LAB Flashcards
1
Q
- How does soap work?
A. Creates a sheetlike microscopic barrier between the skin and microorganisms in the environment
B. Emulsifies fat and oil so that dirt and microorganisms can be mechanically removed
C. Kills all microorganisms exposed to the lather
D. Removes visible soiling but is ineffective in isolating, removing, or killing microorganisms
A
B. Emulsifies fat and oil so that dirt and microorganisms can be mechanically removed
2
Q
- What is the primary purpose of appropriate hand hygiene?
A. To remove all microorganisms from the hands
B. To prevent or control the transmission of infectious microorganisms from any source
C. To leave a protective antimicrobial film on the hands
D. To minimize exposure to microorganisms on contaminated sinks, medication containers, catheters, and other hard surfaces
A
B. To prevent or control the transmission of infectious microorganisms from any source
3
Q
- In which situation would it be appropriate for the nurse to use an antiseptic hand rub to perform hand hygiene?
A. The nurse has dry, cracked skin.
B. The nurse’s hands are not visibly soiled.
C. The nurse is sensitive to antimicrobial soap.
D. The nurse has been exposed to a protein-based contaminant.
A
B
4
Q
- The nurse is discussing the guidelines for proper hand hygiene with nursing assistive personnel (NAP). Which statement made by NAP requires follow-up by the nurse?
A. “I always perform hand hygiene after I use the computer workstation in the patient’s room.”
B. “To prevent dry skin, I avoid using soap and water.”
C. “It takes at least 15 seconds of rubbing to wash the hands properly.”
D. “I do hand hygiene before and after lifting or moving my patients.”
A
B
5
Q
- Which patient is at the greatest risk for hospital-acquired infection (HAI)?
A. A middle-age female patient receiving chemotherapy for lung cancer
B. An older adult male patient who experienced a myocardial infarction 3 days ago
C. A young man recovering from bilateral femur fractures and a mild concussion sustained in a car accident
D. A young woman with abdominal pain who is scheduled for exploratory surgery in the morning
A
A
6
Q
WHAT ARE BODY MECHANICS?
A
The coordinated effort of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living.
7
Q
- The nurse is preparing to make an occupied bed for a patient who is on aspiration precautions. What will the nurse do to ensure the safety of this patient during the bed change?
A. Keep the head of the bed no lower than a 30-degree angle.
B. Fold a pillow in half and place it under the patient’s head.
C. Lower the bed to a flat position and place two pillows beneath the patient’s head.
D. Ask another caregiver to hold the patient’s head during the bed change.
A
A
8
Q
The nurse is directing nursing assistive personnel (NAP) to make an occupied bed. What will the nurse say to minimize the risk of disease transmission to staff and patient during the bed change?
A. “You’ll need to apply Standard Precautions during this task.”
B. “Soiled linen should be rolled toward your uniform.”
C. “Soiled linen should be kept away from your uniform.”
D. “Keep the linen bag at the foot of the bed.”
A
A
9
Q
Which action ensures that a patient will not have unnecessary pain during a linen change?
A. Discontinue the bed change if the patient expresses or displays physical signs of pain.
B. Explain the procedure to the patient before beginning the linen change.
C. Administer a prescribed analgesic 30 to 60 minutes before the bed change if needed.
D. Postpone the bed change if the patient reports having physical pain before you begin.
A
C
10
Q
The nurse is changing the bed linen of a patient on bed rest. When the nurse is ready to make the other side of the bed, what will the nurse do before having the patient turn onto the side that has already been made?
A. Lower the head of the bed
B. Raise the side rails
C. Apply the topsheet
D. Discard the soiled linen in the linen bag
A
B
11
Q
What will the nurse do right after placing a clean topsheet on the patient?
A. Make a cuff with the top of the sheet.
B. Make a horizontal toe pleat.
C. Tuck the remaining portion of the sheet under the foot of the mattress.
D. Remove the bath blanket.
A
D
12
Q
The nurse who is preparing to make an unoccupied bed should do what to ensure his or her personal safety?
A. Put on sterile gloves.
B. Place the call light within the nurse’s reach.
C. Place the bed at a comfortable working height.
D. Place a laundry bag on the bedside chair.
A
C
13
Q
The nurse is preparing to change the soiled linen of a patient’s unoccupied bed. Which precaution minimizes the risk of transmitting microorganisms?
A. Perform hand hygiene and apply clean gloves.
B. Place fresh linen on a clean bedside table or chair.
C. Put soiled linen in a pillow case before placing in a hamper.
D. Roll soiled linen together with the dirty sides toward the center.
A
A
14
Q
What would the nurse instruct the nursing assistive personnel (NAP) to do before making an unoccupied bed if the mattress is soiled?
A. Wash the mattress with hot water.
B. Wipe off moisture with antiseptic solution, and dry thoroughly.
C. Flip the mattress.
D. Apply a waterproof pad over the soiled area.
A
B
15
Q
The nurse is reviewing placement of an unfitted bottom sheet with nursing assistive personnel (NAP) assigned to make an unoccupied bed. What should the nurse include in this teaching?
A. The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress.
B. Keep enough material to miter the lower mattress corners.
C. Apply the drawsheet on the cleaned mattress first.
D. Make the top of the bed first, moving to the bottom of the bed.
A
A
16
Q
When making an unoccupied bed, where would the nurse place a waterproof pad?
A. Directly on the mattress.
B. Beneath the drawsheet.
C. Over the bottom sheet.
D. Over the top sheet.
A
C
17
Q
When making a surgical bed with no patient present, at which time is it unnecessary to perform hand hygiene?
A. Before making the bed.
B. After gloving, washing the mattress with an antiseptic solution, and ungloving.
C. After disposing of soiled linen that is not visibly soiled.
D. After fanfolding the sheets to complete the open bed.
A
C
18
Q
A new nursing assistive personnel (NAP) is making a surgical bed for a patient who is having abdominal surgery. Where will you instruct the NAP to place the waterproof pad on this bed?
