Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
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*Answer: A*
*A patient has been on bed rest for over
Rationale: Immobility disrupts normal
4 days. On assessment, the nurse iden-
metabolic functioning: decreasing the
tifies the following as a sign associated
metabolic rate; altering the metabolism
with immobility:*
of carbohydrates, fats, and proteins;
A. Decreased peristalsis
causing fluid, electrolyte, and calcium
B. Decreased heart rate
imbalances; and causing gastrointesti-
C. Increased blood pressure
nal disturbances such as decreased ap-
D. Increased urinary output
petite and slowing of peristalsis.
*A nurse is caring for an older adult who
has had a fractured hip repaired. In the
first few postoperative days, which of the *Answer: A*
following nursing measures will best fa- Rationale: The trapeze bar allows the
cilitate the resumption of activities of dai- patient to pull with the upper extremi-
ly living for this patient?* ties to raise the trunk off the bed, aid in
A. Encouraging use of an overhead transfer from bed to wheelchair, or per-
trapeze for positioning and transfer. form upper-arm exercises. It increases
B. Frequent family visits independence and maintains upper body
C. Assisting the patient to a wheelchair strength to help in performing activities of
once per day daily living.
D. Ensuring that there is an order for
physical therapy
*An older-adult patient has been bedrid- *Answer: D*
den for 2 weeks. Which of the following Rationale: Patients whose mobility is re-
complaints by the patient indicates to the stricted require range-of-motion (ROM)
nurse that he or she is developing a com- exercises daily to reduce the hazards
plication of immobility?* of immobility. Temporary immobilization
A. Loss of appetite results in some muscle atrophy, loss
B. Gum soreness of muscle tone, and joint stiffness. Two
C. Difficulty swallowing weeks of joint immobilization without
D. Left-ankle joint stiffness ROM can quickly result in contractures.
*The nurse is caring for a patient whose
calcium intake must increase because of
high risk factors for osteoporosis. Which *Answer: A*
of the following menus should the nurse Rationale: Teach patient and/or caregiv-
recommend?* er the current recommended dietary al-
A. Cream of broccoli soup with whole
wheat crackers, cheese, and tapioca for
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
Study online at https://quizlet.com/_azq624
dessert
B. Hot dog on whole wheat bun with a
side salad and an apple for dessert lowances for calcium and review foods
C. Low-fat turkey chili with sour cream high in calcium (e.g., milk fortified with vi-
with a side salad and fresh pears for tamin D, leafy green vegetables, yogurt,
dessert and cheese).
D. Turkey salad on toast with tomato and
lettuce and honey bun for dessert
*A patient on prolonged bed rest is at an *Answer: C*
increased risk to develop this common Rationale: Immobility is a major risk fac-
complication of immobility if preventive tor for pressure ulcers. Any break in the
measures are not taken:* integrity of the skin is difficult to heal.
A. Myoclonus Preventing a pressure ulcer is much less
B. Pathological fractures expensive than treating one; therefore
C. Pressure ulcers preventive nursing interventions are im-
D. Pruritus perative.
*To prevent complications of immobility,
what would be the most effective activity *Answer: B*
on the first postoperative day for a patient Rationale: Prevention of complications of
who has had abdominal surgery?* immobility begins when the patient be-
A. Turn, cough, and deep breathe every comes immobilized. Every 30 minutes is
30 minutes while awake not necessary and disruptive to the heal-
B. Ambulate patient to chair in the hall ing process. Active patient participation
C. Passive range of motion 4 times a day in exercises is more beneficial to prevent-
D. Immobility is not a concern the first ing venous stasis.
postoperative day
*Which of the following nursing interven-
tions should be implemented to maintain
a patent airway in a patient on bed rest?*
*Answer: D*
A. Isometric exercises
Rationale: Incentive spirometry opens
B. Administration of low-dose heparin
the airway, preventing atelectasis.
C. Suctioning every 4 hours
D. Use of incentive spirometer every 2
hours while awake
*What is the correct order in which elas-
tic stockings should be applied?
