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NSG 3130 EXAM 2 (GALEN) NEWEST 2026 ACTUAL
EXAM| NSG3130 FUNDAMENTAL CONCEPTS &
SKILLS FOR NURSING PRACTICE II EXAM 2 REVIEW
WITH 300 REAL EXAM QUESTIONS AND CORRECT
DETAILED ANSWERES (VERIFIED ANSWERS)
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Written instructions showing pictures of the steps necessary to test blood glucose, along with demonstration and a return demonstration of the steps, would most benefit which learners? a. Affective b. VARK c. Psychomotor d. Cognitive - Correct Answer - c. Psychomotor Psychomotor learning involves physical movement and the use of motor skills such as demonstration and return demonstration. The affective domain involves emotion, and the cognitive domain is memorization and recall. VARK (verbal, aural, read/write, kinesthetic) refers to a method of assessing learning style. A patient has hemiplegia as a result of a brain attack (cerebrovascular accident). Which complication of immobility is a concern to the nurse? a. Contractures b. Dehydration c. Incontinence d. Hypertension - Correct Answer - a. Contractures
The nurse raises a patient's arm forward and upward over the head during range-of-motion exercises. Which word should the nurse use when documenting exactly what was done during this range-of-motion exercise? a. Hyperextension b. Opposition c. Supination d. Flexion - Correct Answer - d. Flexion Which area of the central nervous system has most likely sustained damage if a patient exhibits a lack of coordination and an unsteady gait after a traumatic head injury? a. Medulla oblongata b. Articular disk c. Brainstem d. Cerebellum - Correct Answer - d. Cerebellum Injury to the cerebellum directly affects a patient's ability to ambulate and control movement. The medulla oblongata regulates heart rate, breathing, blood pressure, and reflexive actions (such as vomiting). The articular disk is fibrous connective tissue in the temporomandibular joint, which facilitates jaw movement. The brainstem connects the spinal cord to the hemispheres of the brain. Which cue during an admission assessment of a patient transferred from a long-term care facility does the nurse recognize as the result of immobility? a. Bilateral elbow contractures b. Increased muscle tone
b. Lower extremity circulatory status c. Circumoral cyanosis d. Altered bowel sounds - Correct Answer - b. The nurse must document the date and time of initiating SCD placement and the results of a skin, circulatory, and neurologic assessment of the lower extremities. SCDs do not affect the upper extremities, cardiac or respiratory status leading to circumoral cyanosis, or altered bowel sounds. The nurse recommends follow up auditory testing for a child who was exposed in utero to: A. Rubella. B. Excessive oxygen. C. Alcohol. D. Respiratory infection. - Correct Answer - A. Rubella. The nurse is working with older adult patients in an extended care facility. To enhance the patient's gustatory sense, the nurse should: A. Mix foods together. B. Assist with oral hygiene. C. Make sure foods are extremely spicy. D. Provide foods of similar texture and consistency. - Correct Answer - B. Assist with oral hygiene. The nurse has completed the admission assessment for a patient admitted to the hospitals subacute care unit. Of the following nursing diagnosis identified by the nurse, which takes the highest priority?
a. Isolation from social activity. b. Potential for injury. c. Inability to manage adjustment. d. Ineffective verbal communication. - Correct Answer - b. Potential for injury. The nurse recognizes the stages of sleep and knows that a patient is most easily aroused in which stage? a. NREM 1. b. NREM 2. c. NREM 3. d. NREM 4. - Correct Answer - a. NREM 1. Which of the following is an antidepressant medication that be be prescribed to promote sleep? a. Elavil. b. Haldol. c. Versed. d. Benadryl. - Correct Answer - a. Elavil. An occupational health nurse is going to provide a workshop to employees on basic body mechanics. In planning the presentation and preparing the materials, what information would be most helpful for the nurse to obtain in advance of the presentation? a. Specific ages of all the employees b. Names of the employees
A home safety measure specific for a patient with diminished olfaction is the use of: a. Extra lighting in hallways. b. Amplified telephone receivers. c. Smoke detectors on all levels. d. Mild water heater temperatures. - Correct Answer - c. Smoke detectors on all levels. When teaching an older adult patient, the nurse should incorporate which teaching strategy into the plan? a. Keep the teaching sessions short. b. Teach in the later evening. c. Include as many concepts as possible. d. Focus on teaching the family members. - Correct Answer - a. Keep the teaching sessions short. Which of the following statements by the patient indicates that he may not be ready to learn at this time? a. "I'll call and make an appointment with the physical therapist for follow-up on the exercises." b. "I want to know more about the side effects of the medications." c. "There's no sense in talking about this now. I don't feel very well." d. "Let me know if I am doing this dressing the right way." - Correct Answer - c. "There's no sense in talking about this now. I don't feel very well."
