Question 1

The nurse instructs a patient in a wheelchair that the risk for pressure ulcers can be diminished if the patient will:

Accepted Answer

A)  Use a ring pillow on the seat of the chair. 
B)  Lift the weight of the body using the arms of the wheelchair every 15 minutes. 
C)  Scoot forward and back in the seat to stimulate circulation. 
D)  Wear underwear that holds moisture close to skin. 
A)  Use a ring pillow on the seat of the chair. 
B)  Lift the weight of the body using the arms of the wheelchair every 15 minutes. 
C)  Scoot forward and back in the seat to stimulate circulation. 
D)  Wear underwear that holds moisture close to skin.

Question 2

A patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer.She asks the nurse how a pressure ulcer could occur after only 2 days of immobility.The nurse's response is based on her knowledge that:

Accepted Answer

A)  "Erythema can occur in 1 to 2 hours, even in a person with healthy skin and adequate circulation." 
B)  "It takes several days for a pressure ulcer to form." 
C)  "The pressure ulcer probably occurred when you fell." 
D)  "The cause of pressure ulcers isn't really known." 
A)  "Erythema can occur in 1 to 2 hours, even in a person with healthy skin and adequate circulation." 
B)  "It takes several days for a pressure ulcer to form." 
C)  "The pressure ulcer probably occurred when you fell." 
D)  "The cause of pressure ulcers isn't really known."

Question 3

To prevent respiratory complications resulting from immobility,the best nursing interventions would be to:

Accepted Answer

A)  Suction every 4 to 6 hours. 
B)  Administer pain medications as frequently as possible. 
C)  Teach the patient the technique of pursed lip breathing. 
D)  Reposition the patient, and encourage him or her to cough and deep-breathe at least every 2 hours. 
A)  Suction every 4 to 6 hours. 
B)  Administer pain medications as frequently as possible. 
C)  Teach the patient the technique of pursed lip breathing. 
D)  Reposition the patient, and encourage him or her to cough and deep-breathe at least every 2 hours.

Question 4

The nurse assesses a patient's risk for developing a pressure ulcer using the Norton scale.The patient's score is 18.The nurse should:

Accepted Answer

A)  Call the physician immediately. 
B)  Implement a pressure ulcer prevention program. 
C)  Document the score. 
D)  Order an alternating air mattress. 
A)  Call the physician immediately. 
B)  Implement a pressure ulcer prevention program. 
C)  Document the score. 
D)  Order an alternating air mattress.

Question 5

The nurse is instructing a patient relative to the characteristics of a stage I pressure ulcer,which are: (Select all that apply.)

Accepted Answer

A)  The area is regular and well-defined. 
B)  Tissue hardening is present. 
C)  Swelling has occurred at the site. 
D)  The condition is reversible. 
E)  Nonblanching erythema is observed. 
A)  The area is regular and well-defined. 
B)  Tissue hardening is present. 
C)  Swelling has occurred at the site. 
D)  The condition is reversible. 
E)  Nonblanching erythema is observed.

Question 6

When planning the care of a patient who is immobile,the nurse should remember that the patient will be at risk for urinary tract infection because the:

Accepted Answer

A)  Urine will pool in the bladder when the patient remains in a supine position. 
B)  Patient is likely to have urinary incontinence. 
C)  Patient's appetite may be decreased. 
D)  Patient may not be able to move quickly enough to get to the bathroom. 
A)  Urine will pool in the bladder when the patient remains in a supine position. 
B)  Patient is likely to have urinary incontinence. 
C)  Patient's appetite may be decreased. 
D)  Patient may not be able to move quickly enough to get to the bathroom.

Question 7

When the nurse's assessment reveals an area of erythema on an immobilized patient's sacrum,the first step should be to:

Accepted Answer

A)  Apply a wet-to-dry dressing. 
B)  Massage the reddened area. 
C)  Reposition the patient. 
D)  Rub the area with alcohol. 
A)  Apply a wet-to-dry dressing. 
B)  Massage the reddened area. 
C)  Reposition the patient. 
D)  Rub the area with alcohol.

Question 8

The nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer.The nurse understands that the purpose of this type of dressing is to:

Accepted Answer

A)  Keep the wound moist. 
B)  Prevent infection. 
C)  Débride necrotic tissue. 
D)  Increase circulation to the tissue. 
A)  Keep the wound moist. 
B)  Prevent infection. 
C)  Débride necrotic tissue. 
D)  Increase circulation to the tissue.