1. Identify patient using two identifiers.
2. Smooth any creases or wrinkles.
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
Study online at https://quizlet.com/_azq624
3. Slide the remainder of the stocking
over the patient's heel and up the leg
4. Turn the stocking inside out until heel
is reached.
5. Assess the condition of the patient's
skin and circulation of the legs.
6. Place toes into foot of the stocking.
*Answer: C*
7. Use tape measure to measure pa-
tient's legs to determine proper stocking
size.*
A. 1, 5, 7, 4, 6, 2, 3
B. 1, 7, 5, 4, 6, 2, 3
C. 1, 5, 7, 4, 6, 3, 2
D. 1, 5, 4, 7, 6, 3, 2
*Which of the following are physiological *Answer: C*
outcomes of immobility?* Rationale: Physiologic outcomes of im-
A. Increased metabolism mobility include decreased metabolism,
B. Reduced cardiac workload increased cardiac workload, decreased
C. Decreased lung expansion lung expansion, and increased oxygen
D. Decreased oxygen demand demand.
*An older adult has limited mobility as a
result of a total knee replacement. Dur-
ing assessment you note that the patient *Answer: B, C, D*
has difficulty breathing while lying flat. Rationale: Patients who are immobile are
Which of the following assessment data at high risk for developing pulmonary
support a possible pulmonary problem complications. The most common respi-
related to impaired mobility? (Select all ratory complications are atelectasis (col-
that apply.)* lapse of alveoli) and hypostatic pneumo-
A. B/P = 128/84 nia (inflammation of the lung from stasis
B. Respirations 26/min on room air or pooling of secretions). Ultimately the
C. HR 114 distribution of mucus in the bronchi in-
D. Crackles over lower lobes heard on creases, particularly when the patient is
auscultation in the supine, prone, or lateral position.
E. Pain reported as 3 on scale of 0 to 10
after medication
*A nurse is teaching a community group
about ways to minimize the risk of devel-
oping osteoporosis. Which of the follow-
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
Study online at https://quizlet.com/_azq624
ing statements reflect understanding of
what was taught? (Select all that apply.)*
A. "I usually go swimming with my family
*Answer: A, B, C*
at the YMCA 3 times a week."
Rationale: Patients at risk for or diag-
B. "I need to ask my doctor if I should
nosed with osteoporosis have special
have a bone mineral density check this
health promotion needs. Encourage pa-
year."
tients at risk to be screened for osteo-
C. "If I don't drink milk at dinner, I'll eat
porosis and assess their diets for calci-
broccoli or cabbage to get the calcium
um and vitamin D intake. Multivitamins
that I need in my diet."
do not always have the needed amount
D. "I'll check the label of my multivitamin.
of calcium for every individual. A patient
If it has calcium, I can save money by not
needs to know his or her requirement
taking another pill."
and make a decision based on that.
E. "My lactose intolerance should not be
a concern when considering my calcium
intake."
*A patient is receiving 5000 units of
heparin subcutaneously every 12 hours
while on prolonged bed rest to prevent
*Answer: A, C, D*
thrombophlebitis. Because bleeding is a
Rationale: Because bleeding is a po-
potential side effect of this medication,
tential side effect of these medications,
the nurse should continually assess the
continually assess the patient for signs
patient for the following signs of bleeding:
of bleeding such as hematuria, bruising,
(Select all that apply.)*
coffee ground-like vomitus or gastroin-
A. Bruising
testinal aspirate, guaiac-positive stools,
B. Pale yellow urine
and bleeding gums.
C. Bleeding gums
D. Coffee ground-like vomitus
E. Light brown stool
*The nurse evaluates that the NAP has
*Answer: B & C*
applied a patient's sequential compres-
Rationale: The most effective way to pre-
sion device (SCD) appropriately when
vent deep vein thrombosis is through
which of the following is observed? (Se-
an aggressive program of prophylaxis.
lect all that apply.)*
A properly functioning SCD inflates with
A. Initial patient measurement is made
a pressure around 40 mm Hg. Inflation
around the calves
pressure averages 40 mm Hg, and the
B. Inflation pressure averages 40 mm Hg
patient's leg should be placed in the SCD
C. Patient's leg placed in SCD sleeve
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*Answer: A*
*A patient has been on bed rest for over
Rationale: Immobility disrupts normal
4 days. On assessment, the nurse iden-
metabolic functioning: decreasing the
tifies the following as a sign associated
metabolic rate; altering the metabolism
with immobility:*
of carbohydrates, fats, and proteins;
A. Decreased peristalsis
causing fluid, electrolyte, and calcium
B. Decreased heart rate
imbalances; and causing gastrointesti-
C. Increased blood pressure
nal disturbances such as decreased ap-
D. Increased urinary output
petite and slowing of peristalsis.
