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WorksheetsInfection Prevention & Mobility
Total questions: 116
Worksheet time: 3hrs 43mins
Name
Class
Date
1.
A patient says to the nurse, “what is a culture?” What would be the best response by the nurse?
a)
“A culture measures the level of an antibiotic.”
b)
“A culture identifies an antibiotic’s effect on a pathogen.”
c)
“A culture determines the appropriate medication dosage to be used.”
d)
“A culture identifies the presence of disease-causing microorganisms.”
2.
The nurse is reviewing patient care needs with a nursing assistant. Which intervention should the nurse explain as being the most important means of preventing the spread of infection?
a)
gloving
b)
gowning
c)
hand washing
d)
wearing a mask
3.
The nurse wants to ensure that a hospitalized patient with a healthy immune system does not contract an infectious disease. What nursing action should the nurse identify to reduce this patient’s susceptibility to an infection?
a)
Planning adequate nutrition
b)
Daily bathing with soap and water
c)
Assessing vital signs every 4 hours
d)
Admitting the patient to a private room
4.
The nurse is preparing to give a newly prescribed antibiotic to a patient with an infected surgical incision. Which action is essential for the nurse to do before giving the antibiotic?
a)
Perform ordered cultures.
b)
Check the patient’s temperature.
c)
Give the patient something to eat.
d)
Document the wound’s appearance.
5.
The nurse is collecting data from a patient with a systemic infection. Which finding should the nurse expect in this patient?
a)
Warm skin
b)
Skin redness
c)
General malaise
d)
Purulent drainage
6.
The nurse is caring for a patient who has influenza. In which type of transmission-based precaution should the patient be placed?
a)
contact
b)
droplet
c)
airborne
d)
respiratory
7.
A patient requires care that might cause the splattering of body secretions. Which item should the nurse wear when caring for this patient?
a)
cap
b)
gown
c)
face shield
d)
shoe covers
8.
The nurse is contributing to a staff education program about infection control. What information from the following list should the nurse recommend including about methods that are effective in destroying bacterial spores?
a)
Prolonged drying times
b)
Prolonged high temperatures
c)
Cleansing with soap and water
d)
Brief exposure to room temperatures
9.
The nurse is contributing to a staff education program about infection control. Which information should the nurse recommend including as an example of a portal of exit for a pathogen in the chain of infection?
a)
hair
b)
nails
c)
mucous membranes
d)
central nervous system
10.
The nurse is caring for a patient who is immunocompromised. Which action should the nurse take to ensure that the patient does not develop a hospital-acquired infection?
a)
Restrict oral fluids
b)
Apply lotion to dry skin
c)
Provide alcohol-based mouthwash
d)
Massage back with a skin drying agent
11.
The school nurse is planning to teach a group of school-age children on cough etiquette. What should the nurse emphasize with these students?
a)
Sneeze into hands if a tissue is not available.
b)
Place used tissues in back packs or pockets of clothing.
c)
Wash hands with soap and water for 20 seconds after blowing the nose.
d)
Move 1 foot away from another person when having to sneeze or cough.
12.
Which of the following behaviors indicates the highest potential for spreading infections among clients? The nurse:
a)
disinfects dirty hands with antibacterial soap.
b)
allows alcohol-based rub to dry for 10 seconds.
c)
washes hands only when leaving each room.
d)
uses cold water for medical asepsis.
13.
What is the most frequent cause of the spread of infection among institutionalized patients?
a)
Airborne microbes from other patients
b)
Contact with contaminated equipment
c)
Hands of healthcare workers
d)
Exposure from family members
14.
A patient admitted to the hospital with pneumonia has been receiving antibiotics for 2 days. His condition has stabilized, and his temperature has returned to normal. sWhich stage of infection is the patient most likely experiencing?
a)
incubation
b)
prodromal
c)
decline
d)
convalescence
15.