Question 9

The patient complains that his "bottom" is sore.The nurse assesses the area and finds an open area on the sacrum that appears blistered.The nurse should:

Accepted Answer

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. 
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.

Question 10

During the skin integrity assessment,the nurse notices an area on the right heel that is black and draining purulent,foul-smelling exudate.The nurse should document this as a pressure ulcer in:

Accepted Answer

A)  Stage I 
B)  Stage II 
C)  Stage III 
D)  Stage IV 
A)  Stage I 
B)  Stage II 
C)  Stage III 
D)  Stage IV

Question 11

The nursing assistant is bathing a patient who has a stage I pressure ulcer on the right shoulder.The nurse reminds the nursing assistant that the tissue could become more damaged if she:

Accepted Answer

A)  Positions the patient on the left side. 
B)  Massages the reddened area. 
C)  Cleans the area with mild soap and water. 
D)  Positions the patient in a prone position. 
A)  Positions the patient on the left side. 
B)  Massages the reddened area. 
C)  Cleans the area with mild soap and water. 
D)  Positions the patient in a prone position.

Question 12

When preparing a plan care for an older adult patient,the nurse should consider the common problems associated with immobility.These problems may be classified as:

Accepted Answer

A)  Environmental and intellectual 
B)  Internal and external 
C)  Mental and medical 
D)  Physical and psychosocial 
A)  Environmental and intellectual 
B)  Internal and external 
C)  Mental and medical 
D)  Physical and psychosocial

Question 13

When a bacteria is localized at the site of a Stage III pressure ulcer,it is said to be_____________.

Accepted Answer

Colonized
Colonized

Exam 21: Immobility

The nurse instructs a patient in a wheelchair that the risk for pressure ulcers can be diminished if the patient will:

A patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer.She asks the nurse how a pressure ulcer could occur after only 2 days of immobility.The nurse's response is based on her knowledge that:

To prevent respiratory complications resulting from immobility,the best nursing interventions would be to:

The nurse assesses a patient's risk for developing a pressure ulcer using the Norton scale.The patient's score is 18.The nurse should:

The nurse is instructing a patient relative to the characteristics of a stage I pressure ulcer,which are: (Select all that apply.)

When planning the care of a patient who is immobile,the nurse should remember that the patient will be at risk for urinary tract infection because the:

When the nurse's assessment reveals an area of erythema on an immobilized patient's sacrum,the first step should be to:

The nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer.The nurse understands that the purpose of this type of dressing is to:

The patient complains that his "bottom" is sore.The nurse assesses the area and finds an open area on the sacrum that appears blistered.The nurse should:

During the skin integrity assessment,the nurse notices an area on the right heel that is black and draining purulent,foul-smelling exudate.The nurse should document this as a pressure ulcer in:

The nursing assistant is bathing a patient who has a stage I pressure ulcer on the right shoulder.The nurse reminds the nursing assistant that the tissue could become more damaged if she:

When preparing a plan care for an older adult patient,the nurse should consider the common problems associated with immobility.These problems may be classified as:

When a bacteria is localized at the site of a Stage III pressure ulcer,it is said to be_____________.

The Health Care System

Patient Care Settings

Legal and Ethical Considerations

The Leadership Role of the Licensed Practical Nurse

The Nurse-Patient Relationship

Cultural Aspects of Nursing Care

The Nurse and the Family

Health and Illness

Nutrition

Developmental Processes

The Older Patient

The Nursing Process and Critical Thinking

Inflammation, Infection, and Immunity

Fluids and Electrolytes

Pain Management

First Aid, Emergency Care, and Disaster Management

Surgical Care

Intravenous Therapy

Shock

Falls

Confusion

Incontinence

Loss,Death,and End-of-Life Care

The Patient with Cancer

The Patient with an Ostomy

Neurologic Disorders

Cerebrovascular Accident

Spinal Cord Injury

Acute Respiratory Disorders

Chronic Respiratory Disorders

Hematologic Disorders

Immunologic Disorders

Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome

Cardiac Disorders

Vascular Disorders

Hypertension

Digestive Tract Disorders

Disorders of the Liver, Gallbladder, and Pancreas

Urologic Disorders

Connective Tissue Disorders

Fractures

Amputations

Pituitary and Adrenal Disorders

Thyroid and Parathyroid Disorders

Diabetes Mellitus and Hypoglycemia

Female Reproductive Disorders

Male Reproductive Disorders

Sexually Transmitted Infections

Skin Disorders

Eye and Vision Disorders

Ear and Hearing Disorders

Nose, Sinus, and Throat Disorders

Psychologic Responses to Illness

Psychiatric Disorders

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