A. Over the mattress
B. Over the bottom sheet
C. Over the top sheet
D. A waterproof pad should not be used for this patient
A
B
19
Q
For a surgical bed, why is the linen formed into a triangle and fanfolded away from the side on which the patient will be transferred?
A. To protect the linen from soiling
B. To ensure that the toe pleat is not pulled out
C. To keep the linen out of the way during the transfer
D. To keep the flat sheet taut during the transfer
A
C
20
Q
A nursing assistive personnel (NAP) has finished making a surgical bed for a patient in surgery. How would the nurse instruct the NAP to leave the bed to transfer the surgical patient safely?
A. Raise the head of the bed to a 30-degree angle.
B. Raise the top two side rails.
C. Raise the height of the bed.
D. Release the bed wheels.
A
C
21
Q
When making a surgical bed, why does the nurse avoid shaking the linen being removed from the bed?
A. To keep the linen folded correctly
B. To prevent contamination to the environment and the nurse’s uniform
C. To keep it separate from the towels and washcloths in the linen bag
D. To reduce the amount of time needed to make the bed
A
B
22
Q
When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first?
A. Coordinate extra help.
B. Assess the patient’s vital signs.
C. Assess the patient’s physiological capacity to transfer.
D. Determine whether to transfer the patient to a wheelchair or chair.
A
C
23
Q
Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt?
A. “When I count to three, please rock yourself into a standing position.”
B. “Please hold on to my waist while I help you stand.”
C. “Please tell me how I can best help you get up off the bed and stand up.”
D. “Please push down onto the mattress with both hands and stand when I count to three.”
A
D
24
Q
A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed?
A. Help the patient put on skid-resistant footwear.
B. Raise the head of the bed 30 degrees.
C. Place the transfer belt over the patient’s clothing.
D. Position the chair so that the patient will move toward his or her stronger side.
A
B
25
The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume?
A. Place both feet together on the floor.
B. Place your weaker foot forward and your stronger leg toward the back.
C. Extend both of your legs and feet.
D. Place your stronger leg forward and your weaker leg toward the back.
D
26
A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair?
A. Remove the wheelchair leg rests.
B. Ask the patient to rate his or her pain level.
C. Lower the foot rests, and place the patient's feet on them.
D. Remove the transfer belt.
C
27
When positioning a hemiplegic patient in the supported Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs?
A. To reduce the risk of a fall while the side rails are down
B. To reduce the risk of contracture
C. To control pain
D. To cushion the legs
B
28
To which position would the nurse assist the patient who is experiencing difficulty with breathing?
A. Sims’ position
B. 30-degree lateral position
C. Fowler’s position
D. Prone position
C
29
When repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward?
A. Apply therapeutic boots to the feet.
B. Place sandbags along the legs.
C. Place a small pillow at the lumbar region of the back.
D. Place a pillow under the calves.
B
30
The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side?
A. Place a small pillow under the shoulder.
B. Use the affected arm as a guide during rolling.
C. Place a pillow on the abdomen.
D. Place rolled bath blankets along the dependent leg.
C
31
The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned?
A. To position the pillows
B. To keep the spine in alignment
C. To roll the patient as a unit
D. To ease the patient back onto the support pillows
C - To roll the patient as a unit
32
The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient?
A. On the patient’s strong side
B. On the patient’s weak side
C. Behind the patient
D. In front of the patient
B. On the patient’s weak side
33
The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk?
A. Ask the patient how far she would like to go.
B. Review the health care provider’s order.
C. Review the medical record to see how far the patient has walked during the past several therapeutic ambulations.
D. Review the records of other patients who are at a similar point in their stroke rehabilitation.
A. Ask the patient how far she would like to go.
34
The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse’s initial response?
A. Slowly lower the patient to the floor.
B. Attempt to sit the patient down on a chair just a few steps away.
C. Try to hold the patient up until the dizziness passes.
D. Call for assistance in a loud but calm voice.
A. Slowly lower the patient to the floor.
35
The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up?
A. “I will be sure to put nonskid slippers on the patient before getting him up to ambulate.”
B. “I will use the under-axillae technique to help him up to a standing position.”
C. “Rocking the heavier patient into a standing position seems to work really well for me.”
D. “I will grasp the gait belt in the middle of the patient’s back.”
B. “I will use the under-axillae technique to help him up to a standing position.”
36
The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do?
A. Return the patient to the bed or chair (whichever is closer).
B. Encourage the patient to complete the distance of ambulation.
C. Help him to the restroom.
D. Ease him to the floor.
A. Return the patient to the bed or chair (whichever is closer).
37
To which patient might the nurse apply a physical restraint?
A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling.
B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
C. A 74-year-old patient confined to bed who is at risk of pressure ulcers.
D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.
B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
38
Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours?
A. To try a less restrictive type of restraint if a more confining restraint has proved effective
B. To double-check the size by inserting one finger between the wrist and the restraint
C. To check the skin integrity and range of motion of the wrist
D. To comply with Joint Commission standards
C. To check the skin integrity and range of motion of the wrist
39
What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint?
A. “Tell me if the patient’s pulse changes.”
B. “Tell me if the skin under the restraint becomes abraded or raw.”
C. “Let me know if you think she’s ready for them to come off.”
D. “Let me know if the patient needs anything for pain.”
B. “Tell me if the skin under the restraint becomes abraded or raw.”
40
The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse’s best response when the patient’s wife says, “I don’t like him being tied down in the bed?”
A. “I’m sure you don’t want him to fall again.”
B. “Can you suggest an alternative?”
C. “What did you do to prevent him from falling when he was at home?”
D. “We will try all other alternatives before using physical restraints.”
D. “We will try all other alternatives before using physical restraints.”
41
When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient’s gown bunched around the patient’s chest and the patient asking for help. What would the NAP do?
