EXAM 1 Chapter 28, 29, 39, 40, 48 (Infection Control, Hygiene, Activity & Exercise,
Immobility, Skin Integrity & Wound Care)
1- A 26 year old is being admitted from the recovery room and is identified as at risk
for falls. Which of the following best describes the rationale for this nursing diagnosis?
Select one:
a. Depression
b. Surgical tooth extraction
c. Pain medication
d. History of asthma
2- A cognitively intact bedridden patient is unable to reach all body parts. Which type of
bath will the nurse assign to the nursing assistive personnel?
Select one:
a. Bag bath
b. Partial bed bath
c. Complete bed bath
d. Sponge bath
3- A diabetic patient presents to the clinic for a dressing change. The wound is located on
the right foot and has purulent yellow drainage. Which action will the nurse take to
prevent the spread of infection?
Select one:
a. Review the medication list that the patient brought from home.
b. Position the patient comfortably on the stretcher.
c. Don gloves and other appropriate personal protective equipment.
d. Explain the procedure for dressing change to the patient.
4- After providing perineal hygiene an intact male patient, the nurse ensures:
Select one:
a. The foreskin remains retracted for the glans to dry
b. The patient knows to replace the foreskin back over the glans in 15-20 minutes
after drying
c. The patient knows to use soap and water with hygiene to the glans going forward
d. The foreskin is replaced back over the glans
,5- A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess?
Select one:
a. All of the above
b. Race
c. Pregnancy status
d. Emotional factors
Question 6
A nurse is assessing a patients skin. Which patient is most at risk for skin breakdown?
Select one:
a. A patient who is diaphoretic
b. A patient who is afebrile
c. A patient with adequate skin turgor
d. A patient with strong pedal pulses
7- A nurse is assessing a patients wound. Which nursing observation will the nurse
anticipate in a wound healing by secondary intention?
Select one:
a. Scarring that may be severe
b. Minimal loss of tissue function
c. Minimal scar tissue
d. Permanent dark redness at site
8- A nurse is assessing a patient with activity intolerance for possible orthostatic
hypotension. Which finding will help confirm orthostatic hypotension?
Select one:
a. Blood pressure sitting 120/64; blood pressure 140/70 standing
b. Blood pressure sitting 140/60; blood pressure 130/54 standing
c. Blood pressure sitting 130/60; blood pressure 110/60 standing
d. Blood pressure sitting 126/64; blood pressure 120/58 standing
9- ulcer open to air and does not apply a dressing. To which patient did the nurse
provide care?
Select one:
a. A patient with a clean Stage I
, b. A patient with a clean Stage IV
c. A patient with a clean Stage II
d. A patient with a clean Stage III
11- A nurse is assisting the patient to perform exercises. Which action will the nurse take?
Select one:
a. Set the pace for the exercise session.
b. Force muscles or joints to go just beyond resistance.
c. Stop the exercise if pain is experienced.
d. Encourage wearing tight shoes.
12- A nurse is caring for an immobile patient. Which metabolic alteration will the nurse
monitor for in this patient?
Select one:
a. Increased diarrhea
b. Increased metabolic rate
c. Increased appetite
d. Altered nutrient metabolism
13- A nurse is caring for a patient who has just had major abdominal surgery to resect a
portion of his colon. What is the most reliable sign that the patient has significant
postoperative pain?
Select one:
a. The patient is moaning softly and frowning, with a pinched expression on his face.
b. The patient rates his pain a 7 on a scale of 0 to 10.
c. The patient winces and guards the area as the nurse gently palpates the abdomen.
d. The patient is having trouble sleeping and has become irritable.
14- A nurse is caring for a patient with a wound. Which assessment data will be most
important for the nurse to gather with regard to wound healing?
Select one:
a. Sleep assessment
b. Muscular strength assessment
c. Pulse oximetry assessment
d. Sensation assessment
Immobility, Skin Integrity & Wound Care)
1- A 26 year old is being admitted from the recovery room and is identified as at risk
for falls. Which of the following best describes the rationale for this nursing diagnosis?
Select one:
a. Depression
b. Surgical tooth extraction
c. Pain medication
d. History of asthma
2- A cognitively intact bedridden patient is unable to reach all body parts. Which type of
bath will the nurse assign to the nursing assistive personnel?
Select one:
a. Bag bath
b. Partial bed bath
c. Complete bed bath
d. Sponge bath
3- A diabetic patient presents to the clinic for a dressing change. The wound is located on
the right foot and has purulent yellow drainage. Which action will the nurse take to
prevent the spread of infection?
Select one:
a. Review the medication list that the patient brought from home.
b. Position the patient comfortably on the stretcher.
c. Don gloves and other appropriate personal protective equipment.
d. Explain the procedure for dressing change to the patient.
4- After providing perineal hygiene an intact male patient, the nurse ensures:
Select one:
a. The foreskin remains retracted for the glans to dry
b. The patient knows to replace the foreskin back over the glans in 15-20 minutes
after drying
c. The patient knows to use soap and water with hygiene to the glans going forward
d. The foreskin is replaced back over the glans
,5- A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess?
Select one:
a. All of the above
b. Race
c. Pregnancy status
d. Emotional factors
Question 6
A nurse is assessing a patients skin. Which patient is most at risk for skin breakdown?
Select one:
a. A patient who is diaphoretic
b. A patient who is afebrile
c. A patient with adequate skin turgor
d. A patient with strong pedal pulses
7- A nurse is assessing a patients wound. Which nursing observation will the nurse
anticipate in a wound healing by secondary intention?
Select one:
a. Scarring that may be severe
b. Minimal loss of tissue function
c. Minimal scar tissue
d. Permanent dark redness at site
8- A nurse is assessing a patient with activity intolerance for possible orthostatic
hypotension. Which finding will help confirm orthostatic hypotension?
Select one:
a. Blood pressure sitting 120/64; blood pressure 140/70 standing
b. Blood pressure sitting 140/60; blood pressure 130/54 standing
c. Blood pressure sitting 130/60; blood pressure 110/60 standing
d. Blood pressure sitting 126/64; blood pressure 120/58 standing
9- ulcer open to air and does not apply a dressing. To which patient did the nurse
provide care?
Select one:
a. A patient with a clean Stage I
, b. A patient with a clean Stage IV
c. A patient with a clean Stage II
d. A patient with a clean Stage III
11- A nurse is assisting the patient to perform exercises. Which action will the nurse take?
Select one:
a. Set the pace for the exercise session.
b. Force muscles or joints to go just beyond resistance.
c. Stop the exercise if pain is experienced.
d. Encourage wearing tight shoes.
12- A nurse is caring for an immobile patient. Which metabolic alteration will the nurse
monitor for in this patient?
Select one:
a. Increased diarrhea
b. Increased metabolic rate
c. Increased appetite
d. Altered nutrient metabolism
13- A nurse is caring for a patient who has just had major abdominal surgery to resect a
portion of his colon. What is the most reliable sign that the patient has significant
postoperative pain?
Select one:
a. The patient is moaning softly and frowning, with a pinched expression on his face.
b. The patient rates his pain a 7 on a scale of 0 to 10.
c. The patient winces and guards the area as the nurse gently palpates the abdomen.
d. The patient is having trouble sleeping and has become irritable.
14- A nurse is caring for a patient with a wound. Which assessment data will be most
important for the nurse to gather with regard to wound healing?
Select one:
a. Sleep assessment
b. Muscular strength assessment
c. Pulse oximetry assessment
d. Sensation assessment
