NUR 101 | NUR 101 Nursing Fundamentals Exam 3
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. When preparing to ambulate a patient who has been on bed rest for several days,
which action should the nurse take first to ensure safety?
A. Apply a gait belt and assist the patient to a standing position immediately.
B. Have the patient sit on the edge of the bed and dangle their legs for several
minutes.
C. Encourage the patient to perform isometric exercises while lying in the supine
position.
D. Check the patient’s blood pressure while they are lying in the bed.
Correct Answer: B
Expert Explanation: The nurse should first allow the patient to dangle their legs to
prevent orthostatic hypotension. This gradual change in position allows the
cardiovascular system to compensate for the effects of gravity. If the patient
becomes dizzy or lightheaded, they can easily be assisted back into a lying position.
Monitoring the patient during this transition is a critical safety intervention for
those on prolonged bed rest. Documentation of the patient’s response to dangling
helps guide future mobilization efforts.
,2. A patient is recovering from a hip replacement and requires a cane for ambulation.
On which side should the nurse instruct the patient to hold the cane?
A. On the weaker side of the body.
B. Alternate between the left and right sides to ensure balance.
C. On whichever side feels more comfortable for the patient.
D. On the stronger side of the body.
Correct Answer: D
Expert Explanation: A cane should always be held on the stronger side of the body
to provide maximal support. By holding the cane on the unaffected side, the patient
can shift their weight away from the weaker limb. The cane and the affected leg
should move forward together to maintain a stable base of support. This technique
mimics the natural gait cycle and reduces the risk of falls. The nurse must observe
the patient’s technique to ensure the cane height is appropriate and used correctly.
3. The nurse is educating a patient on how to use crutches to go up a flight of stairs.
Which movement should the nurse instruct the patient to perform first?
A. Move the crutches up to the next step.
B. Move the affected leg up to the next step.
C. Move the unaffected leg up to the next step.
,D. Move both crutches and the affected leg up together.
Correct Answer: C
Expert Explanation: When going up stairs with crutches, the patient should lead
with the unaffected or ‘good’ leg. This allows the stronger leg to lift the body’s
weight up to the next step. Once the unaffected leg is secure, the crutches and the
affected leg follow. This sequence provides the most stability and reduces the risk of
losing balance on the stairs. Using the phrase ‘up with the good and down with the
bad’ is an effective way to teach patients this skill.
4. Which complication of immobility is the nurse attempting to prevent by
encouraging the use of an incentive spirometer every hour?
A. Orthostatic hypotension.
B. Deep vein thrombosis.
C. Atelectasis.
D. Muscle atrophy.
Correct Answer: C
Expert Explanation: Immobile patients are at high risk for atelectasis, which is the
collapse of alveoli in the lungs. Using an incentive spirometer encourages deep
breathing and expansion of the lower lung fields. This nursing intervention helps
mobilize secretions and improves gas exchange during periods of decreased activity.
, Preventing respiratory complications is a priority in the care of post-operative or
bed-bound patients. Consistent patient education regarding the use of this device is
essential for positive outcomes.
5. Which body mechanics principle should the nurse utilize when moving a heavy
patient up in bed?
A. Flex the knees and use the large muscles of the legs.
B. Place the feet close together to maintain balance.
C. Keep the knees straight and bend at the waist.
D. Pull the patient using only the strength of the arms.
Correct Answer: A
Expert Explanation: Proper body mechanics involve using the large muscle groups
of the legs rather than the back. By flexing the knees and keeping a wide base of
support, the nurse lowers their center of gravity. This approach reduces the risk of
musculoskeletal injury to the healthcare provider. Nurses should also keep the
weight of the patient close to their own body during the move. Utilizing assistive
devices or additional staff is also recommended for heavy lifting tasks.
6. A nurse is preparing to administer an enema to a patient. In which position should
the patient be placed for this procedure?