A. Check the patient’s blood pressure and pulse before smoothing the gown
B. Untie the restraint and smooth the patient’s gown
C. Put on the call light for help
D. Ask the patient what specific help she would like
B. Untie the restraint and smooth the patient’s gown
42
What will the nurse instruct nursing assistive personnel (NAP) to do when measuring a patient’s rectal temperature using an electronic thermometer?
A. Place the patient in the Fowler’s position.
B. Wear sterile gloves during the process.
C. Insert the probe in the direction of the knees.
D. Use the probe with the red tip.
D. Use the probe with the red tip.
43
Which of the following is contraindicated with taking a rectal temperature measurement?
A. Patient requires assistance to move to a side-lying position.
B. Patient has painful and swollen hemorrhoids.
C. Patient is incontinent of urine.
D. The last temperature recorded was 0.2° F above baseline.
B. Patient has painful and swollen hemorrhoids.
44
Which nursing action best evaluates the effectiveness of an antipyretic medication in a patient with an oral temperature of 101.6° F?
A. Assess for physical aches.
B. Assess skin temperature by touching the forehead.
C. Assess oral temperature 30 minutes after the agent is administered.
D. Assess skin color for signs of fever-related flushing.
C. Assess oral temperature 30 minutes after the agent is administered.
45
Which instruction might the nurse give to nursing assistive personal (NAP) that is applicable only to tympanic temperature assessment?
A. Leave the probe in place until the reading is complete.
B. Put on a new disposable probe cover for each patient.
C. Gently tug the pinna backward, up, and out before inserting the probe.
D. Check for any impacted cerumen in the ear.
C. Gently tug the pinna backward, up, and out before inserting the probe.
46
Which instruction might the nurse give to nursing assistive personnel (NAP) that is applicable only to temporal artery temperature assessment?
A. An accurate temperature reading is obtained with moisture on the forehead.
B. Put on a disposable sensor cover before taking the temporal artery temperature.
C. Place the sensor flush on the patient’s forehead.
D. Obtain the temperature reading on the lower neck.
C. Place the sensor flush on the patient’s forehead.
47
PERIPHERAL PULSE SITES
TEMPORAL, CAROTID, APICAL, BRACHIAL, RADIAL, ULNAR, FEMORAL, POPLITEAL, POSTERIOR TIBIAL, DORSALIS PEDIS
48
EMERGENCY PULSE SITES
femoral or carotid pulses
49
What is the primary purpose of initially assessing an apical pulse?
A. Assessment of the patient’s cardiac function
B. Establishment of a baseline as part of the patient’s vital signs
C. Assessment of the patient’s risk for cardiovascular disease
D. Determination of oxygen saturation
B. Establishment of a baseline as part of the patient’s vital signs
50
What instruction should the nurse give nursing assistive personnel (NAP) regarding the appropriate technique when measuring the adult patient’s apical pulse?
A. Document the patient’s pulse rate and rhythm.
B. Place the patient in the right lateral position before measuring the apical pulse.
C. Review the patient’s previous apical pulse measurements.
D. Place your stethoscope at the fifth intercostal space over the left midclavicular line.
D. Place your stethoscope at the fifth intercostal space over the left midclavicular line.
51
Which action would take priority if a patient’s apical pulse has an irregular rhythm?
A. Reassess the pulse for 1 full minute.
B. Assess the patient’s peripheral pulses.
C. Wait 5 minutes, and then reassess the apical pulse.
D. Review documentation regarding an irregular rhythm.
A. Reassess the pulse for 1 full minute.
52
Which statement demonstrates an understanding of the importance of communicating changes in the patient’s apical pulse rate?
A. “The patient’s apical pulse is recorded as you asked.”
B. “The apical pulse is more difficult to hear when the patient is sitting up.”
C. “The apical pulse is usually slower in the morning than it is in the afternoon.”
D. “The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom.”
D. “The apical pulse increased from 78 to 110, but the patient had just returned from the bathroom.”
53
The nurse can best determine the effect of crying on a patient’s apical pulse by doing what?
A. Measuring the patient’s apical pulse before and after crying
B. Assessing the patient’s apical pulse 30 minutes after crying
C. Measuring the patient’s pulse deficit after crying
D. Comparing the patient’s post-crying apical pulse rate with her baseline or previous rate
D. Comparing the patient’s post-crying apical pulse rate with her baseline or previous rate
54
What is the major health problem resulting from a pulse deficit?
A. Bradycardia
B. Activity intolerance
C. Decreased cardiac output
D. Impaired tissue perfusion
C. Decreased cardiac output
55
What should the nurse do when a pulse deficit is suspected?
A. Measure the radial pulse for 1 minute, and then measure the apical pulse for 1 minute.
B. Measure the radial pulse for 30 seconds, and then measure the apical pulse for 30 seconds.
C. Measure the radial pulse for 1 minute, wait 5 minutes, and then measure the apical pulse for 1 minute.
D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.
D. Ask another health care provider to count the radial pulse while the nurse counts the apical pulse.
56
Which action should the nurse perform after identifying a pulse deficit?
A. Reassess the apical-radial pulse in 5 minutes.
B. Assess the patient for signs of decreased cardiac output.
C. Notify the primary health care provider of the pulse deficit.
D. Initiate interventions directed toward managing the patient’s symptoms.
B. Assess the patient for signs of decreased cardiac output.
57
Which of the following is an early manifestation of decreased cardiac output?
A. Fatigue
B. Substernal pain
C. Nail bed cyanosis
D. Shortness of breath
A. Fatigue
58
Which action can the nurse take to keep a patient from consciously controlling his or her breathing during an assessment?
A. Take the patient’s temperature while counting the respiratory rate.
B. Assess respiration after measuring the pulse.
C. Assess respiration after taking the blood pressure.
D. Assess respiration before measuring the blood pressure.
B. Assess respiration after measuring the pulse.
59
On the last assessment of a patient’s respiration, her respiratory rate was 10 breaths per minute. What should the nurse do when conducting the next assessment of this patient’s respiratory rate?
A. Count breaths for 10 seconds and multiply by 6.
B. Count breaths for 15 seconds and multiply by 4
C. Count breaths for 30 seconds and multiply by 2.
D. Count breaths for 60 seconds.
D. Count breaths for 60 seconds.
60
When measuring a patient’s respiratory rate, the nurse will count the number of completed respiratory cycles per minute. What is the definition of a respiratory cycle?
A. The number of inspirations per minute.
B. The number of expirations per minute.
C. The number of sighs per minute.
D. The number of inspirations and expirations per minute.
D. The number of inspirations and expirations per minute.
61
During the assessment of a patient’s respiratory rate, when the second hand reaches the 15-second mark, the respiratory count is 8. What should the nurse do at this time?
A. Stop the assessment.
B. Stop the assessment, and multiply the number 8 by 2.
C. Stop the assessment, and multiply the number 8 by 6.
D. Continue to count the patient’s breaths for a full 60 seconds.
D. Continue to count the patient’s breaths for a full 60 seconds.
62
he nurse plans to assess a patient’s respiratory rate; however, the patient has just returned from ambulating to the bathroom. What should the nurse do to minimize the effect of exercise on the patient’s respiratory rate?
A. Assess the pulse for a full 60 seconds before assessing respiration.
B. Encourage the patient to rest for 10 minutes before assessing respiration.
C. Compare the postexercise respiratory rate with his baseline findings.
D. Compare the postexercise findings with the previous at-rest findings.
B. Encourage the patient to rest for 10 minutes before assessing respiration.
63
Normal Adult Vitals
* Temperature 36.0-38.0
* Pulse 60-100 beats/min
* Respirations 12-20 /min
64
The nurse is planning to measure a patient’s blood pressure. What does the systolic measurement represent?
A. Minimal pressure on the arterial walls.
B. The pressure exerted against the arterial wall.
C. The change in pressure from a lying to a sitting position.
D. The last sound heard when measuring the blood pressure.
B. The pressure exerted against the arterial wall.
65
You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. You notice that the NAP’s last three patients have had unusually low blood pressure that you have had to confirm. What is the most likely reason the NAP is obtaining falsely low blood pressure readings?
A. The blood pressure cuff is too wide for arm circumference.
B. The bladder was deflated too slowly.
C. The patient’s arm was not supported while the measurement was taken.
D. The blood pressure cuff was not wrapped evenly around the arm.
A. The blood pressure cuff is too wide for arm circumference.
66
What should the nurse do if the patient’s blood pressure is not within normal limits?
A. Review the blood pressure readings in the patient’s record.
B. Assess for proper cuff size and arm positioning.
C. Promptly report the assessment data to the nurse in charge or to the health care provider.
D. Encourage the patient to rest quietly in bed for 30 minutes, and then retake the blood pressure.
C. Promptly report the assessment data to the nurse in charge or to the health care provider.
67
What would the nurse do to prevent the spread of infection when assessing a patient’s blood pressure?
A. Wear gloves.
B. Avoid using an arm in which an intravenous catheter has been inserted.
C. Clean the stethoscope with alcohol before and after using it.
D. Inflate the cuff 30 mm higher than the expected systolic pressure.
C. Clean the stethoscope with alcohol before and after using it.
68
You have assigned a new nursing assistive personnel (NAP) to take routine vital signs. An experienced NAP has been asked to retake a blood pressure that the newly hired NAP has taken three times this week. As the nurse, what action do you take?
A. Do not delegate vital signs to the NAP.
B. Delegate only temperature and respiratory rate to the NAP.
C. Report the NAP to your supervisor.
D. Observe the NAP as he or she obtains a blood pressure and pulse on a patient.
D. Observe the NAP as he or she obtains a blood pressure and pulse on a patient.
69
The nurse is preparing to assess a patient’s blood pressure. What would cause the blood pressure reading to be inaccurately high?
A. Blood pressure cuff is too wide
B. Blood pressure cuff is too loose around the arm
C. Taking the blood pressure in an arm into which intravenous fluids are infusing
D. Arm is positioned above the level of the heart
B. Blood pressure cuff is too loose around the arm
70
What would cause the nurse to delay the assessment of a patient’s blood pressure?
A. Patient is resting in bed, reading a book
B. Patient received medication within the last 10 minutes
C. Patient is visiting with family
D. Patient has just finished having a cigarette
D. Patient has just finished having a cigarette
71
The nurse has just measured a patient’s blood pressure and is waiting 2 minutes to measure the pressure again. What is the purpose of taking two measurements?
A. Minimize the effect of anxiety
B. Distract the patient
C. Listen for the second and third Korotkoff sounds
D. Confirm that the cuff was applied correctly
A. Minimize the effect of anxiety
72
The nurse is teaching a patient about ways to reduce blood pressure. What will the nurse include in these instructions?
A. Follow your regular healthy diet.
B. Limit physical activity.
C. Ensure an adequate daily intake of sodium and fat.
D. Ensure that your diet has an adequate daily intake of calcium.
D. Ensure that your diet has an adequate daily intake of calcium.
73
Where should the nurse measure the blood pressure of a patient recovering from a left-sided mastectomy?
A. Use the left arm to take the blood pressure.
B. Use the right arm to take the blood pressure.
C. Do not take the blood pressure.
D. Use a lower extremity to take the blood pressure.
B. Use the right arm to take the blood pressure.
74
Which of the following is a risk factor for decreased oxygen saturation level in a patient?
A. Chest wall injury
B. Restlessness
C. Hypotension
D. Prescribed bronchodilators
A. Chest wall injury
75
What should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient’s oxygen saturation level?
A. “Do not use the fingers if her nails are polished.”
B. “I’ve checked her capillary refill, and it’s acceptable in both her hands and feet.”
C. “Please review the patient’s previously documented pulse oximetry readings for the site used.”
D. “Ask the patient to keep her finger motionless while you are monitoring her oxygen saturation.”
B. “I’ve checked her capillary refill, and it’s acceptable in both her hands and feet.”
76
The nurse measures a patient’s oxygen saturation level as being 83%. What would the nurse do first?
