test Bank —NR 224 Exam Review: Mobility, Elimination, Pain,
Perioperative, Fluids & Electrolytes, Legal/Ethics
SECTION 1: MOBILITY & IMMOBILITY
Q1. A patient on week-long bed rest is now performing isometric exercises. Which
nursing diagnosis best addresses the safety of this patient?
• A) Disturbed thought processes
• B) Impaired skin integrity
• C) Disturbed body image
• D) Risk for activity intolerance
☑ correct answers: D
Rationale: Isometric exercises involve muscle contraction without joint
movement. The patient on prolonged bed rest is at risk for activity intolerance
when beginning exercises, which requires monitoring for fatigue, dyspnea, and
vital sign changes .
Q2. The nurse puts elastic stockings on a patient following major abdominal
surgery. The nurse teaches the patient that the stockings are used after a surgical
procedure to:
• A) Prevent varicose veins
, • B) Prevent muscular atrophy
• C) Ensure joint mobility and prevent contractures
• D) Promote venous return to the heart
☑ correct answers: D
Rationale: Elastic stockings (anti-embolism stockings) promote venous return by
providing graduated external compression, which prevents venous stasis and
reduces the risk of deep vein thrombosis (DVT) .
Q3. Select the statements that apply to the proper use of a cane. (Select all that
apply)
• A) For maximum support, the patient places the cane forward 15 to 25 cm,
keeping body weight on both legs.
• B) A person's cane length is equal to the distance between the elbow and
the floor.
• C) Canes provide less support than a walker and are less stable.
• D) The patient needs to learn that two points of support need to be present
at all times.
☑ correct answerss: A, C, D
Rationale: Cane length should be measured from the greater trochanter to the
floor, not the elbow. Canes provide less stability than walkers. Patients should
maintain two points of support (both feet or one foot and the cane) at all times .
,Q4. Which of the following activities does the nurse delegate to nursing assistive
personnel in regard to crutch walking? (Select all that apply)
• A) Notify nurse if patient reports pain before, during, or after exercise
• B) Notify nurse of patient complaints of increased fatigue, dizziness, light-
headedness
• C) Notify nurse of vital sign values
• D) Evaluate the patient's ability to use crutches properly
• E) Prepare the patient for exercise by assisting in dressing and putting on
shoes
☑ correct answerss: A, B, C, E
Rationale: Evaluation of a patient's ability to use crutches properly requires
nursing judgment and cannot be delegated to UAP. The other tasks (reporting
symptoms, vital signs, preparation) are appropriate for delegation .
Q5. The patient at greatest risk for developing multiple adverse effects of
immobility is a:
• A) 1-year-old child with a hernia repair
• B) 80-year-old woman who has suffered a hemorrhagic cerebrovascular
accident (CVA)
• C) 51-year-old woman following a thyroidectomy
, • D) 38-year-old woman undergoing a hysterectomy
☑ correct answers: B
Rationale: The elderly patient with CVA (stroke) has multiple risk factors:
advanced age, neurological impairment, limited mobility, and potential for
prolonged immobility. This combination places her at highest risk for
complications including pressure injuries, DVT, pneumonia, and contractures .
Q6. One of your assigned patients has been restrained. Which nursing action is
most important when caring for a patient in restraints?
• A) Offer fluids every 2 hours
• B) Offer assistance with eating every 4 hours
• C) Assess the patient's comfort level every 4 hours
• D) Remove the restraint and assess skin condition at least every 2 hours
☑ correct answers: D
Rationale: Restraints require frequent monitoring. Skin should be assessed and
restraints removed at least every 2 hours to check circulation, skin integrity, and
provide range of motion and basic needs .
Q7. A patient has her call bell on and looks frightened when you enter the room.
She has been on bed rest for 3 days following a fractured femur. She says, "It
hurts when I try to breathe, and I can't catch my breath." Your first action is to:
