A diabetic patient requires foot care. Which statement by the patient indicates a need for further education?

“I will wear loose-fitting shoes at all times.”

A nurse is teaching a patient about active range-of-motion exercises. Which instruction is appropriate?

"Perform these movements to the point of mild discomfort."

What is an example of health promotion?

Teaching a class on stress management

A patient has dry, brittle hair and reports itching. Which intervention is most appropriate?

Recommending the use of medicated shampoos

What is the correct sequence for removing a patient's soiled linens during a bed change?

Hold the soiled linens away from the body

Which of the following is the most appropriate method for documenting a medication error?

Completing an incident report without placing blame

A nurse is providing oral care to an unconscious client. Which intervention is appropriate?

Turning the client’s head to the side

A patient with limited mobility requires frequent repositioning. What is the best explanation for this intervention?

It helps prevent pressure injuries and skin breakdown.

A nurse is preparing to apply restraints. Which condition justifies their use?

Risk of patient harming themselves or others

[Select all that apply]** When implementing an exercise plan for a client with chronic illness, the nurse considers:

The client’s baseline activity level, The client’s nutritional status, The need for frequent rest periods

A nurse is preparing a care plan for a patient with impaired mobility. What is the priority intervention?

Promoting exercises to prevent complications

A fall risk assessment indicates a patient is at high risk for falls. What is the nurse’s first action?

Moving the patient closer to the nurse’s station

A nurse is planning care for a diverse patient population. Which principle demonstrates culturally competent care?

Adapting care to align with cultural preferences

The nurse is providing oral care to an unconscious patient. Which action is correct?

Using a sponge-tipped applicator moistened with water

A nurse is documenting a telephone order received from a physician. Which action ensures the accuracy of the order?

Verifying the order by reading it back to the physician

"What should a nurse do if they see a staff member neglecting hand hygiene before entering a patient's room?"

Privately remind the staff member of the protocol

[Select all that apply] What should the nurse assess when performing perineal care?

Skin integrity, Presence of discharge, Presence of swelling or redness

Which intervention best promotes safety in older adults at home?

Installing grab bars in the bathroom

A patient with limited mobility is at risk for complications. Which intervention is the nurse’s priority?

Performing range-of-motion (ROM) exercises

A patient requires the use of restraints. Which action by the nurse is correct?

Documenting the need for restraints thoroughly

What is the focus of secondary prevention?

Early detection and treatment of disease

A patient with dementia wanders frequently. What is the best alternative to using restraints?

Assigning a sitter to remain with the patient

A nurse is caring for a patient with mobility limitations. What is the first step in planning care?

Assessing the patient’s baseline mobility

How should a nurse handle a cognitively impaired patient who resists hygiene care?

Using a calm and patient approach to encourage cooperation

Select all that apply]** Which interventions help prevent complications of immobility?

Using compression stockings, Encouraging frequent position changes

Which patient is most at risk for the effects of immobility?

A 72-year-old recovering from hip surgery

A patient expresses fear about an upcoming surgery. Which therapeutic response is best?

“It’s normal to feel scared. Can you tell me about your concerns?"

A nurse is assessing a patient’s room for fall risks. Which item poses the greatest danger?

IV tubing draped across the floor

What is the priority action for a nurse assisting a patient who becomes dizzy during ambulation?

Lower the patient to the floor safely

**[Select all that apply]** Effective therapeutic communication includes:

Silence, Active listening, Clarification

A nurse is using standard precautions when caring for a patient. This includes:

Washing hands before and after patient care

**[Select all that apply]** Which complications can arise from prolonged immobility?

Deep vein thrombosis (DVT), Constipation, Pressure injuries

**[Select all that apply]** Risk factor modification involves:

Encouraging small, incremental changes, Providing education on health risks, Assessing the patient's readiness to change

What is the primary goal of the nurse in the healthcare environment?

Ensure client-centered care and positive outcomes

A patient is at risk for injury due to a history of seizures. Which precaution should the nurse take?

Keep padded side rails up at all times

An immobile is prescribed passive range-of-motion exercises. Which statement explains this intervention

"I will move your joints for you to prevent stiffness."

A nurse is assisting a patient with crutch walking. Which instruction is correct?

Move the crutches and affected leg forward together

**[Select all that apply]** Critical thinking in nursing includes:

Gathering relevant information, Considering alternative solutions

Which patient is most at risk for developing pressure injuries?