A. Reassess the oxygen saturation in a different location.
B. Promptly report the assessment data to the charge nurse.
C. Encourage the patient to rest quietly in bed for 30 minutes.
D. Ask the patient whether he or she is having trouble breathing.
D. Ask the patient whether he or she is having trouble breathing.
77
The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement?
A. Place the sensor on the ear.
B. Place the sensor on the bridge of the nose.
C. Place the sensor on a finger.
D. Use a disposable tape-on sensor.
D. Use a disposable tape-on sensor.
78
A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits?
A. Low of 85% and high of 100%
B. Low of 80% and high of 100%
C. Low of 75% and high of 90%
D. Low of 82% and high of 95%
A. Low of 85% and high of 100%
79
Which instruction would the nurse give when asking nursing assistive personnel (NAP) to give a complete bed bath to a patient?
A. Do not massage any reddened areas on the patient's skin.
B. Be sure to wash the patient's face with soap.
C. Disconnect the intravenous tubing when changing the gown.
D. Wear gloves if necessary.
A. Do not massage any reddened areas on the patient's skin.
80
The nurse has washed a patient’s arms. Which area should the nurse wash next?
A. Hands
B. Chest
C. Abdomen
D. Legs
A. Hands
81
A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient's safety?
A. Use the call light to ask someone else to bring a washcloth.
B. Raise all four side rails on the patient’s bed.
C. Make sure the call light is within the patient’s reach.
D. Raise the bed to its highest position.
C. Make sure the call light is within the patient’s reach.
82
Which patient should not have his or her feet soaked during a complete bed bath?
A. A patient with arthritis
B. A patient who has just complained of shoulder pain
C. A patient with diabetes mellitus
D. A patient who is nauseated
C. A patient with diabetes mellitus
83
The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient's eyes?
A. Remove eye crusts with soapy water.
B. Avoid closing the patient's eyes.
C. Use eye patches or shields taped in place.
D. Tape the patient's eyelids closed.
C. Use eye patches or shields taped in place.
84
Which nursing action reduces the risk of falling as a patient is getting into or out of a bathtub?
A. Add 1 oz of bath oil to the tub water before the patient gets into the tub.
B. Place an "Occupied" sign on the bathroom door.
C. Fill the tub half full of water at 110°F to 115°F.
D. Place a skidproof disposable bath mat in front of the tub.
D. Place a skidproof disposable bath mat in front of the tub.
85
A patient with left-sided muscle weakness is prescribed a bath every other day. Which precaution would help the nurse reduce this patient's risk of falling?
A. Maintain the water temperature at 104°F.
B. Allow the patient to remain in the bath for 45 minutes.
C. Decline the patient's request to add scented oil to the bathwater.
D. Discuss the patient's level of fatigue after the bath.
C
86
The nurse has just helped a patient into the bathtub. Before leaving the bathroom, what would the nurse do to help ensure the patient's safety?
A. Show him how to use the call signal.
B. Place an "Occupied" sign on the door.
C. Check the cleanliness of the room.
D. Remove unneeded supplies from the bathroom.
A. Show him how to use the call signal.
87
The nurse is assisting a patient with a tub bath. After the patient has been safely positioned in the tub, he tells the nurse, "I'll call you when I’m done." What is the nurse's best response?
A. "All right. Just holler when you're ready, and I'll come and help you get out of the tub."
B. "Well, I'll check back with you in about 5 minutes to see if you need anything."
C. "That's not safe. I'll wait right outside the door for you to finish."
D. "I'll be back in 15 minutes. That should be enough time for you to finish up."
B
88
The nurse is helping a patient get out of a bathtub, and the patient appears to be unsteady on her feet. What should the nurse do to help ensure the patient's safety?
A. Drape a bath towel over the patient's shoulders.
B. Demonstrate how to use the call light for assistance.
C. Drain the bathtub before the patient gets out.
D. Apply lotion to the patient's freshly dried skin.
C. Drain the bathtub before the patient gets out.
89
The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?
A. "I'll ask for assistance if I need help positioning her."
B. "I'll see if she's up to the care right now."
C. "I'll let you know if I notice any signs of redness or discharge."
D. "I'll be sure to use hot, soapy water, since she has been incontinent."
D. "I'll be sure to use hot, soapy water, since she has been incontinent."
90
The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?
A. Supine
B. Prone
C. Side-lying
D. Dorsal recumbent
D. Dorsal recumbent
91
As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?
A. Provide all the necessary supplies and linen for this task.
B. Assess the patient's ability to perform proper perineal care.
C. Ensure that the patient has privacy while performing perineal care.
D. Document any complaints of irritation or pain in the perineal area.
B. Assess the patient's ability to perform proper perineal care.
92
How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?
A. By avoiding the application of tension on the catheter.
B. By patting, not rubbing, the skin dry after thoroughly rinsing it.
C. By cleansing the patient's labia from the pubic area toward the rectum.
D. By using warm water to cleanse the patient's entire perineal area.
C. By cleansing the patient's labia from the pubic area toward the rectum.
93
The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care?
A. Wear sterile gloves.
B. Wear clean gloves.
C. Wear an isolation gown.
D. Use hot water.
B. Wear clean gloves.
94
Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?
A. Wear clean gloves during care.
B. Assess the patient's ability to provide self-care.
C. Encourage the patient to report any pain originating from the catheter.
D. Monitor the amount of urine in the drainage bag to prevent overflow.
A. Wear clean gloves during care.
95
The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up?
A. Assisting the patient into the supine position in bed.
B. Cleansing the tip of the penis with a circular motion, starting at the meatus.
C. Reserving the cleansing of the tip of the penis as the final step in perineal care.
D. Using a gloved hand to grasp the shaft of the penis in order to retract the foreskin.
C. Reserving the cleansing of the tip of the penis as the final step in perineal care.
96
A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response?