A patient develops localized heat and erythema over an area on the lower leg. These findings are indicative of which secondary defense against infection?
a)
Phagocytosis
b)
Complement cascade
c)
Inflammation
d)
Immunity
16.
A patient asks the nurse why there is no vaccine available for the common cold. Which response by the nurse is correct?
a)
The virus mutates too rapidly to develop a vaccine.
b)
Vaccines are developed only for very serious illnesses.
c)
Researchers are focusing efforts on an HIV vaccine.
d)
The virus for the common cold has not been identified.
17.
A patient who has a temperature of 101°F (38.3°C) most likely requires:
a)
acetaminophen (Tylenol).
b)
increased fluids.
c)
bedrest
d)
tepid baths
18.
To assure effectiveness, when should the nurse stop rubbing antiseptic hand solution over all surfaces of the hands?
a)
When fingers feel sticky
b)
After 5 to 10 seconds
c)
When leaving the client’s room
d)
Once fingers and hands feel dry
19.
The nurse is removing personal protective equipment (PPE). Which item should be removed first?
a)
gown
b)
gloves
c)
face shield
d)
hair covering
20.
The nurse points out that covering the mouth and nose with a tissue for a sneeze will reduce the probability of infection being spread by the _____ route.
a)
droplet
b)
airborne
c)
direct contact
d)
indirect contact
21.
The nurse is providing infection control teaching to a patient. Additional patient teaching is warranted by which patient statement?
a)
“It is important that I get my whooping cough vaccination as directed by my health care provider.”
b)
“Getting plenty of sleep each night will help my immune system.”
c)
“I should wash my hands before preparing my food.”
d)
“It is important that I take my antibiotic until I feel infection free.”
22.
The home health nurse advises the patient to treat a fever of 100° F with:
a)
aspirin
b)
Tylenol
c)
cool baths
d)
nothing at all
23.
The home health nurse is providing dietary recommendations to keep the immune system healthy. The patient demonstrates understanding by increasing which in the diet?
a)
proteins
b)
fluids
c)
carbohydrates
d)
unsaturated fats
24.
The nurse explains that a vaccination provides defense against infection via:
a)
innate immunity.
b)
the inflammatory response.
c)
antibody-mediated immunity.
d)
cell-mediated immunity.
25.
Which of the following best represents an example of infectious disease spreading via a vector?
a)
Being bitten by an infected mosquito
b)
Disease spreading from infected mother to infant via the placenta
c)
A group of partygoers hugging and shaking hands
d)
Two persons, one of whom is infected, sharing a glass of soda
26.
A client is using a primary prevention strategy to prevent infectious disease. Which of the following actions is the client most likely taking?
a)
A client receives a tetanus booster every 10 years.
b)
A client receives a tetanus booster after stepping on a nail.
c)
A client receives tetanus immunoglobulin after stepping on a nail.
d)
A client with tetanus is given antibiotics and is placed on seizure precautions.
27.
Which of the following infectious disease interventions best represents the use of secondary prevention?
a)
Clients with HIV infection are encouraged to use condoms to protect sexual partners.
b)
Clients with HIV infection are given medications to improve immunological response.
c)
Health care workers are encouraged to receive annual vaccinations for influenza.
d)
Health care workers are required to have a tuberculosis skin test or chest x-ray.
28.
A college-aged student has influenza. At what stage of the infection is the student most infectious?
a)
Incubation period
b)
Prodromal stage
c)
Full stage of illness
d)
Convalescent period
29.
The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating a
a)
host
b)
mode of transmission.
c)
portal of entry.
d)
reservoir.
30.
Health personnel should wash their hands with soap and water at the beginning of the shift for:
a)
10 seconds
b)
15 seconds
c)
1 minute
d)
2 minutes
31.