An older adult who is bedridden

The nurse is changing a patient’s bed linens. Which principle is essential to prevent infection?

Wearing gloves while handling used linens

Which statement demonstrates a nurse’s use of evidence-based practice?

“I implement interventions based on the latest research findings.”

**[Select all that apply]** Proper hand hygiene includes:

Washing hands for at least 20 seconds, Using warm water and soap, . Rubbing hands until they are visibly dry

**[Select all that apply]** Which factors can impair skin integrity?

Immobility, Poor nutrition, Moisture from incontinence, Use of harsh soaps

A patient with diabetes is receiving foot care. What is the nurse's priority?

Avoiding moisturizing between the toes

A patient requires assistance with ambulation using crutches. What is the nurse’s priority action?

Ensuring the crutches are properly sized

Which of the following is an appropriate nursing intervention to prevent DVT in an immobile patient?

Apply sequential compression devices (SCDs)

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Exam 1 Nurse foundations (nurse 105 )

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Questions 80

Answers

1
A diabetic patient requires foot care. Which statement by the patient indicates a need for further education?
“I will avoid soaking my feet in hot water.”
“I will inspect my feet daily for sores.”
“I will wear loose-fitting shoes at all times.”
“I will apply lotion to the tops and bottoms of my feet.”
2
A nurse is teaching a patient about active range-of-motion exercises. Which instruction is appropriate?
"Perform these movements at least once per week."
"I will perform the exercises for you."
"Perform these movements to the point of mild discomfort."
"Avoid performing these exercises if you feel any pain."
3
What is an example of health promotion?
Prescribing antibiotics for an infection
Administering a flu vaccine
Performing a colonoscopy
Teaching a class on stress management
4
What is the most effective method for preventing the spread of infection in healthcare settings?
Using disposable equipment
Administering antibiotics to all patients
Performing proper hand hygiene
Wearing sterile gloves for all procedures
5
A patient has dry, brittle hair and reports itching. Which intervention is most appropriate?
Using harsh detergents to clean the scalp
Applying lotion directly to the hair
Recommending the use of medicated shampoos
Avoiding hair washing for a week
6
The nurse is caring for a patient who has been immobile for several weeks. Which complication is the greatest concern?
Muscle atrophy
Decreased appetite
Impaired social interaction
Orthostatic hypotension
7
What is the correct sequence for removing a patient's soiled linens during a bed change?
Hold the soiled linens away from the body
Place the linens on the floor temporarily
Roll the linens tightly and place in a laundry bag
Shake out the linens to remove debris
8
Which of the following is the most appropriate method for documenting a medication error?
Avoiding mention of the error to prevent legal issues
Making a note of the error in the nurse's personal log
Recording the error in the patient's medical record
Completing an incident report without placing blame
9
A nurse is providing oral care to an unconscious client. Which intervention is appropriate?
Placing the client in a supine position
Turning the client’s head to the side
Using a tongue depressor to open the mouth forcefully
Using an alcohol-based mouthwash
10
A patient with limited mobility requires frequent repositioning. What is the best explanation for this intervention?
It improves respiratory function.
It encourages the patient to regain independence.
It helps prevent pressure injuries and skin breakdown.
It decreases the need for physical therapy.
11
A nurse is preparing to apply restraints. Which condition justifies their use?
Family request for the patient’s safety
Patient’s refusal of treatment
Difficulty managing the patient’s care schedule
Risk of patient harming themselves or others
12
[Select all that apply]** When implementing an exercise plan for a client with chronic illness, the nurse considers:
The client’s desire to compete in sports
The client’s baseline activity level
The client’s nutritional status
The need for frequent rest periods
13
A nurse is preparing a care plan for a patient with impaired mobility. What is the priority intervention?
Providing emotional support for social isolation
Promoting exercises to prevent complications
Encouraging family visits to improve mood
Assisting the patient with meals to ensure nutrition
14
A fall risk assessment indicates a patient is at high risk for falls. What is the nurse’s first action?
Teaching the patient how to use the call bell
Moving the patient closer to the nurse’s station
Removing all assistive devices from the patient’s room
Placing a restraint on the patient
15
Which factor increases the risk of hospital-acquired pressure injuries
Proper use of pressure-relieving devices
Moisture from incontinence
Adequate protein intake
Frequent repositioning
16
A nurse is planning care for a diverse patient population. Which principle demonstrates culturally competent care?
