Move It!
Chapter 38
Question
What assessment tool is commonly used to determine a hospitalized patient's mobility level and the safest level of assistance?
A. Morse Fall Scale
B. BMAT
C. Braden Scale
D. Glasgow Coma Scale
B. BMAT (Bedside Mobility Assessment Tool)
Rationale
The BMAT is a standardized mobility assessment that helps determine whether a patient can safely ambulate independently, requires assistance, or needs a mechanical lift.
Chapter 42
Question
What is considered the BEST indicator of a patient's overall fluid balance?
A. Blood pressure
B. Daily weight
C. Intake and output
D. Heart rate
Answer
B. Daily Weight
Rationale
Daily weight is the most accurate indicator of fluid gain or loss.
One kilogram equals approximately one liter of fluid.
Chapter 42
Question
Which electrolyte imbalance is most associated with life-threatening cardiac dysrhythmias?
A. Sodium
B. Potassium
C. Calcium
D. Magnesium
Answer
B. Potassium
Rationale
Potassium directly affects cardiac electrical conduction.
Both hyperkalemia and hypokalemia may produce lethal dysrhythmias.
Chapter 42
Question
Which two organs primarily regulate acid-base balance?
A. Heart and lungs
B. Liver and kidneys
C. Lungs and kidneys
D. Brain and kidneys
Answer
C
Rationale
The lungs regulate carbon dioxide while the kidneys regulate bicarbonate.
Mixed (Chapters 38 & 42)
Question
A patient reports burning and swelling at the IV site while potassium is infusing.
What is the nurse's FIRST action?
A. Slow the infusion
B. Apply a warm compress
C. Stop the infusion and assess the IV site
D. Notify the provider
Answer
C
Rationale
Potassium is highly irritating to veins.
Burning or swelling may indicate infiltration or phlebitis and requires immediate assessment.
Chapter 38
Question
A postoperative patient is hesitant to get out of bed because they are afraid it will hurt.
What is the nurse's BEST response?
A. "Stay in bed until Physical Therapy arrives."
B. "Walking isn't necessary until tomorrow."
C. "Early mobility helps prevent pneumonia, blood clots, constipation, and muscle weakness."
D. "Just perform ankle pumps instead."
Answer
C
Rationale
Early mobility decreases postoperative complications including atelectasis, pneumonia, venous thromboembolism, constipation, pressure injuries, and muscle deconditioning.
Chapter 42
Question
Which patient is MOST likely experiencing fluid volume excess?
A. Dry mucous membranes
B. Flat neck veins
C. Bilateral crackles with peripheral edema
D. Increased urine output
Answer
C
Rationale
Fluid overload commonly presents with:
Crackles
Edema
Weight gain
Jugular venous distention
Dyspnea
Chapter 42
Question
Which ECG finding is classically associated with hyperkalemia?
A. Flattened T waves
B. Peaked T waves
C. Prolonged QT interval
D. ST depression
Rationale
As potassium increases, T waves become tall and peaked.
Severe hyperkalemia can progress to widened QRS complexes and cardiac arrest.
Chapter 42
Question
A patient begins hyperventilating during a panic attack.
Which acid-base imbalance is MOST likely?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer
B
Rationale
Rapid breathing causes excessive CO₂ loss.
Less carbon dioxide means less acid, increasing the pH.
Mixed (Chapters 38 & 42)
Question
Which hospitalized patient should the nurse assist out of bed FIRST?
A. Patient with cellulitis
B. Postoperative day one abdominal surgery patient
C. Patient waiting for discharge paperwork
D. Patient eating breakfast independently
B
Rationale
Early postoperative ambulation prevents respiratory, cardiovascular, gastrointestinal, and musculoskeletal complications.
📘 Chapter 38
Question
The nurse is caring for four hospitalized patients. Which patient should receive early mobility FIRST?
A. Stable COPD patient receiving 2 L/min oxygen
B. Postoperative patient who has been in bed for 24 hours and has not yet ambulated
C. Patient receiving continuous tube feedings
D. Patient with chronic arthritis awaiting discharge
Answer
B
Rationale
Early postoperative mobility decreases the risk for:
Atelectasis
Pneumonia
Venous thromboembolism
Ileus
Pressure injuries
Muscle deconditioning
📘 Chapter 42
Question
Which patient requires the highest priority assessment?
A. +1 pedal edema
B. Crackles halfway up both lung fields with SpO₂ 88%
C. Complains of thirst
D. Dry lips
Answer
B
Rationale
The patient is experiencing impaired oxygenation from fluid overload.
ABCs always take priority.
📘 Chapter 42
Question
A patient has a potassium level of 2.8 mEq/L.
Which assessment finding would the nurse expect?