When the nurse performs a procedure using sterile technique in the patient’s unit, it means that:
a)
the equipment and supplies used are disposable and clean.
b)
all organisms have been killed or removed from materials that come in contact with the patient.
c)
the nurse will do a 10-minute surgical scrub before beginning the procedure.
d)
the nurse will be required to don a sterile gown, mask, and eye shields.
32.
A nurse teaching family members about hand hygiene in the home would emphasize:
a)
keeping fingernails short and avoiding wearing rings.
b)
washing hands up to the elbows for 2 minutes the first time in the day, and for 1 minute after a diaper change.
c)
using disposable gloves after hand hygiene when feeding the infant.
d)
that home care requires less attention to medical asepsis, so hand hygiene is necessary only after toileting or handling soiled diapers.
33.
When removing a used face mask, the nurse correctly:
a)
lowers it below his chin to use the next time he enters that patient’s room.
b)
removes the mask first before removing any other PPE.
c)
unties the bottom ties first, then the top, and disposes of the mask without touching it.
d)
discards the mask only if it is wet; otherwise, he folds and stores it to reuse the next time.
34.
The nurse uses the Standard Precautions, as outlined by the Centers for Disease Control and Prevention (CDC), when:
a)
there is a suspicion of or risk of infection.
b)
preventing transmission of respiratory and wound infections.
c)
caring for patients who have wounds draining body fluids.
d)
caring for all patients.
35.
The situation in which protective eyewear is required is:
a)
suctioning a tracheotomy.
b)
applying a dressing on the leg.
c)
changing a baby’s diaper.
d)
gathering the linens off a contaminated bed.
36.
To prevent a urinary infection in an elderly patient who is in traction for a broken femur, the nurse would:
a)
request a Foley catheter to be inserted.
b)
encourage fluid intake to keep urine dilute.
c)
encourage intake of apple juice to keep urine acidic.
d)
offer a urinal every 2 hours.
37.
The nurse explains that the body’s normal flora serve as:
a)
aids to digestion and blood production.
b)
prevention to the colonizing of pathogens.
c)
managers of fluid balance of the body.
d)
cell rebuilders.
38.
The nurse is aware that the first barrier to pathogen invasion is the:
a)
skin
b)
immunizations
c)
good hygiene.
d)
immune response.
39.
A patient with a respiratory infection reports that he is not yet on an antibiotic. The nurse explains that the physician is waiting on the results of the culture and sensitivity. What does this test determine?
a)
What media the bacteria requires to grow
b)
How fast the bacteria grow
c)
Which antibiotics stop bacterial growth
d)
When the bacteria colonize
40.
What additional complication does a disease caused by a virus have compared to a disease caused by bacteria?
a)
Multiplies rapidly
b)
Returns frequently
c)
Is not killed by antibiotics
d)
Is unable to be cultured
41.
The nurse observes a patient demonstrating wound cleaning. What action indicates the need for further instruction?
a)
Using sterile gloves to perform the cleaning
b)
Applying an antiseptic to the area
c)
Cleaning the area from the outside in
d)
Washing hands with soap
42.
When assessing a patient for signs of an infection, the nurse recognizes which laboratory result as indicative of an infection?
a)
Lowered red blood cell count
b)
Increased white blood cell count
c)
Lowered white blood cell count
d)
Increased red blood cell count
43.
Recognizing the stages of an infection assists the nurse in identifying the progression of an infection. What is the nonspecific to specific symptom stage of an infection?
a)
Convalescent
b)
Illness
c)
Prodromal
d)
Incubation
44.
The nurse is providing teaching to elementary students regarding vectors. What example will the nurse provide as an example of a vector?
a)
Child with measles giving it to his sister
b)
Tick whose bite causes Lyme disease
c)
Woman with syphilis infecting her partner
d)
Dog whose bite causes rabies
45.
According to assessment findings, the nurse determines that a client is experiencing an inflammatory process. Which of the following did the nurse assess in this client?
a)
Redness, swelling, heat, and pain
b)
Reduced urine output
c)
Thirst
d)
Elevated blood pressure and slow heart rate
46.