Adapting care to align with cultural preferences
Providing the same care for all clients
Prioritizing the nurse's cultural beliefs
Avoiding discussions about culture
17
The nurse is providing oral care to an unconscious patient. Which action is correct?
Using a sponge-tipped applicator moistened with water
Applying petroleum jelly to the patient’s lips
Inserting a toothbrush deep into the patient’s throat
Placing the patient in a supine position
18
A nurse is documenting a telephone order received from a physician. Which action ensures the accuracy of the order?
Verifying the order by reading it back to the physician
Writing the order immediately after the call ends
Asking the physician to send a written order later
Having another nurse confirm the order after documentation
19
"What should a nurse do if they see a staff member neglecting hand hygiene before entering a patient's room?"
Report the staff member to the supervisor immediately
Privately remind the staff member of the protocol
Perform hand hygiene for the staff member
Ignore the situation to avoid conflict
20
[Select all that apply] What should the nurse assess when performing perineal care?
Skin integrity
Presence of discharge
Presence of swelling or redness
Level of patient independence
21
Which intervention best promotes safety in older adults at home?
Installing grab bars in the bathroom
Encouraging the use of dim lighting at night
Ensuring all rooms are carpeted
Limiting fluid intake to prevent nighttime trips to the bathroom
22
A patient with limited mobility is at risk for complications. Which intervention is the nurse’s priority?
Encouraging daily fluid intake of 1500 mL
Encouraging a high-protein diet
Performing range-of-motion (ROM) exercises
Administering analgesics for pain relief
23
A patient requires the use of restraints. Which action by the nurse is correct?
Leaving the restraints on for 24 hours without reassessment
Documenting the need for restraints thoroughly
Using restraints for staff convenience
Applying restraints as a first-line intervention
24
What is the focus of secondary prevention?
Rehabilitation to restore function
providing pallative care
Preventing the occurrence of illness
Early detection and treatment of disease
25
A patient with dementia wanders frequently. What is the best alternative to using restraints?
Administering sedatives to calm the patient
Allowing the patient unrestricted mobility
Locking the patient’s room to prevent wandering
Assigning a sitter to remain with the patient
26
A nurse is caring for a patient with mobility limitations. What is the first step in planning care?
Identifying the patient’s goals
Selecting interventions to promote mobility
Evaluating the patient’s progress
Assessing the patient’s baseline mobility
27
How should a nurse handle a cognitively impaired patient who resists hygiene care?
Skipping the care until the patient cooperates
Forcing the patient to complete the hygiene tasks
Using a calm and patient approach to encourage cooperation
Delegating the task to an unlicensed staff member
28
Select all that apply]** Which interventions help prevent complications of immobility?
Using compression stockings
Encouraging frequent position changes
Administering pain medications regularly
Increasing the patient’s caloric intake
29
Which patient is most at risk for the effects of immobility?
A 60-year-old undergoing routine health screenings
A 45-year-old with hypertension
A 72-year-old recovering from hip surgery
A 35-year-old with acute bronchitis
30
A patient expresses fear about an upcoming surgery. Which therapeutic response is best?
“There’s nothing to worry about; the surgery is routine.”
“Why are you scared? Have you had a bad experience?”
“Don’t worry, your doctor is very experienced.”
“It’s normal to feel scared. Can you tell me about your concerns?"
31
A nurse is assessing a patient’s room for fall risks. Which item poses the greatest danger?
Non-skid socks on the patient’s feet
IV tubing draped across the floor
Bed in the lowest position
Call light within reach
32
What is the priority action for a nurse assisting a patient who becomes dizzy during ambulation?
Encourage the patient to continue walking
Lower the patient to the floor safely
Quickly return the patient to bed
Call for assistance immediately
33
**[Select all that apply]** Effective therapeutic communication includes:
Silence
Giving personal advice
Active listening
Clarification
34
A nurse is using standard precautions when caring for a patient. This includes:
Using a gown for all patient interactions
Wearing gloves during any patient contact
Placing all patients in isolation rooms
Washing hands before and after patient care
35
**[Select all that apply]** Which complications can arise from prolonged immobility?
Increased joint flexibility
Deep vein thrombosis (DVT)
Constipation
Pressure injuries
36
According to Transtheoretical Model, what stage is a patient in if they want 2 quit smoking but find it too difficult?
Action
Contemplation
Preparation
Maintenance
37
**[Select all that apply]** Risk factor modification involves:
Making decisions without patient input
Encouraging small, incremental changes
