NURS 341 FINAL EXAM QUESTIONS AND

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NURS 341 FINAL EXAM QUESTIONS AND

ANSWERS LATEST UPDATE COMPLETE

• 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):

• Increased blood pressure
• Decreased heart rate
• Increased urinary output
• Decreased peristalsis - ANSWER>>Decreased peristalsis
• A 61-year-old client recently suffered 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?

• Encourage an even gait when walking in place.
• Assess the extremities for unilateral swelling and muscle atrophy.
• Encourage holding the breath frequently to hyperinflate the client's lungs.
• Teach the use of a two-point crutch technique for ambulation. - ANSWER>>Assess the

extremities for unilateral swelling and muscle atrophy.

• Two nurses are standing on opposite sides of the bed to move the client up in bed with a

drawsheet. Where should the nurses be standing in relation to the client's body as they prepare for the move?

• Even with the thorax
• Even with the shoulders 1 / 4

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• Even with the hips
• Even with the knees - ANSWER>>Even with the shoulders
• A client is leaving for surgery and because of preoperative sedation needs complete assistance

to transfer from the bed to the stretcher. Which of the following should the nurse do first?

• Elevate the head of the bed.
• Explain the procedure to the client.
• Place the client in the prone position.
• Assess the situation for any potentially unsafe complications. - ANSWER>>Assess the

situation for any potentially unsafe complications.

• A client has sequential compression stockings in place. The nurse evaluates that they are

implemented appropriately by the new staff nurse when the:

• Initial measurement is made around the client's calves
• Intermittent pressure is set at 40 mm Hg
• Stockings are wrapped directly over the leg from ankle to knee
• Stockings are removed every hour during application - ANSWER>>Intermittent pressure is

set at 40 mm Hg

• The nurse assesses that the client has torticollis and that this may adversely influence the

client's mobility. This individual has a(n):

• Exaggeration of the lumbar spine curvature
• Increased convexity of the thoracic spine
• Abnormal anteroposterior and lateral curvature of the spine 2 / 4

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• Contracture of the sternocleidomastoid muscle with a head incline - ANSWER>>Contracture

of the sternocleidomastoid muscle with a head incline

• An immobilized client is suspected of having atelectasis. This is assessed by the nurse upon

auscultation as:

• Harsh crackles
• Wheezing on inspiration
• Diminished breath sounds
• Bronchovesicular whooshing - ANSWER>>Diminished breath sounds
• The best approach for the nurse to use to assess the presence of thrombosis in an immobilized

client is to:

• Measure the calf and thigh circumferences
• Attempt to elicit Homans' sign
• Palpate the temperature of the feet
• Observe for a loss of hair and skin turgor in the lower legs - ANSWER>>Measure the calf and

thigh circumferences

• A client is getting up for the first time after a period of bed rest. The nurse should first:
• Assess respiratory function
• Obtain a baseline blood pressure
• Assist the client with sitting at the edge of the bed
• Ask the client if he or she feels light-headed - ANSWER>>Obtain a baseline blood pressure
• To promote respiratory function in the immobilized client, the nurse should: 3 / 4

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• Change the client's position every 4 to 8 hours
• Encourage deep breathing and coughing every hour
• Use oxygen and nebulizer treatments regularly
• Suction the client's secretions every hour - ANSWER>>Encourage deep breathing and

coughing every hour

• Antiembolic stockings (thromboembolic device [TED] hose) are ordered for the client on bed

rest following surgery. The nurse explains to the client that the primary purpose for the TEDs is

to:

• Keep the skin warm and dry
• Prevent abnormal joint flexion
• Apply external pressure
• Prevent bleeding - ANSWER>>Apply external pressure
• To provide for the psychosocial needs of an immobilized client, an appropriate statement by

the nurse is which of the following?

• "The staff will limit your visitors so that you will not be bothered."
• "A roommate can be a real bother. You'd probably rather have a private room."
• "Let's discuss the routine to see if there are any changes we can make."
• "I think you should have your hair done and put on some makeup." - ANSWER>>"Let's

discuss the routine to see if there are any changes we can make."

• To reduce the chance of external hip rotation in a client on prolonged bed rest, the nurse

should implement the use of a:

• Footboard
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