A client is being admitted to a health care facility. Which type of precautions will the nurse implement at this time?
a)
airborne
b)
contact
c)
droplet
d)
standard
47.
The nurse is aware that an antiviral medication is most effective when given during which phase of the infectious process?
a)
Prodromal stage
b)
Incubation period
c)
Full stage of illness
d)
Convalescent period
48.
Which of the following most accurately defines an infection?
a)
An illness resulting from living in an unclean environment
b)
The result of lack of knowledge about food preparation
c)
A disease resulting from pathogens in or on the body
d)
An acute or chronic illness resulting from traumatic injury
49.
A nurse caring for a client who has gas gangrene knows that this infection originated in which of the following reservoirs?
a)
Other people
b)
Food
c)
Soil
d)
Animals
50.
A client with an upper respiratory infection (common cold) tells the nurse, “I am so angry with the nurse practitioner because he would not give me any antibiotics.” What would be the most accurate response by the nurse?
a)
“Antibiotics have no effect on viruses.”
b)
“Let me talk to him and see what we can do.”
c)
“Why do you think you need an antibiotic?”
d)
“I know what you mean; you need an antibiotic.”
51.
A woman tests positive for the human immunodeficiency virus antibody but has no symptoms. She is considered a carrier. What component of the infection cycle does the woman illustrate?
a)
A reservoir
b)
An infectious agent
c)
A portal of exit
d)
A portal of entry
52.
A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called “the kissing disease.” The nurse explains that the organisms causing this disease were transmitted by:
a)
direct contact.
b)
indirect contact.
c)
airborne route.
d)
vectors.
53.
Which of the following questions asked by the nurse when taking a client’s health history would collect data about infection control?
a)
Tell me what you eat in each 24-hour period.
b)
Do you sleep well and wake up feeling healthy?
c)
What were the causes of death for your family members?
d)
When did you complete your immunizations?
54.
A nurse is educating adolescents on how to prevent infections. What statement by one of the adolescents indicates that more education is needed?
a)
“I will wash my hands before and after going to the bathroom.”
b)
“I don’t wear a condom when I have sex, but I know my partners.”
c)
“I always eat fruits and vegetables, and I sleep eight hours a night.”
d)
“When I have an infection, I rest and take my medications.”
55.
The following procedures have been ordered and implemented for a hospitalized client. Which procedure carries the greatest risk for a nosocomial infection?
a)
Enema
b)
Intramuscular injections
c)
Heat lamp
d)
Urinary catheterization
56.
A nursing home recently has had a significant number of nosocomial infections. Which of the following measures might be instituted to decrease this trend?
a)
Mandating antibiotics for all nursing home residents
b)
Have written, infection-prevention practices for all employees
c)
Requiring all employees to have monthly screenings for skin flora
d)
Restricting visitors and community activities for residents
57.
What are the recommended cleansing agents for hand hygiene in any setting when the risk of infection is high?
a)
Liquid or bar hand soap
b)
Cold water
c)
Hot water
d)
Antimicrobial products
58.
What is the correct rationale for using body substance precautions?
a)
The risk of transmitting HIV in sputum and urine is nonexistent.
b)
Disease-specific isolation procedures are adequate protection.
c)
Only actively infected clients are considered contagious.
d)
All body substances are considered potentially infectious.
59.
A nurse is changing the bed linen of a client admitted to the health care facility. Which of the following isolation precautions should the nurse follow?
a)
Standard precautions
b)
Droplet precautions
c)
Contact precautions
d)
Airborne precautions
60.
Which of the following statements about glove use and hand hygiene is true?
a)
Artificial fingernails should not be worn by staff involved in direct client care.
b)
Nonsterile gloves can be decontaminated with alcohol-based hand rub, but must be changed between clients.
c)
Use of alcohol-based hand rubs is appropriate after using the restroom.
d)
The use of sterile gloves reduces the need for hand hygiene.