*A nurse is caring for an older adult who
has had a fractured hip repaired. In the
first few postoperative days, which of the *Answer: A*
following nursing measures will best fa- Rationale: The trapeze bar allows the
cilitate the resumption of activities of dai- patient to pull with the upper extremi-
ly living for this patient?* ties to raise the trunk off the bed, aid in
A. Encouraging use of an overhead transfer from bed to wheelchair, or per-
trapeze for positioning and transfer. form upper-arm exercises. It increases
B. Frequent family visits independence and maintains upper body
C. Assisting the patient to a wheelchair strength to help in performing activities of
once per day daily living.
D. Ensuring that there is an order for
physical therapy
*An older-adult patient has been bedrid- *Answer: D*
den for 2 weeks. Which of the following Rationale: Patients whose mobility is re-
complaints by the patient indicates to the stricted require range-of-motion (ROM)
nurse that he or she is developing a com- exercises daily to reduce the hazards
plication of immobility?* of immobility. Temporary immobilization
A. Loss of appetite results in some muscle atrophy, loss
B. Gum soreness of muscle tone, and joint stiffness. Two
C. Difficulty swallowing weeks of joint immobilization without
D. Left-ankle joint stiffness ROM can quickly result in contractures.
*The nurse is caring for a patient whose
calcium intake must increase because of
high risk factors for osteoporosis. Which *Answer: A*
of the following menus should the nurse Rationale: Teach patient and/or caregiv-
recommend?* er the current recommended dietary al-
A. Cream of broccoli soup with whole
wheat crackers, cheese, and tapioca for
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
Study online at https://quizlet.com/_azq624
dessert
B. Hot dog on whole wheat bun with a
side salad and an apple for dessert lowances for calcium and review foods
C. Low-fat turkey chili with sour cream high in calcium (e.g., milk fortified with vi-
with a side salad and fresh pears for tamin D, leafy green vegetables, yogurt,
dessert and cheese).
D. Turkey salad on toast with tomato and
lettuce and honey bun for dessert
*A patient on prolonged bed rest is at an *Answer: C*
increased risk to develop this common Rationale: Immobility is a major risk fac-
complication of immobility if preventive tor for pressure ulcers. Any break in the
measures are not taken:* integrity of the skin is difficult to heal.
A. Myoclonus Preventing a pressure ulcer is much less
B. Pathological fractures expensive than treating one; therefore
C. Pressure ulcers preventive nursing interventions are im-
D. Pruritus perative.
*To prevent complications of immobility,
what would be the most effective activity *Answer: B*
on the first postoperative day for a patient Rationale: Prevention of complications of
who has had abdominal surgery?* immobility begins when the patient be-
A. Turn, cough, and deep breathe every comes immobilized. Every 30 minutes is
30 minutes while awake not necessary and disruptive to the heal-
B. Ambulate patient to chair in the hall ing process. Active patient participation
C. Passive range of motion 4 times a day in exercises is more beneficial to prevent-
D. Immobility is not a concern the first ing venous stasis.
postoperative day
*Which of the following nursing interven-
tions should be implemented to maintain
a patent airway in a patient on bed rest?*
*Answer: D*
A. Isometric exercises
Rationale: Incentive spirometry opens
B. Administration of low-dose heparin
the airway, preventing atelectasis.
C. Suctioning every 4 hours
D. Use of incentive spirometer every 2
hours while awake
*What is the correct order in which elas-
tic stockings should be applied?