A. Peaked T waves
B. Muscle weakness with flattened T waves
C. Hypertension
D. Facial flushing
Rationale
Hypokalemia commonly causes:
Muscle weakness
Fatigue
Constipation
Flattened T waves
U waves
Dysrhythmias
📘 Chapter 42
Question
Interpret these ABGs:
pH 7.30
PaCO₂ 52
HCO₃ 24
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Answer
A
Rationale
The pH is acidic and the CO₂ is elevated, indicating respiratory acidosis.
📘 Mixed (Chapters 38 & 42)
Question
A patient receiving IV potassium reports burning at the IV site.
What should the nurse do FIRST?
A. Silence the infusion pump
B. Stop the infusion and assess the IV site
C. Slow the infusion
D. Notify the provider
Answer
B
Rationale
Burning may indicate infiltration or phlebitis.
Immediate assessment prevents tissue injury.
$400
📘 Chapter 38
Question
Which patient is the BEST candidate for nurse-led ambulation?
A. BP 84/46 with dizziness
B. Post-op day 1 abdominal surgery, pain controlled, stable vital signs
C. Receiving vasopressors for septic shock
D. Active chest pain awaiting cardiac catheterization
Answer
B
Rationale
A stable postoperative patient benefits from early ambulation. Always assess pain, vital signs, dizziness, oxygen needs, and safety before mobilizing.
📘 Chapter 42
Question
A patient with heart failure has:
Weight gain 4 pounds in 2 days
Crackles
2+ edema
BP 162/90
SpO₂ 90%
Which intervention should the nurse perform FIRST?
A. Encourage fluids
B. Elevate legs and notify provider
C. Apply oxygen and assess respiratory status
D. Teach sodium restriction
Answer
C
Rationale
Airway and breathing take priority over education or provider notification.
📘 Chapter 42
Question
Which laboratory value requires immediate provider notification?
A. Sodium 133
B. Potassium 6.4
C. Calcium 8.3
D. Magnesium 1.7
Answer
B
Rationale
Hyperkalemia places the patient at immediate risk for fatal dysrhythmias.
$400
📘 Chapter 42
Question
A patient with COPD has these ABGs:
pH 7.36
PaCO₂ 56
HCO₃ 31
How should the nurse interpret these results?
A. Uncompensated Respiratory Acidosis
B. Fully Compensated Respiratory Acidosis
C. Metabolic Alkalosis
D. Respiratory Alkalosis
Answer
B
Rationale
The pH is normal but leaning acidic, CO₂ is elevated, and bicarbonate is elevated, showing renal compensation.
📘 Mixed
Question
Which patient should the RN assess FIRST?
A. Potassium 3.4 requesting pain medication
B. Sodium 127 with increasing confusion
C. Chronic edema requesting lunch
D. Patient awaiting discharge
Answer
B
Rationale
Neurological changes associated with hyponatremia indicate cerebral edema and possible seizure activity.
📘 Chapter 38
Question
The nurse is preparing to ambulate a patient on postoperative day 1 following a colectomy. The patient reports feeling dizzy when sitting on the side of the bed.
What is the nurse's BEST action?
A. Encourage the patient to walk quickly to improve circulation.
B. Return the patient to a lying position, reassess vital signs, and evaluate for orthostatic hypotension.
C. Tell the patient dizziness is expected after surgery and continue ambulation.
D. Call physical therapy immediately.
B
Rationale
Patient safety always comes first.
Possible causes include:
Orthostatic hypotension
Hypovolemia
Medication effects
Blood loss
Reassess before attempting mobility.
📘 Chapter 42
Question
A patient with heart failure suddenly develops:
RR 30
SpO₂ 86%
Crackles
Pink frothy sputum
What should the nurse do FIRST?
A. Restrict oral fluids.
B. Administer scheduled oral Lasix.
C. Apply oxygen, sit the patient upright, and call for immediate assistance.
D. Obtain a daily weight.
C
Rationale
The patient is experiencing acute pulmonary edema.
Priorities:
Oxygenation
Airway
Breathing
📘 Chapter 42
Question
Which patient requires immediate intervention?
A.
Na 132
Alert
B.
K 6.8
Peaked T waves
C.
Ca 8.2
Fatigue
D.
Mg 1.5
Constipation
B
Rationale
Hyperkalemia with ECG changes is an immediate cardiac emergency.
📘 Chapter 42
Question
Interpret these ABGs:
pH 7.18
PaCO₂ 60
HCO₃ 22
Patient becoming difficult to arouse.
Priority?
A. Encourage fluids.
B. Increase oxygen only.
C. Assess airway and prepare for ventilatory support.
D. Encourage ambulation.
C
Rationale
This patient has severe respiratory acidosis with respiratory failure.
Ventilation—not just oxygenation—is the priority.
📘 Mixed
Question
Who should the nurse assess FIRST?
A.
COPD patient waiting for breakfast
B.
Potassium 2.9 with new palpitations
C.
Patient requesting pain medication
D.
Patient awaiting discharge
B
Rationale
Symptomatic hypokalemia places the patient at immediate risk for life-threatening dysrhythmias.