Providing education on health risks
Assessing the patient's readiness to change
38
What is the primary reason for providing frequent perineal care to an incontinent patient?
To increase patient comfort
To reduce odors
To maintain patient dignity
To prevent skin breakdown
39
What is the primary goal of the nurse in the healthcare environment?
Avoid delegating tasks
Act as an advocate for physicians
Administer medications as prescribed
Ensure client-centered care and positive outcomes
40
A patient is at risk for injury due to a history of seizures. Which precaution should the nurse take?
Place the patient in a supine position during a seizure
Keep padded side rails up at all times
Insert a tongue blade to prevent biting
Administer seizure medication only during an episode
41
An immobile is prescribed passive range-of-motion exercises. Which statement explains this intervention
"This will prevent pain caused by muscle contractions."
"I will move your joints for you to prevent stiffness."
"This will improve your lung capacity over time."
"These exercises will help you increase your strength."
42
A nurse is assisting a patient with crutch walking. Which instruction is correct?
Lean on the crutches for extended periods to rest
Place crutches slightly behind the body when walking
Always look down while walking
Move the crutches and affected leg forward together
43
**[Select all that apply]** Critical thinking in nursing includes:
Ignoring contradictory evidence
Gathering relevant information
Considering alternative solutions
Making decisions based solely on intuition
44
Which patient is most at risk for developing pressure injuries?
An older adult who is bedridden
A middle-aged patient undergoing chemotherapy
A young adult with a broken leg
A teenager recovering from appendicitis
45
The nurse is changing a patient’s bed linens. Which principle is essential to prevent infection?
Wearing gloves while handling used linens
Placing soiled linens directly on the floor
Reusing linens to conserve resources
Avoiding frequent linen changes
46
Which statement demonstrates a nurse’s use of evidence-based practice?
“I rely on my instincts to determine the best course of action.”
“I only use interventions I’ve personally tried.”
I always follow the policies of my hospital.”
“I implement interventions based on the latest research findings.”
47
**[Select all that apply]** Proper hand hygiene includes:
Washing hands for at least 20 seconds
Using warm water and soap
. Rubbing hands until they are visibly dry
. Using hand sanitizer when hands are visibly soiled
48
**[Select all that apply]** Which factors can impair skin integrity?
Immobility
Poor nutrition
Moisture from incontinence
Use of harsh soaps
49
A patient with diabetes is receiving foot care. What is the nurse's priority?
Avoiding moisturizing between the toes
Clipping toenails straight across
Encouraging the patient to go barefoot at home
Using alcohol to disinfect foot wounds
50
A patient requires assistance with ambulation using crutches. What is the nurse’s priority action?
Evaluating the patient’s arm strength
Teaching the patient how to maintain balance
Ensuring the crutches are properly sized
Assessing the patient’s ability to bear weight
51
Which of the following is an appropriate nursing intervention to prevent DVT in an immobile patient?
Encourage the patient to remain still
Elevate the patient’s legs above heart level
Administer anticoagulants without a physician's order
Apply sequential compression devices (SCDs)
52
A nurse is assisting an older adult with bathing. What is the most important consideration?
Allowing the patient to perform all tasks independently
Completing the bath as quickly as possible
Encouraging the use of hot water to clean thoroughly
Using gentle soaps to avoid skin irritation
53
Which of the following best describes the role of professional nursing in today’s healthcare environment?
Social, political snd economic changes
The physcian's role in healthcare
. Historical nursing practices
advanced nursing education
54
What is the primary purpose of no-lift policies in healthcare settings?
To ensure all patients can ambulate independently
To reduce workplace injuries for staff
To standardize patient care procedures
To improve efficiency in patient transfers
55
**[Select all that apply]** Which nursing interventions can reduce the risk of falls in elderly patients?
Providing assistive devices like walkers
Using side rails as a restraint
Keeping frequently used items within reach
Ensuring adequate lighting in the room
56
A nurse is changing a bed while the patient is in it. What action is essential for infection control?
Keeping soiled linens on the floor temporarily
Avoiding shaking the linens
Wearing Sterile Gloves
Reusing clean-looking linens
57
Which action reduces the risk of a patient developing pneumonia during immobility?
Encouraging deep breathing and coughing exercises
Maintaining a supine position
Using ice packs to reduce inflammation
Providing high-calorie meals
58
**[Select all that apply]** Which factors increase the risk of falls in older adults?
Medication causing dizziness
Poor vision
history of previous falls