61.
An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which of the following is an accurate guideline that should be discussed?
a)
The use of gloves eliminates the need for hand hygiene.
b)
The use of hand hygiene eliminates the need for gloves.
c)
Hand hygiene must be performed after contact with inanimate objects near the client.
d)
Hand lotions should not be used after hand hygiene.
62.
The time interval between invasion by an infectious agent and the first appearance of signs and symptoms of the disease is called:
a)
Communicable period
b)
Incubation period
c)
Infectiousness
d)
Pathologic reaction
63.
An example of a vector is:
a)
Contaminated water
b)
A tick
c)
A dirty needle
d)
An infected person
64.
Adoption of universal precautions by health care workers is an example of:
a)
Primary prevention
b)
Secondary prevention
c)
Tertiary prevention
d)
Specific protection
65.
A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. In assessment of the client, the nurse is alert to a(n):
a)
Increased blood pressure
b)
Decreased heart rate
c)
Increased urinary output
d)
Decreased peristalsis
66.
A 61-year-old client recently had left-sided paralysis from a cerebrovascular accident (stroke). In planning care for this client, the nurse implements which one of the following as an appropriate intervention?
a)
Encourage an even gait when walking in place.
b)
Assess the extremities for unilateral swelling and muscle atrophy.
c)
Encourage holding the breath frequently to hyperinflate his lungs.
d)
Teach the use of a two-point crutch technique for ambulation .
67.
Two nurses are standing on opposite sides of the bed to move the client up in bed with a draw sheet. Where should the nurses be standing in relation to the client’s body as they prepare for the move?
a)
Even with the thorax
b)
Even with the shoulders
c)
Even with the hips
d)
Even with the knees
68.
The best approach for the nurse to use to assess the presence of thrombosis in an immobilized client is to:
a)
Measure the calf and thigh diameters
b)
Attempt to elicit Homan’s sign
c)
Palpate the temperature of the feet
d)
Observe for a loss of hair and skin turgor in the lower legs
69.
A client is getting up for the first time after a period of bed rest. The nurse should first:
a)
Assess respiratory function
b)
Obtain a baseline blood pressure
c)
Assist the client to sit at the edge of the bed
d)
Ask the client if he or she feels lightheaded
70.
To promote respiratory function in the immobilized client, the nurse should:
a)
Change the client’s position q4-8h.
b)
Encourage deep breathing and coughing every hour
c)
Use oxygen and nebulizer treatments regularly
d)
Suction the client every hour
71.
To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse should implement the use of a:
a)
footboard
b)
trochanter roll
c)
Trapeze bar
d)
Bed board
72.
To reduce the chance of plantar flexion (foot drop) in a client on prolonged bed rest, the nurse should implement the use of:
a)
Trapeze bars
b)
High-top sneakers
c)
Trochanter rolls
d)
30-degree lateral positioning
73.
The nurse is caring for a patient who had surgery 2 days ago. The nurse correctly recognizes which of the following as having the greatest ability to reduce the incidence of deep vein thrombosis (DVT)?
a)
Early ambulation
b)
Bedrest
c)
Preoperative exercise
d)
Frequent turning in bed in the postoperative period
74.
Which nursing strategy will prevent the dislocation of the hip prosthesis?
a)
Turning on the affected side
b)
Crossing the legs when sitting
c)
Sitting at a 90-degree angle
d)
Maintaining abduction
75.
A young adult woman has had orthopedic surgery on her right knee. The first time she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse correctly recognizes which of the following conditions is likely affecting the patient?
a)
Thrombophlebitis
b)
Anemia
c)
Orthostatic hypotension
d)
Bradycardia
76.
The nurse is caring for a patient who is on strict bed rest. Her medical history includes partial paralysis from a stroke suffered several years ago. There is also evidence of early dementia. The nurse correctly recognizes the patient is at an increased risk for which of the following complications?
a)
Altered gait
b)
Prone to fractures
c)
Suffer from edema
d)
Muscle atrophy
77.