Which one of the following examples is an evaluation of cognitive learning? The patient: a. explains the use of the incentive spirometer. b. looks at the site of the amputation. c. uses the crutches to go up and down the stairs. d. completes hygienic care independently - Correct Answer - a. explains the use of the incentive spirometer. In the affective domain of learning, the patient exhibits the ability to do which of the following? a. Perform self-catheterization b. Provide information on dialysis c. Return-demonstrate blood pressure measurement d. Verbalize feelings about how to manage arthritis pain - Correct Answer - d. Verbalize feelings about how to manage arthritis pain To promote a patient's cognitive learning, the nurse decides to use which teaching strategy? a. Demonstrating a procedure b. Modeling appropriate ways to interact c. Showing a DVD about the disease process
or magazines?" "What language is spoken at home?", and "Would you read this paragraph for me?" b. In planning teaching sessions, you will want to have written information in the patient's language and photos or drawings. There may also be a need for an interpreter. Family members who will be involved with the patient's care should be included in the teaching, if the patient approves. c. In addition to asking the patient to explain the procedure, you will want the patient to demonstrate their ability to do the colostomy care (psychomotor learning). Again, an interpreter may be necessary to assist in evaluating the patient's cognitive learning. An uncooperative 70-year-old male with right-sided paralysis from a recent cerebrovascular accident (CVA) has to be transferred from the bed to a wheelchair. Which action indicates the best method to transfer this patient? a. A two-person lift is performed, with one person on each side of the patient. b. The patient is steadied under the arms and pivoted on his left leg. c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP). d. A stand assist lift is used with the help of another nurse. - Correct Answer - c. A full-body sling lift is used with the help of unlicensed assistive personnel (UAP). According to safe patient handling algorithms, a full-body sling with more than one caregiver is indicated because the patient is uncooperative and able to bear only partial weight. Lifting a patient manually has the potential to injure the patient and the care providers. The stand-and-pivot
technique is not indicated because the patient is uncooperative. The stand assist lift is not indicated because the patient is uncooperative. After instruction, which action by a patient who can bear weight on both feet indicates an understanding of the proper use of crutches? a. Adjusting the crutches so that they rest directly under the axilla b. Moving the opposing crutch and leg together for a two-point crutch walk c. Using a four-point crutch walk when not weight bearing on the left leg d. Placing the crutches 12 inches forward and then swinging both legs forward - Correct Answer - b. Moving the opposing crutch and leg together for a two-point crutch walk Moving the opposing crutch and leg together provides needed stability for patients who can bear partial weight on each foot. Crutches must rest at minimum of two to three finger widths below the axilla to prevent brachial nerve damage. The patient can bear weight on both legs. Crutches should be advanced no more than 6 to 8 inches, and the swing- to gait is not appropriate for this patient. What bony prominences are at greatest risk for skin breakdown on a patient who is restricted to bed rest and placed in the side-lying position? (Select all that apply.) a. Sternum b. Ears c. Elbows
a. Early ambulation after surgery b. Administering calcium with vitamin D c. Coughing and deep breathing exercises d. Referring the patient to occupational therapy - Correct Answer - a. Early ambulation after surgery Ambulation is the most effective intervention to promote maintenance of muscle tone and prevent flaccidity. Calcium with vitamin D helps prevent osteoporosis. Coughing and deep breathing are important for the prevention of pneumonia associated with immobility, and occupational therapy is typically ordered to help patients regain their ability to complete activities of daily living (ADLs) independently. Identify all nursing interventions that are necessary when caring for a quadriplegic patient injured 2 years earlier in a motor vehicle accident. (Select all that apply.) a. Monitoring respiratory status and breathing difficulties b. Assisting with feeding and activities of daily living (ADLs) c. Developing a care plan with the patient's power of attorney d. Using mechanical lifts to assist with transferring the patient e. Placing a gait belt around the patient's waist before ambulation - Correct Answer - a, b, d Quadriplegia is the result of a high spinal cord injury that affects a patient's ability to breathe without mechanical assistance and severely limits the patient's ability to move all extremities. Most quadriplegics are
confined to a wheelchair and unable to ambulate even with assistance. Mechanical lifts should be used to safely transfer this patient. Quadriplegic patients should be given the opportunity to direct their care and fully participate in setting care plan goals. The patient is being discharged to home after being evaluated for meniere disease and episodes of dizziness. Which one of the following statements alerts the nurse that further reinforcement is necessary for safety? A. "I'll be careful in the morning when I first get out of bed". B. "It will be good to get back to my job on the train". C. "I have a small bench that I can use when I'm taking a shower". D. "I'm going to be changing to brighter lightbulbs in the hallway". B. "It will be good to get back to my job on the train". Spasticity - Correct Answer - Increased muscle tone Quadriplegia - Correct Answer - Inability to move all four extremities Necrosis - Correct Answer - Death of cells, tissues, or organs Gait - Correct Answer - Manner of walking Ischemia - Correct Answer - Reduced blood flow
- Genetic disorders (e.g., muscular dystrophy); muscle weakness and gradual muscle wasting, difficulty with maintaining posture and impairing mobility. b. Neurological
- Damage to the cerebrum or cerebellum of the brain and spinal cord injury; directly affects ability to ambulate and control movement.