A. "When did you start experiencing the pain?"
B. "Rate the pain on a scale of 1 to 10."
C. "I'll assess your perineal area for the possible cause of the pain."
D. "Would you like some pain medication before I continue with your care?"
A. "When did you start experiencing the pain?"
97
The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up?
A. "I will check to see if he cleans himself well."
B. "I will let you know if I see any redness or drainage."
C. "I will ask him if he is experiencing any pain in that area."
D. "I will be sure to use hot, soapy water to be sure he's clean."
D. "I will be sure to use hot, soapy water to be sure he's clean."
98
What is the primary reason for performing perineal care on a male patient with incontinence?
A. To provide comfort and a relaxed, refreshed feeling
B. To promote personal hygiene while minimizing perineal odor
C. To remove all microorganisms from the patient's perineal area
D. To reduce the risk of skin breakdown in the patient's genital and perineal area
D. To reduce the risk of skin breakdown in the patient's genital and perineal area
99
For which patient would the nurse most likely ask for a podiatrist consult for nail care?
A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot.
B. A middle-aged man with mobility impairment that has lasted several weeks after a fall from a ladder.
C. An older adult woman with dementia who has broken her pelvis after falling on the kitchen floor.
D. A 12-year-old girl with a broken foot.
A. A middle-aged man with type 2 diabetes mellitus who feels tingling in his right foot.
100
Why would the nurse plan to perform foot care for a patient with peripheral vascular disease (PVD), rather than delegate this activity to nursing assistive personnel (NAP)?
A. The patient prefers that the nurse provide the care.
B. NAP are not trained to perform foot care.
C. The patient’s elevated risk of infection makes it unsafe for NAP to perform the care.
D. The patient’s condition requires that he remain on bed rest.
C. The patient’s elevated risk of infection makes it unsafe for NAP to perform the care.
101
Which action would the nurse encourage an older adult with foot problems to take at home?
A. Apply oval pads to treat corns.
B. Wear socks made of natural fibers.
C. Carefully shave off calluses with a razor blade.
D. If a bandage is needed, apply gauze squares with adhesive tape.
B. Wear socks made of natural fibers.
102
In providing foot care, the nurse would soak the feet and hands of which patient?
A. A 30-year-old man with type 1 diabetes.
B. An 86-year-old woman with generalized weakness.
C. A 56-year-old patient with vascular insufficiency who was bathed the day before.
D. A 56-year-old patient with vascular insufficiency who was not bathed the day before.
B. An 86-year-old woman with generalized weakness.
103
A patient with diabetes remarks during foot care that she has been letting her skin air-dry after bathing at home because her doctor told her to use plenty of moisturizer on her hands and feet. What should the nurse teach the patient?
A. To apply moisturizer after air-drying thoroughly
B. To apply moisturizer while the skin is still wet
C. To skip the moisturizer
D. To towel-dry thoroughly before applying moisturizer
D. To towel-dry thoroughly before applying moisturizer
104
When preparing to assist a patient with hair care, why does the nurse first check the patient’s scalp for inflammation?
A. To determine what type of shampoo to use
B. To plan enough time to perform hair care
C. To determine if the patient can perform the care independently
D. To ensure that the care can be performed without injuring the scalp
D
105
What is the primary reason the nurse encourages the patient to participate in hair care?
A. To free up the staff’s time for patient care
B. To make sure the care is performed according to the patient’s preferences
C. To encourage the patient’s sense of independence
D. To allow the nurse to evaluate the patient’s ability to manipulate objects
C
106
What is the purpose of parting the patient’s hair into sections?
A. To identify the areas to be groomed
B. To style the hair attractively
C. To check for pediculosis (head lice)
D. To make brushing and combing more effective
A
107
For which of the following patients would it be necessary to use a disposable shampoo cap, rather than a shampoo board?
A. An older adult woman with a drainage tube in place following a mastectomy.
B. An older adult man with a history of bleeding problems.
C. A young woman whose arm and leg have been immobilized on the right side following a car accident.
D. A young man who has sustained a fracture of the upper spine in a football game.
D
108
Which action should be avoided when providing hair care for a bed-bound patient with a history of dizziness?
A. Raising the patient quickly into a sitting position after completing a bed shampoo.
B. Getting water into the patient’s ears during the rinsing phase of the shampoo.
C. Placing the neck in a hyperextended position during the shampoo process.
D. Having the entire shampooing process last longer than 15 minutes.
C
109
When preparing to help a male patient shave, why does the nurse first review the patient’s medical history?
A. To determine the patient’s risk of bleeding
B. To see how often he prefers to shave
C. To learn which is his dominant hand
D. To determine whether he can perform the task himself
A
110
Why would the nurse encourage a male patient to use an electric razor for shaving?
A. To reduce the use of hospital supplies
B. To reduce the risk of infection
C. To reduce the risk of bleeding from a disposable razor
D. To encourage him to shave himself
C
111
Which action is most important in minimizing the patient’s risk for injury when preparing to shave a patient with a history of bleeding?
A. Fully explain the process to the patient in order to secure his cooperation.
B. Pay particular attention to technique in order to avoid nicks and cuts.
C. Ensure that the provider has ordered the intervention.
D. Review current platelet count and anticoagulation studies.
D
112
Why would the nurse instruct nursing assistive personnel (NAP) to hand the patient a mirror before trimming his moustache and beard?
A. To distract him so that he will stay still
B. To allow him to point out which areas he would like to have trimmed
C. To promote his sense of independence
D. To keep his hands away from his face
B
113
What is the best way for the nurse to ensure that the patient is comfortable while he is being shaved?
A. Administer a prescribed analgesic 30 minutes before beginning the procedure.
B. Gently pull the skin taut in order to avoid nicks and cuts.
C. Ask the patient if he is comfortable several times during the procedure.
D. Encourage the patient to shave himself if he is capable of doing so.
C
114
The nurse would not offer back massage to which of the following patients?