A. High-Fowler’s position.
Version 3 | Questions with Correct Answers and
Expert Explanation for Each Question | Saint Paul’s
School of Nursing
1. When preparing to ambulate a patient who has been on bed rest for several days,
which action should the nurse take first to ensure safety?
A. Apply a gait belt and assist the patient to a standing position immediately.
B. Have the patient sit on the edge of the bed and dangle their legs for several
minutes.
C. Encourage the patient to perform isometric exercises while lying in the supine
position.
D. Check the patient’s blood pressure while they are lying in the bed.
Correct Answer: B
Expert Explanation: The nurse should first allow the patient to dangle their legs to
prevent orthostatic hypotension. This gradual change in position allows the
cardiovascular system to compensate for the effects of gravity. If the patient
becomes dizzy or lightheaded, they can easily be assisted back into a lying position.
Monitoring the patient during this transition is a critical safety intervention for
those on prolonged bed rest. Documentation of the patient’s response to dangling
helps guide future mobilization efforts.
,2. A patient is recovering from a hip replacement and requires a cane for ambulation.
On which side should the nurse instruct the patient to hold the cane?
A. On the weaker side of the body.
B. Alternate between the left and right sides to ensure balance.
C. On whichever side feels more comfortable for the patient.
D. On the stronger side of the body.
Correct Answer: D
Expert Explanation: A cane should always be held on the stronger side of the body
to provide maximal support. By holding the cane on the unaffected side, the patient
can shift their weight away from the weaker limb. The cane and the affected leg
should move forward together to maintain a stable base of support. This technique
mimics the natural gait cycle and reduces the risk of falls. The nurse must observe
the patient’s technique to ensure the cane height is appropriate and used correctly.
3. The nurse is educating a patient on how to use crutches to go up a flight of stairs.
Which movement should the nurse instruct the patient to perform first?
A. Move the crutches up to the next step.
B. Move the affected leg up to the next step.
C. Move the unaffected leg up to the next step.
,D. Move both crutches and the affected leg up together.
Correct Answer: C
Expert Explanation: When going up stairs with crutches, the patient should lead
with the unaffected or ‘good’ leg. This allows the stronger leg to lift the body’s
weight up to the next step. Once the unaffected leg is secure, the crutches and the
affected leg follow. This sequence provides the most stability and reduces the risk of
losing balance on the stairs. Using the phrase ‘up with the good and down with the
bad’ is an effective way to teach patients this skill.
4. Which complication of immobility is the nurse attempting to prevent by
encouraging the use of an incentive spirometer every hour?
A. Orthostatic hypotension.
B. Deep vein thrombosis.
C. Atelectasis.
D. Muscle atrophy.
Correct Answer: C
Expert Explanation: Immobile patients are at high risk for atelectasis, which is the
collapse of alveoli in the lungs. Using an incentive spirometer encourages deep
breathing and expansion of the lower lung fields. This nursing intervention helps
mobilize secretions and improves gas exchange during periods of decreased activity.
, Preventing respiratory complications is a priority in the care of post-operative or
bed-bound patients. Consistent patient education regarding the use of this device is
essential for positive outcomes.
5. Which body mechanics principle should the nurse utilize when moving a heavy
patient up in bed?
A. Flex the knees and use the large muscles of the legs.
B. Place the feet close together to maintain balance.
C. Keep the knees straight and bend at the waist.
D. Pull the patient using only the strength of the arms.
Correct Answer: A
Expert Explanation: Proper body mechanics involve using the large muscle groups
of the legs rather than the back. By flexing the knees and keeping a wide base of
support, the nurse lowers their center of gravity. This approach reduces the risk of
musculoskeletal injury to the healthcare provider. Nurses should also keep the
weight of the patient close to their own body during the move. Utilizing assistive
devices or additional staff is also recommended for heavy lifting tasks.
6. A nurse is preparing to administer an enema to a patient. In which position should
the patient be placed for this procedure?
A. High-Fowler’s position.
