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

Using a calm and patient approach to encourage cooperation

"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

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

Performing range-of-motion (ROM) exercises

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

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

Hold the soiled linens away from the body

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

Wearing gloves while handling used linens

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

Lower the patient to the floor safely

What is the primary purpose of no-lift policies in healthcare settings?

To reduce workplace injuries for staff

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

Move the crutches and affected leg forward together

What is an example of health promotion?

Teaching a class on stress management

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

Adapting care to align with cultural preferences

**[Select all that apply]** How can nurses maintain patient confidentiality?

Logging off computer systems after use, Avoiding posting patient information on social media, Using encrypted communication channels, Discussing patient care only in private settings

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

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

Which patient is most at risk for developing pressure injuries?

An older adult who is bedridden

Which statement by a nurse demonstrates active listening?

“I understand you are worried about the procedure. Tell me more.”

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

Turning the client’s head to the side

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

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

The nurse observes an electrical hazard in a patient’s room. What is the priority action?

Reporting the hazard to the maintenance department

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

Using compression stockings, Encouraging frequent position changes

**[Select all that apply]** Which nursing interventions can reduce the risk of falls in elderly patients?

Providing assistive devices like walkers, Ensuring adequate lighting in the room, Keeping frequently used items within reach

Which intervention best promotes safety in older adults at home?

Installing grab bars in the bathroom

What is the priority intervention for a patient with impaired mobility?

Repositioning the patient every 2 hours

[Select all that apply] Which factors increase the risk of falls in older adults?

Poor vision, Muscle weakness, History of falls

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

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

A patient recovering from a stroke is using a mechanical lift for transfers. The purpose of this equipment is:

To ensure the safety of both the patient and staff

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

Gathering relevant information, Considering alternative solutions

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

Avoiding moisturizing between the toes

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

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

During a home visit, a nurse finds medications stored with cleaning supplies. What is the best intervention?

Educate the patient on safe medication storage

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

Ensure client-centered care and positive outcomes

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

A 72-year-old recovering from hip surgery

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 assisting an older adult with bathing. What is the most important consideration?

Using gentle soaps to avoid skin irritation

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

When documenting a verbal order from a physician, the nurse should:

Repeat the order back to the physician for confirmation

Which of the following breaks the chain of infection at the portal of entry?

Using aseptic techniques for wound care

Which action reduces the risk of a patient developing pneumonia during immobility?

Encouraging deep breathing and coughing exercises

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

Clarification, Active listening, Silence

What is the most important intervention for preventing falls in older adults?

Ensuring proper lighting in the room

The U.S. healthcare system emphasizes which care approach

Preventive care and chronic disease management

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

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

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

What is the primary purpose of performing range-of-motion (ROM) exercises?

To prevent joint contractures and maintain flexibility

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

Apply sequential compression devices (SCDs)

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

Promoting exercises to prevent complications

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

Ensuring the crutches are properly sized

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Exam 1 Nurse foundations (nurse 105 )

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Questions 80

Answers

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

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