A. Patient with abdominal pain
B. Patient who has a controlled-release transdermal analgesic patch
C. Patient who receives peritoneal dialysis for renal failure
D. Patient who is receiving continuous epidural analgesia
D
115
A patient with difficulty breathing requests a back massage. In which position would the nurse instruct nursing assistive personnel (NAP) to place the patient during the massage?
A. Prone
B. Side-lying
C. Supine
D. Fowler's
B
116
After performing back massage for a patient experiencing pain, what is the primary reason the nurse asks her to rate her current pain level on a scale of 1 to 10?
A. To determine how soon the next massage should be offered
B. To evaluate the effectiveness of the massage in relieving pain
C. To determine if it is time to give the patient another dose of analgesic medication
D. To help gauge the patient's level of consciousness
B
117
The nurse delegates a patient's back massage to nursing assistive personnel (NAP). Which statement by the NAP requires the nurse to follow up?
A. "She likes that special lotion her daughter brought. I'll see if she wants me to use it."
B. "The muscles of her lower back twitch when I start to rub it, but they calm down if I keep massaging her."
C. "She's been complaining of soreness in her shoulders. I'll give them special attention."
D. "The family usually visits about now. I'll check and see if she wants to wait until later."
B
118
When preparing to delegate a patient's back massage to nursing assistive personnel (NAP), the nurse would do what first?
A. Observe the NAP performing the skill
B. Determine if the NAP has enough muscle endurance to give a complete back massage
C. Assess the NAP's understanding of the proper technique for back massage
D. Have the NAP determine whether the patient is interested in a back massage
C
119
When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what?
A. Assessing the patient’s gag reflex
B. Inspecting the patient’s oral cavity
C. Placing the bed in a flat position
D. Connecting the suction equipment
A
120
What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided?
A. To make the oral cavity easily accessible
B. To prevent possible musculoskeletal injury
C. To reduce plaque buildup in the mouth
D. To reduce the risk of aspiration
D
121
The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient’s mouth?
A. Upside down, or with the curve facing up
B. Right side up, or with the curve facing down
C. With the curve angled toward the patient’s left cheek
D. With the curve angled toward the patient’s right cheek
A
122
When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line?
A. To give the nurse a firm grip on the brush handle
B. To ensure that the bristles reach all tooth surfaces
C. To allow the bristles to reach beneath the gum line
D. To reduce pressure on sensitive oral tissues
C
123
What must the nurse avoid when brushing the tongue of an unconscious patient?
A. Dislodging bacteria
B. Stimulating the gag reflex
C. Moistening the oral mucosa
D. Using suction
B
124
Which patient is least at risk for dysphagia?
A. A 22-year-old patient with a traumatic brain injury (TBI) sustained during combat.
B. A 40-year-old woman undergoing stroke rehabilitation who had been smoking and taking oral contraceptives.
C. A 76-year-old patient with dementia.
D. A 55-year-old patient with pancreatic cancer who is receiving palliative care.
c
125
What is the most effective way of preventing aspiration?
A. Observe the patient closely for coughing, gagging, choking, and voice alteration.
B. Monitor oxygen saturation with pulse oximetry.
C. Put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist (SLP).
D. Watch for subtle signs that aspiration may have occurred, such as lack of speech, depressed alertness, wet quality to the voice, difficulty controlling secretions, and absence of a gag reflex.
c
126
Which action will the nurse perform first when preparing to change a patient’s urostomy pouching system?
A. Apply clean gloves.
B. Drape the patient appropriately.
C. Position absorbent padding beneath the patient.
D. Apply sterile gloves.
A
127
What is the nurse’s initial action when preparing to change a patient’s colostomy pouching system?
A. Applying clean gloves
B. Draping the patient appropriately
C. Emptying the colostomy
D. Assessing the surrounding skin for signs of irritation
A
128
When pouching a patient’s colostomy, which action reduces the patient’s risk for injury?
A. Measuring output when emptying the contents of the pouch
B. Maintaining the patient’s bowel elimination function
C. Promoting the patient’s autonomy with bowel elimination care
D. Protecting the skin from irritation caused by fecal drainage
D
129
When changing the pouching system, which routine step best minimizes irritation of the skin surrounding the stoma?
A. Using adhesive remover
B. Emptying the ostomy bag only when full
C. Avoiding unnecessary changes of the pouching system
D. Wearing clean gloves
B
130
Which initial nursing action would best help the patient learn self-care of a colostomy pouching system?
A. Giving the patient handouts on self care of a colostomy
B. Allowing the patient to examine an ostomy device
C. Identifying a family member who can participate in the ostomy appliance process
D. Giving the patient a handheld mirror to watch the nurse provide care
D
131
Which instruction might the nurse give to nursing assistive personnel (NAP) regarding the care of a patient with a newly established colostomy?
A. “Be sure to pat-dry the skin surrounding the stoma before applying the new pouch.”
B. “Alert me immediately if you see any blood in the fecal matter in the pouch.”
C. “Using the stoma guide, cut the pouch opening about one-eighth of an inch bigger than the stoma.”
D. “Remember to change your gloves after cleaning the stoma and the surrounding skin.”
B
132
A male patient on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping him to a standing position?
A. Determine his risk for orthostatic hypotension
B. Assess his genitals for signs of impaired skin integrity
C. Ask him to demonstrate proper use of a urinal
D. Instruct him to use the call light when he is finished
A
133
The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response?
A. “All right, my name is Robin, and I’ll be right across the hall. Just call me when you’re finished.”
B. “Fine. Recap the urinal, hang it on your side rail, and use your call light to let me know you’re finished.”
C. “I'll check on you as soon as I get a chance.”
D. “I'll be back in 15 minutes. That should be enough time for you to finish up.”
B
134
Which action promotes infection control when assisting a patient with a urinal?