When the patient restricts use of her dominant arm because of pain and the nurse notes that the measurement of the circumference of the patient’s nondominant arm is greater than her dominant arm, the nurse determines that the lack of use has resulted in the dominant arm’s
a)
atrophy
b)
hypertrophy
c)
dystrophy
d)
malrotation
78.
A nurse caring for a patient who has been prescribed bed rest for 1 week notices a reddened area on the patient’s left hip. The skin is intact, but when the nurse presses on the area, the redness does not fade. How should this area of pressure be classified?
a)
Stage I
b)
Stage II
c)
Stage III
d)
Stage IV
79.
A nurse transcribes a discharge order for the patient with left-sided weakness after having a stroke indicating to teach the patient to perform range-of-motion exercises on affected extremities. The patient asks why she needs to do range-of-motion exercises. What is the nurse’s best response?
a)
“Because the physician has ordered it.”
b)
“You will regain full use of your arm and leg if you will do the exercises correctly.”
c)
“They prevent the muscles and tendons from shortening and becoming unmovable.”
d)
“It will give you something to do because you can’t work anymore.”
80.
A patient complains that his “bottom” is sore. The nurse assesses the area and finds an open area on the sacrum that appears blistered. What action should the nurse implement?
a)
Document the cause of the burn.
b)
Clean with alcohol, apply moisturizer, and cover with a set dressing.
c)
Massage the area to promote circulation.
d)
Clean with mild soap, dry, and apply a light dressing.
81.
A nurse is instructing a patient on performing isometric exercises. What instruction should the nurse include?
a)
Contract the muscle for several seconds, then relax the muscle for a few seconds, and contract it again.
b)
Perform full range-of-motion exercises of each joint.
c)
Have a family member perform full range-of-motion exercises on each of the patient’s joints.
d)
Stand in front of a wall and push with the arms without bending the elbow.
82.
A nurse is caring for a 25-year-old male quadriplegic patient. Which of the following treatments would the nurse perform to decrease the risk of joint contracture and promote joint mobility?
a)
Active ROM
b)
Turning the patient every 2 hours
c)
Passive ROM
d)
Administering glucosamine supplements
83.
The nurse explains that range-of-motion exercises are necessary so that movement improves venous circulation by:
a)
vasodilation.
b)
compression of muscles on venous walls.
c)
increased metabolism.
d)
maintaining strength in muscles.
84.
A frail older patient is able to stand but not to ambulate. She has an order to be up in a wheelchair as desired during the day. A safe and appropriate way to assist her up to a chair is to:
a)
use a mechanical lift to transfer her from the bed to a chair.
b)
assist her to stand and pivot to a chair at right angles to the bed, using a transfer belt.
c)
have another staff member help lift her out of bed to the chair on the count of three.
d)
place a chair close to the bed and use a roller board to slide her into it.
85.
A nurse and an assistant are preparing to get a patient out of bed for the first time after a week of bed rest. They begin by having the patient dangle on the edge of the bed. The nurse should:
a)
allow the patient to dangle for 10 to 15 minutes and then transfer her to a nearby chair.
b)
perform passive range-of-motion exercises on the patient’s arms and legs while she is dangling to improve circulation.
c)
assess the patient’s response to the changed position, looking for orthostatic hypotension, nausea, or dizziness before proceeding.
d)
dangle the patient only momentarily and then assist her to ambulate as far as she is able.
86.
A patient in the skilled nursing facility has left-sided paralysis from a stroke several years before, as well as generalized weakness. The nurse should ensure that which of the following devices is in place to prevent flexion contractures?
a)
A trochanter roll to keep her legs from turning outward
b)
A rolled washcloth in the palm of her left hand or a hand splint
c)
A protective vest to keep her sitting upright in the chair
d)
A trapeze to permit her to change her position in bed more easily
87.