Inadequate foot wear
59
Which intervention is tertiary prevention for a client at risk of cardiovascular disease?
Smoking cessation counseling
Rehabilitating after a myocardial infarction
Performing regular blood pressure checks
Prescribing blood pressure medication
60
During a home visit, a nurse finds medications stored with cleaning supplies. What is the best intervention?
Relocate the medications to a safer area
Remove the cleaning supplies from the home
Educate the patient on safe medication storage
Document the finding and take no further action
61
When documenting a verbal order from a physician, the nurse should:
Write the order exactly as given and implement it immediately
Have another nurse verify the order
Record the order without clarification
Repeat the order back to the physician for confirmation
62
What is the most important intervention for preventing falls in older adults?
Restricting ambulation to prevent accidents
Ensuring proper lighting in the room
Restricting ambulation to prevent accidents
Keeping bedrails up at all times
63
**[Select all that apply]** How can nurses maintain patient confidentiality?
Using encrypted communication channels
Logging off computer systems after use
Discussing patient care only in private settings
Avoiding posting patient information on social media
64
Which of the following breaks the chain of infection at the portal of entry?
Using aseptic techniques for wound care
Administering vaccinations
Disposing of soiled linens properly
Placing patients in isolation
65
Which system plays a primary role in regulating activity and exercise?
Musculoskeletal system
Endocrine system
Integumentary system
Cardiovascular system
66
Which intervention is most effective for preventing healthcare-associated infections (HAIs)?
Using hand sanitizer before and after patient care
Replacing all IV lines daily
Administering antibiotics prophylactically
Wearing a mask for all patient interactions
67
The U.S. healthcare system emphasizes which care approach
Home-based care only
Acute Care Services
Preventive care and chronic disease management
Hospital-based care exclusively.
68
Which statement by a nurse demonstrates active listening?
“I understand you are worried about the procedure. Tell me more.”
“I’ll explain later; I need to finish this task.”
“Don’t worry; everything will be fine.”
“Let’s talk about something positive instead.”
69
A patient is on bed rest. What is the primary nursing intervention to prevent deep vein thrombosis (DVT)?
Encouraging ambulation within the room
Massaging the patient’s calves frequently
Using compression devices on the legs
Administering anticoagulant medications
70
Which of the following is an expected physiological change with immobility?
Increased cardiac output
Improved joint flexibility
Decreased respiratory depth
Reduced risk of thrombus formation
71
What is the primary purpose of performing range-of-motion (ROM) exercises?
To reduce cardiovascular workload
To increase strength in immobilized patients
To promote relaxation and sleep
To prevent joint contractures and maintain flexibility
72
A diabetic patient asks why foot care is important. What is the nurse’s best response?
"It promotes healthy nail growth."
"It reduces your risk of developing foot infections."
"It prevents nail fungus from spreading."
"It helps improve circulation to your feet."
73
**[Select all that apply]** Which roles are part of the nurse's professional responsibilities?
legislator
researcher
Educator
Adovate
74
A confused patient attempts to get out of bed unassisted. What is the nurse’s best action?
Assign a sitter to monitor the patient
Turn off bed alarm
Apply physical restraints
Administer a sedative
75
A patient in a long-term care facility has impaired mobility. Which intervention best prevents pressure injuries?
Encouraging the patient to use a heating pad for comfort
Applying moisture barriers to intact skin
Providing a high-protein diet with adequate hydration
Repositioning the patient every 4 hours
76
The nurse observes an electrical hazard in a patient’s room. What is the priority action?
Unplugging the equipment immediately
Continuing to monitor the equipment
Reporting the hazard to the maintenance department
Placing a warning sign near the equipment
77
A patient recovering from a stroke is using a mechanical lift for transfers. The purpose of this equipment is:
To prevent skin breakdown during prolonged immobility
To minimize patient discomfort during transfers
To ensure the safety of both the patient and staff
To prevent skin breakdown during prolonged immobility
78
[Select all that apply] Which factors increase the risk of falls in older adults?
Muscle weakness
History of falls
Use of assistive devices
Poor vision
79
A nurse is preparing to enter the room of a patient on contact precautions. Which PPE is required?
N95 respirator
Gloves only
Surgical mask
Gloves and gown
80
What is the priority intervention for a patient with impaired mobility?
Avoiding passive range-of-motion exercises
Repositioning the patient every 2 hours
Encouraging bedrest to prevent fatigue
Increasing fluid intake to prevent dehydration

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