- Cerebrovascular accidents (CVAs or strokes) and traumatic brain injuries; hemiparesis, hemiplegia
- Spinal cord injury; lower and/or upper-body paralysis, difficulty with breathing. c. Cardiopulmonary
- Compromised cardiac function, decreased tissue perfusion, and diminished respiratory capacity; affect ability to perform activities of daily living (ADLs) and exercise.
- Congestive heart failure (CHF), peripheral vascular disease, and chronic obstructive pulmonary disease (COPD); decrease ability to deliver oxygen and nutrients to body organs and tissues, diminished capacity for exercise. Which assessment questions will help the nurse determine if a patient is experiencing difficulty with mobility? - Correct Answer - Assessment questions may include:
- Are you experiencing any stiffness, joint discomfort, or pain with movement?
- Have you noticed any difficulty with dizziness or balance?
- Do you become short of breath or easily fatigued when completing your activities of daily living?
- How is your appetite? What is your typical dietary intake in a day?
- What is the frequency of your bowel movements?
- Describe your normal sleep pattern.
- Do you exercise? Identify at least two of the complications associated with immobility in the following body systems and nursing interventions to eliminate or reduce their occurrence: a. Musculoskeletal— b. Cardiopulmonary— c. Gastrointestinal— d. Integumentary— - Correct Answer - a. Musculoskeletal: weakness, decreased muscle tone, de-creased bone (disuse osteoporosis) and muscle mass, potential muscle atrophy, contractures (foot drop) Nursing Interventions: Range of motion, exercise, ambulation Foot board, trochanter roll, hand rolls Turning, positioning Calcium supplements, as indicated b. Cardiopulmonary: atelectasis, orthostatic hypotension, in-creased cardiac work-load, decreased lung capacity, circulatory stasis (DVT) Nursing Interventions: Deep breathing and coughing, incentive spirometer Gradual position changes Exercise, fluids (within any restriction) Antiembolism hose (stockings), sequential compression device (SCD) c. Gastrointestinal: decreased peristalsis: indigestion, anorexia, constipation, distention, impaction
b. Never lift more than 75 pounds independently. c. Push rather than pull patients or objects. d. Bend from the waist when lifting. e. Keep patients or objects close to the body to minimize reach. f. Keep the feet apart to provide a stable base. - Correct Answer - c, e, f What can the nurse do to prevent friction against the immobile patient's skin? - Correct Answer - Reducing friction includes slightly lifting rather than pulling patients, using a trapeze bar, transfer/slide board, or friction-reducing sheets. The patient may also benefit from the use of heel and elbow protectors. For range of motion: a. How many times daily is it usually performed? b. How many times should the joints be put through their motion? - Correct Answer - a. Range of motion is usually performed twice daily. b. Each joint is moved 3 to 5 times. When using a mechanical lift, which of the following techniques are appropriate? Select all that apply. a. Use the device only in life-threatening situations. b. A safety algorithm should be used to determine the assistance required.
c. Determine the operational status before using. d. Check the manufacturer's weight limit for the device before using. e. Use a transfer chair for confused or uncooperative patients. f. Instruct the patient in how the device will work. - Correct Answer - b, c, d, e, f A patient who is immobilized can suffer psychosocial effects. What can the nurse do to prevent or reduce this problem? - Correct Answer - The nurse can include patients in the decision making for their care, encourage visits from family and friends, spend time with the patient, explain procedures, institute reality orientation (clocks, calendars), and have books, TV, and pictures available in the environment. What products are available to prevent friction to the feet and legs? - Correct Answer - Products that are available for heel and lower leg skin protection include the following: Protectors of cloth-covered foam, foam, or sheepskin and can be tubular or shaped like boots. Special AFOs called pressure-relief ankle-foot orthotic (PRAFO) boots can be used to prevent pressure on the heels. A rigid aluminum frame lined in sheepskin is applied to the lower leg and foot using Velcro straps. PRAFO boots have the added benefit of keep-ing the ankle and foot in proper alignment What are two recommendations and goals for log-rolling a patient with a halo brace - Correct Answer - For logrolling, a Safe Patient Handling and Mobility algorithm is recommended to determine the number of personnel needed, and the use of a mechanical or assistive device should be determined. The goals are to pre-vent injury to the patient and nurse(s), maintain the patient's body alignment, and keep all tubes, etc., intact.