While the nurse is assisting a patient to ambulate, the patient suddenly says, “I’m dizzy. I can’t stand up.” As the patient begins to fall, the nurse should:
a)
tell the patient, “Look up, take some deep breaths, and stand up straight. You can do it.”
b)
call for another nurse or aide to get a wheelchair to return the patient to her room via wheelchair.
c)
step behind the patient, grasp her around the waist or chest, and slide her down his leg gently to the floor.
d)
look for the nearest chair and assist the patient to it.
88.
A nurse is instructing one of the facility’s unlicensed assistive personnel (UAPs) regarding body mechanics for moving and lifting. The nurse recognizes that further instruction is warranted when the UAP states, “I will:
a)
lift using my back muscles.”
b)
obtain help whenever possible.”
c)
ask the patient to help if able.”
d)
use a wide base of support.”
89.
A physician orders the nurse to place a patient in Fowler’s position. The nurse should elevate the head of the patient’s bed _____ degrees.
a)
60 to 90
b)
30 to 60
c)
15 to 30
d)
10 to 15
90.
What should the nurse do to reduce the effort of moving a heavy object?
a)
Bring the feet close together and flex the knees
b)
Keep the back straight and bend at the waist
c)
Widen the base of support in the direction of movement
d)
Broaden the base of support and twist toward the direction of movement
91.
Raising the arm of over the head during range-of-motions exercise is called
a)
flexion
b)
abduction
c)
supination
d)
hyperextension
92.
Which is the primary reason why immobilized people develop contractures?
a)
Muscles that flex, adduct, and internally rotate are stronger than weaker opposing muscles
b)
Muscle mass and strength decline at a rate of 5 to 10 percent per week
c)
Muscular contractures occur because of excessive muscle flaccidity
d)
Muscle catabolism exceeds muscle anabolism
93.
Which nursing action is important after transferring a patient to a wheelchair?
a)
Applying a vest restraint with the ties attached to the lower frame behind the seat
b)
Supporting the body so that the hip and knees are at 90 degree angles.
c)
Ensuring the patient is in functional body alignment
d)
Placing the patient in the hall near the nurse's station
94.
Which motion occurs when in the supine position the ankle is bent so that the toes are pointed towards the ceiling?
a)
supination
b)
adduction
c)
dorsal flexion
d)
plantar extension
95.
To best prevent pressure ulcers when a patient is on bed rest, the nurse should:
a)
Place an air mattress on the bed
b)
Massage bony prominences every shift
c)
Apply a moisture barrier to the sacral area
d)
Raise the head of the bed to the low-Fowler's position
96.
Which action occurs when you turn the palm of the hand downward?
a)
External rotation
b)
Circumduction
c)
Lateral flexion
d)
Pronation
97.
When an older adult is afraid of falling, the most common consequence is:
a)
Impaired skin integrity
b)
Occurrence of panic attacks
c)
Self-imposed social isolation
d)
Decreased physical conditioning
98.
When a patient with hemiparesis uses a cane, the nurse needs to teach the patient to:
a)
Advance up a step with the weak leg first followed by the strong leg and cane
b)
Adjust the can height 12 inches lower than the waist
c)
Hold the cane in the strong hand when walking
d)
Look at the feet when walkng
99.
When positioning a patient on the left side, the nurse should position the:
a)
Right leg resting on top of the left leg
b)
Knees in 90 degrees of flexion
c)
Ankles in plantar flexion
d)
Left shoulder protracted
100.
Which causes the MOST concern when a person is in the supine position?
a)
Increased cardiac workload
b)
Urinary tract infection
c)
Venous pooling
d)
Sacral pressure
101.
The presence of which adaptation is most important to assess before administering passive ROM exercises?
a)
weakness
b)
flaccidity
c)
atrophy
d)
pain
102.