1. Identify patient using two identifiers.
2. Smooth any creases or wrinkles.
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
Study online at https://quizlet.com/_azq624
3. Slide the remainder of the stocking
over the patient's heel and up the leg
4. Turn the stocking inside out until heel
is reached.
5. Assess the condition of the patient's
skin and circulation of the legs.
6. Place toes into foot of the stocking.
*Answer: C*
7. Use tape measure to measure pa-
tient's legs to determine proper stocking
size.*
A. 1, 5, 7, 4, 6, 2, 3
B. 1, 7, 5, 4, 6, 2, 3
C. 1, 5, 7, 4, 6, 3, 2
D. 1, 5, 4, 7, 6, 3, 2
*Which of the following are physiological *Answer: C*
outcomes of immobility?* Rationale: Physiologic outcomes of im-
A. Increased metabolism mobility include decreased metabolism,
B. Reduced cardiac workload increased cardiac workload, decreased
C. Decreased lung expansion lung expansion, and increased oxygen
D. Decreased oxygen demand demand.
*An older adult has limited mobility as a
result of a total knee replacement. Dur-
ing assessment you note that the patient *Answer: B, C, D*
has difficulty breathing while lying flat. Rationale: Patients who are immobile are
Which of the following assessment data at high risk for developing pulmonary
support a possible pulmonary problem complications. The most common respi-
related to impaired mobility? (Select all ratory complications are atelectasis (col-
that apply.)* lapse of alveoli) and hypostatic pneumo-
A. B/P = 128/84 nia (inflammation of the lung from stasis
B. Respirations 26/min on room air or pooling of secretions). Ultimately the
C. HR 114 distribution of mucus in the bronchi in-
D. Crackles over lower lobes heard on creases, particularly when the patient is
auscultation in the supine, prone, or lateral position.
E. Pain reported as 3 on scale of 0 to 10
after medication
*A nurse is teaching a community group
about ways to minimize the risk of devel-
oping osteoporosis. Which of the follow-
, Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions)
Study online at https://quizlet.com/_azq624
ing statements reflect understanding of
what was taught? (Select all that apply.)*
A. "I usually go swimming with my family
*Answer: A, B, C*
at the YMCA 3 times a week."
Rationale: Patients at risk for or diag-
B. "I need to ask my doctor if I should
nosed with osteoporosis have special
have a bone mineral density check this
health promotion needs. Encourage pa-
year."
tients at risk to be screened for osteo-
C. "If I don't drink milk at dinner, I'll eat
porosis and assess their diets for calci-
broccoli or cabbage to get the calcium
um and vitamin D intake. Multivitamins
that I need in my diet."
do not always have the needed amount
D. "I'll check the label of my multivitamin.
of calcium for every individual. A patient
If it has calcium, I can save money by not
needs to know his or her requirement
taking another pill."
and make a decision based on that.
E. "My lactose intolerance should not be
a concern when considering my calcium
intake."
*A patient is receiving 5000 units of
heparin subcutaneously every 12 hours
while on prolonged bed rest to prevent
*Answer: A, C, D*
thrombophlebitis. Because bleeding is a
Rationale: Because bleeding is a po-
potential side effect of this medication,
tential side effect of these medications,
the nurse should continually assess the
continually assess the patient for signs
patient for the following signs of bleeding:
of bleeding such as hematuria, bruising,
(Select all that apply.)*
coffee ground-like vomitus or gastroin-
A. Bruising
testinal aspirate, guaiac-positive stools,
B. Pale yellow urine
and bleeding gums.
C. Bleeding gums
D. Coffee ground-like vomitus
E. Light brown stool
*The nurse evaluates that the NAP has
*Answer: B & C*
applied a patient's sequential compres-
Rationale: The most effective way to pre-
sion device (SCD) appropriately when
vent deep vein thrombosis is through
which of the following is observed? (Se-
an aggressive program of prophylaxis.
lect all that apply.)*
A properly functioning SCD inflates with
A. Initial patient measurement is made
a pressure around 40 mm Hg. Inflation
around the calves
pressure averages 40 mm Hg, and the
B. Inflation pressure averages 40 mm Hg
patient's leg should be placed in the SCD
C. Patient's leg placed in SCD sleeve
