Question 1

Which one of the following actions should the nurse take in order to promote respiratory function in the immobilized patient?

Accepted Answer

A)  Change the patient's position every four to eight hours. 
B)  Encourage deep breathing and coughing every hour. 
C)  Use oxygen and nebulizer treatments regularly. 
D)  Suction the patient every hour.

Question 2

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success.What is the next priority nursing action?

Accepted Answer

A)  Preparing the patient for a second tap water enema 
B)  Donning gloves for digital removal of the stool 
C)  Positioning the patient on the left side 
D)  Inserting a rectal tube

Question 3

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation?

Accepted Answer

A)  Elevate the head of the bed 45 degrees 60 minutes after breakfast. 
B)  Use a mobility device to place the patient on a bedside commode. 
C)  Give the patient a pillow to brace against the abdomen while bearing down. 
D)  Administer a soap suds enema every 2 hours.

Question 4

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days.The nurse would expect which other assessment finding?

Accepted Answer

A)  Hypoactive bowel sounds 
B)  Jaundice in sclera 
C)  Decreased skin turgor 
D)  Soft tender abdomen

Question 5

The nurse assesses that the patient has torticollis and that this may adversely influence the patient's mobility.Which of the following signs does this individual exhibit?

Accepted Answer

A)  Exaggeration of the lumbar spine curvature 
B)  Increased convexity of the thoracic spine 
C)  Abnormal anteroposterior and lateral curvature of the spine 
D)  Contracture of the sternocleidomastoid muscle with a head incline

Question 6

Antiembolism stockings,also known as thromboembolic device (TED)hose,are ordered for the patient on bed rest after surgery.Which of the following does the nurse explain to the patient is the primary purpose for these stockings?

Accepted Answer

A)  To keep the skin warm and dry 
B)  To prevent abnormal joint flexion 
C)  To apply external pressure 
D)  To prevent bleeding

Question 7

A 61-year-old patient recently had left-sided paralysis from a cerebrovascular accident (CVA,stroke).In planning care for this patient,the nurse implements which one of the following as an appropriate intervention?

Accepted Answer

A)  Encouraging an even gait when walking in place 
B)  Assessing the extremities for unilateral swelling and muscle atrophy 
C)  Encouraging holding the breath frequently to hyperinflate the lungs 
D)  Teaching the use of a two-point crutch technique for ambulation

Question 8

Fecal impactions occur in which portion of the colon?

Accepted Answer

A)  Ascending 
B)  Descending 
C)  Transverse 
D)  Rectum

Question 9

A nurse is preparing a patient for a magnetic resonance imaging scan.Which nursing action is most important?

Accepted Answer

A)  Ensuring that the patient does not eat or drink 2 hours before the examination 
B)  Removing all of the patient's metallic jewelry 
C)  Administering a colon cleansing product 12 hours before the examination 
D)  Obtaining an order for a pain medication before the test is performed

Question 10

The nurse is caring for a patient who had a colostomy placed yesterday.The nurse should report which assessment finding immediately?

Accepted Answer

A)  Stoma is protruding from the abdomen. 
B)  Stoma is moist. 
C)  Stool is discharging from the stoma. 
D)  Stoma is purple.

Question 11

Two nurses are standing on opposite sides of the bed to move the patient up in bed with a drawsheet.Which of the following describes the correct position for the nurses to take to safely position the patient?

Accepted Answer

A)  The nurses should face the patient. 
B)  The nurses should face the direction of movement. 
C)  The nurses should face each other. 
D)  The nurses should face opposite the direction of movement.

Question 12

The patient is getting up for the first time after a period of bed rest.Which of the following actions should the nurse take first?

Accepted Answer

A)  Assess respiratory function. 
B)  Obtain a baseline blood pressure. 
C)  Assist the patient to sit at the edge of the bed. 
D)  Ask the patient if he or she feels lightheaded.

Question 13

Which of the following is not a function of the large intestine?

Accepted Answer

A)  Absorbing nutrients 
B)  Absorbing water 
C)  Secreting bicarbonate 
D)  Eliminating waste

Question 14

Which physiological change can cause a paralytic ileus?

Accepted Answer

A)  Chronic cathartic abuse 
B)  Surgery for Crohn's disease and anesthesia 
C)  Suppression of hydrochloric acid from medication 
D)  Fecal impaction

Question 15

Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube?

Accepted Answer

A)  Lubricating the nares with water-soluble lubricant 
B)  Applying a small ice bag to the nose for 5 minutes every 4 hours 
C)  Instilling Xylocaine into the nares once a shift 
D)  Changing the tape holding the tube in place once a shift

Question 16

It has been determined that each one of the following patients is at risk for falling.Which one requires the nurse's priority for ambulation?

Accepted Answer

A)  A 16-year-old with a sprained ankle being discharged from the emergency department 
B)  A 54-year-old who has taken the initial dose of an antihypertensive medication 
C)  A 45-year-old postoperative patient up for the first time since knee surgery 
D)  An 81-year-old who is asthmatic and had a hip replaced 18 months ago

Question 17

A nurse is providing discharge teaching for a patient who is going home with a guaiac test.Which statement by the patient indicates the need for further education?

Accepted Answer

A)  "If I get a positive result, I have gastrointestinal bleeding." 
B)  "I should not eat red meat before my examination." 
C)  "I should schedule to perform the examination when I am not menstruating." 
D)  "I will need to perform this test three times if I have a positive result."

Question 18

The nurse is caring for a patient who is confined to the bed.The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because

Accepted Answer

A)  The digested food needs to make room for recently ingested food. 
B)  Mastication triggers the digestive system to begin peristalsis. 
C)  The smell of bowel elimination in the room would deter the patient from eating. 
D)  More ancillary staff members are available after meal times.

Question 19

A patient had an ileostomy surgically placed 2 days ago.Which diet would the nurse recommend to the patient to ease the transition of the new ostomy?

Accepted Answer

A)  Eggs over easy, whole wheat toast, and orange juice with pulp 
B)  Chicken fried rice with stir fried vegetables and iced tea 
C)  Turkey meatloaf with white rice and apple juice 
D)  Fish sticks with macaroni and cheese and soda

Question 20

Which of the following would the nurse expect to use to maintain the patient's legs in abduction after total hip replacement surgery?

Accepted Answer

A)  Foot boot 
B)  Wedge pillow 
C)  Trochanter roll 
D)  Sandbags

Exam 45: Mobility and Immobility