An immobilized bedridden patient is placed on a 2-hour turning and positioning program primarily to:
a)
Support comfort
b)
Promote elimination
c)
Maintain skin integrity
d)
Facilitate respiratory function
103.
To best evaluate an ambulating patient's balance, the nurse should assess the patient's:
a)
posture
b)
strength
c)
energy level
d)
respiratory care
104.
Which assessment reflects a defining characteristic that would support the nursing diagnosis Impaired Physical Mobility?
a)
Exertional fatigue
b)
Sedentary lifestyle
c)
Limited Range of Motion
d)
Increased Respiratory Rate
105.
What is the greatest potential problem associated with Low Fowler's position?
a)
Dorsiflexion contractures of the feet
b)
Pressure on the ischial tuberosities
c)
External rotation of the hips
d)
Adduction of the legs
106.
Which action is most effective in relation to the concept "Immobility can lead to occlusion of blood vessels in areas where bony prominences rest on a mattress"?
a)
Encouraging the patient to deep breathe 10 times per hour
b)
Placing a sheepskin pad under the patient's sacrum
c)
Performing range-of motion exercises twice a day
d)
Repositioning the patient every 2 hours
107.
A recommended intervention for a lifestyle stress indicator and reduction in the incidence of heart disease is:
a)
Regular physical exercise.
b)
Attendance at a support group.
c)
Self-awareness skill development.
d)
Time management.
108.
The mother of a school-aged child voices concern to the nurse about her 4-year-old son continuing to wet the bed at night. What information should be provided by the nurse?
a)
“It is very uncommon for a child of this age to have bedwetting issues.”
b)
“Did any of your other children have this problem?”
c)
“While this is distressing it is not completely uncommon but interventions are not normally introduced until age 6.”
d)
“You will need to strictly restrict intake in the afternoon and evenings to prevent this from happening.”
109.
The nurse working in the long-term care facility correctly recognizes that most falls are related to which of the following?
a)
toileting
b)
confusion
c)
Polypharmacy
d)
Impaired sleep patterns
110.
The nurse is caring for a patient who voices concerns about the development of her 8-month-old daughter. Which of the following findings would be a source of concern?
a)
The child is unable to feed herself finger foods.
b)
The child has begun to eat some solid foods.
c)
The child is unable to hold a spoon to attempt self-feeding.
d)
The child has not been introduced to finger foods for self-feeding.
111.
A nurse is assisting a patient with his bed bath. The patient states, “I can do it myself.” The nurse’s best response is
a)
“I really have limited time. Let me give you your bath right now.”
b)
“I will set up your bath for you. I will come back and help you with your back.”
c)
“You will need to sit up for your bath, and then I will change your bed.”
d)
“You will be able to take your bath by yourself tomorrow when you can get up.”
112.
When an adult patient from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should
a)
Understand that his culture may influence his hygiene and ask him his preference
b)
Ask another nurse to assist in giving the patient a complete bath every other day
c)
Give the patient a bath pan and tell him she will return when he has finished
d)
Encourage the patient to bathe daily as part of protection from infection
113.
The nurse is assessing a client’s gustatory function. What approach by the nurse will assist in assessing this sensation?
a)
“Tell me if the taste on your tongue is sweet, sour, bitter, or salty.”
b)
“Repeat the words that I speak softly to you.”
c)
“Please read this paragraph to me.”
d)
“Close your eyes and tell me what you smell.”
114.
A nurse is using a functional focus to assess a person. Which of the following the nurse be evaluating?
a)
Visual acuity
b)
Pupil reactivity
c)
Ability to drive
d)
The red reflex
115.
Which scenario represents a dysfunctional pattern?
a)
Sexually active teenager who does not use condoms
b)
Salesman who sleeps only 5 hours a night
c)
Single mother of three children
d)
Woman with a small extended family
116.
To what are most health problems in young adults related?
a)
stress
b)
smoking
c)
alcohol consumption
d)
fatigue
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