A. Placing a clean urinal on the overbed table
B. Using a waterproof pad to protect the linen from urine spillage
C. Applying gloves before emptying and cleaning the patient’s urinal
D. Asking if the patient would like to clean the genitals after using the urinal
c
135
What is the most effective way to prevent infection when providing catheter care for a patient?
A. Properly dispose of soiled linen.
B. Perform hand hygiene before positioning the patient.
C. Secure the catheter to the patient’s leg or abdomen.
D. Cleanse from the meatus outward.
D
136
While performing catheter care, the nurse moves her hand, allowing the patient’s labia to close around the catheter. Why would the nurse repeat this part of the care?
A. The catheter may have traumatized the labia.
B. The labia have contaminated the area.
C. The patient’s perineal area must be reassessed for infection.
D. The nurse must ensure that the catheter is not pulling on the bladder.
B
137
. All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one?
A. History of fecal incontinence
B. Use of an indwelling urinary catheter
C. Drainage tubing is kinked
D. Use of plain soap instead of an antiseptic cleanser for perineal hygiene
D
138
The nurse has delegated measurement of a patient’s vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately?
A. Rectal temperature of 99.6° F
B. Pulse rate of 88 beats per minute
C. Redness noted on the external urethral meatus
D. 200 mL of pale yellow urine in the drainage bag
C
139
What is the primary reason the nurse ensures that a patient’s indwelling urinary catheter drainage tubing is free of kinks?
A. Kinks in the tubing cause the patient unnecessary discomfort.
B. Kinks allow the drainage bag to become overly full.
C. Kinks are associated with the development of urinary tract infection (UTI).
D. Kinks result in scant, dark amber-colored urine.
C
140
When preparing to apply a condom catheter/external catheter, the nurse would do what first?
A. Close the door and draw the bedside curtain
B. Obtain the patient’s written informed consent
C. Clamp the drainage tubing
D. Offer the patient a urinal
A
141
Which instruction might the nurse give to nursing assistive personnel (NAP) about applying a condom catheter on a patient?
A. “Check for breaks in the skin before applying the catheter.”
B. “Determine whether the patient is still having problems with incontinence before you put the catheter on him.”
C. “Read the manufacturer’s instructions for applying the adhesive to secure the condom.”
D. “Be sure to get a snug fit between the tip of the penis and the end of the condom catheter.”
C
142
Which instruction would the nurse give to nursing assistive personnel (NAP) to ensure the patient’s comfort when a condom catheter is applied?
A. Wash the penis before applying the catheter.
B. Clip the drainage bag to the bed.
C. Wear gloves when applying the condom catheter.
D. Use a hair guard before applying the condom catheter.
D
143
Why would the nurse ensure that a patient’s condom catheter is not twisted?
A. To prevent the catheter from coming off
B. To make sure the catheter is the correct size
C. To ensure an adequate hourly urine output from the kidneys
D. To prevent an allergic response
A
144
What would the nurse do for a patient who is complaining of penile pain 15 minutes after having a condom catheter/external catheter applied?
A. Offer an anti-inflammatory medication.
B. Drop the level of the urine drainage bag.
C. Remove the catheter.
D. Ensure that the catheter is not twisted.
C
145
The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse’s follow-up?
A. “Do you still need a stool sample for the lab?”
B. “If I can get someone to help, I’ll walk her to the bathroom.”
C. “The patient reports that moving is uncomfortable for her. Has she had pain medication recently?”
D. “The patient told me that she’s had problems with hemorrhoids in the past.”
B
146
A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient’s safety?
A. Close the bedside curtain.
B. Raise the side rail on the side opposite that on which the nurse is working.
C. Obtain help to place the patient on the bedpan.
D. Raise the bed to a comfortable working height.
C
147
A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient’s safety?
A. Respond promptly to the call light.
B. Raise the side rails on the bed before leaving the room.
C. Slide one hand under the patient’s sacrum to help the patient lift off the bedpan.
D. Check in on the patient every 5 minutes until the bedpan can be removed.
B
148
The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan?
A. Raise the knee gatch.
B. Offer a dose of the patient’s prescribed oral pain medication.
C. Evaluate the patient’s ability to move in bed.
D. Elevate the head of the bed to between 30 and 60 degrees.
D
149
After assisting with a bedpan, the nurse notes that the patient’s stool is streaked with bright-red blood. What would the nurse do first?
A. Notify the patient’s health care provider.
B. Ask if the patient has a history of hemorrhoids.
C. Check the medical record to see if the patient has a history of blood in the stool.
D. Document the observation in the medical record, indicating a need for follow-up.
B
150
Which patient is most at risk of developing permanently impaired mobility?
A. A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease)
B. A 55-year-old woman with mental illness who had become malnourished
C. An 11-year-old boy who sustained a fractured pelvis during a fall from his tree house
D. A 79-year-old man recovering from surgery to release a contracture of the connective tissue in his hand
A
151
The nurse is performing passive shoulder and elbow exercises for a patient who is recovering from surgery to remove a soft-tissue tumor in her upper arm. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises?
A. To keep the arm above the level of the heart
B. To assess the patient's muscle tension
C. To listen for crepitus in the joint
D. To ensure stability while exercising the joint
D
152
The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action?
A. Move the joint through the full range of motion exercises.
B. Perform range of motion to the left elbow until resistance is met.
C. Omit all the range of motion exercises until the health care provider is notified.
D. Inform the health care provider that the patient is uncooperative with exercising.
B
153
Which of the following are basic guidelines when assisting a patient with passive range of motion?
A. Exercises should be continued until the point of fatigue and pain.
B. Exercises should be done frequently to lessen pain for the patient.
C. Each joint is exercised to the point of resistance but not pain.
D. Exercises should be performed without the support to each joint.
C
154
Why would the nurse ask a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash?
A. The patient is an older adult or has a chronic condition.
B. The patient is reluctant to perform the exercises because he is worried about reinjury.
C. The patient has orthopedic trauma.
D. The patient has pain exacerbated by exercise.
C
