Chapter 8 NCLEX & back of book and worksheet

Semi-fowlers position, with the foot of the bed flat

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? (Select all that apply)

High Fowler's position

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

Patient C has right-sided weakness in the upper body due to a stroke

Which patient is the most likely candidate for active assisted ROM exercises?

Sims position

Which position would be most comfortable for the patient and provide the best access for the nurse to insert a rectal suppository?

Flexion, Lateral flexion, Rotation

Which range-of-motion exercises can be safely performed on the neck?

Nurse A raises the head of the bed, supports the patients shoulders, and helps to swing the legs around and off the bed using a pivoting motion.

Which situation is the best example of proper ergonomic principles?

Orthopneic

The nurse is assigned to care for a patient who was admitted for exacerbation of chronic obstructive pulmonary disease and pneumonia. The patient is experiencing dyspnea and is unable to rest in a supine position. The nurse elevates the head of the bed to 90 degrees, places a pillow on the overbed table, and assists the patient to lean forward, placing the patients head on the pillow. What position should the nurse document the patient as being in?

Assessment of the patients pulse and respiration's

A 56-year-old patient had an open cholecystectomy. The nurse is going to assist the patient with dangling on the side of the bed before ambulation. After sitting the patient on the edge of my the bed, which nursing intervention should the nurse perform before proceeding with ambulation?

Supine, with the residual limb supported with pillows

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position?

The client leans over a bedside table, the client should sit on the edge of the bed, a time-our is performed before the procedure, a local anesthetic is administered before the procedure

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points should be included in the instructions? (Select all that apply)

Raise the head of the bed to 90 degrees and have the patient lean forward on the over-bed table.

A nurse walks into the patients room and notices that the patient is having trouble breathing. Which position will the nurse use to help relieve the patient's respiratory distress?

The nurse should call for assistance, the nurse should not allow the patient to get out of bed at this time.

A patient becomes faint and diaphoretic while sitting on the side of the bed in preparation to ambulate. To prevent injury to the patient and nurse, which action should the nurse take? (Select all that apply)

Potential for inability to tolerate activity

A patient has been immobilized for 5 days because of extensive abdominal surgery. When this patient is helped out of bed for the first time, which patient problem related to safety applies to this patient? (Select all that apply)

Exert less physical effort

A patient who was admitted with the diagnosis of a stroke has slid to the foot of the bed. With use of appropriate body mechanics, the nurse maintains a wide base of support and faces the patient in the direction of movement. What do these actions allow the nurse to do?

Limit bleeding from the biopsy site

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understand that the purpose of this intervention is to accomplish which?

Ensuring the patients proper body alignment

An 82-year-old patient has had a cerebrovascular accident that affects her right side. The nurse repositions the patient to her left side, placing a pillow between her legs and another behind her back. What is the primary purpose of this intervention?

The nurse should assess the patients needs for pain medication before helping her change position.

An older adult patient has been lying in the supine position for 3 hours and tells the nurse that she is too uncomfortable to move right now. What is the best response by the nurse?

Bone loss that results in fractures

For an older female patient who is at risk for osteoporosis, which associated complication can be minimized by participating in a regular exercise program as prescribed by the provider?

Prone

In which position is the patient lying face down or chest down?

Dorsal recumbent

It is the patients first night after an abdominal hysterectomy. She has not voiced for 9 hours, and the nurse is to insert a 16 French Foley catheter into her bladder. What patient position best allows insertion of the catheter?

"Let's talk about what you used to do at home during the day."

Patients who are immobilized in health care facilities require that their psychosocial needs be met along with their physiologic needs. Which statement by the nurse acknowledges these needs?

Ensure that the upper arm and leg are supported with pillows

The nurse and a UAP are to move a dependent patient from the supine to the lateral position. Which action should be performed first?

"It is important to keep your neck and spine in straight alignment while we help you move onto your side."

The nurse explains to the patient that the log-rolling technique will be used to help the patient change position. The patient asks why this is necessary. Which response is accurate?

Stand directly in front of the person or object being worked with

The nurse had a previous back injury and knows that she should avoid twisting her spine as she cares for patients. What is the best strategy for the nurse to use?

Support her while she is falling and allow her to sit in the floor

The nurse helps angular an 84-year-old female who has peripheral vascular disease that caused a severe stasis ulcer. The patient becomes very weak, reports feeling faint, and begins to fall. What is the most appropriate action to prevent injury to the patient?

The enema will flow into the bowel easily

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims position. The nurse explains that this positioning is preferred because of which reason?

Supine with head elevation no greater than 30 degrees

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position?

A mechanical lift with a sling

The nurse is assigned to care for an 82-year-old patient who weighs 252 pounds (lb) (114.54 kilograms [kg]) and has undergone a bilateral below-the-knee amputation. Which transfer method is the safest for the patient and the nurse?

Patient participation in activities of daily living (ADLs) for 10-15 minutes every 2-3 hours while awake for a total of 2 hours of activity per 24 hours

The nurse is helping plan an activity schedule for an older adult resident at a long-term care facility who is at risk for disuse syndrome. Which plan is the nurse most likely to suggest?

Stands directly in front of the patient and places hands at the patients waist level

The nurse is preparing to assist the patient to transfer from the bed to the chair. Which action demonstrates the nurses proper use of body mechanics?

Use a friction-reducing slide sheet, use a mechanical lift to move the client, keep elbows close and work close to the body, obtain assistance if a second caregiver to assist with mechanical aids

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? (Select all that apply)

Plantar flexion of the foot

The nurse is receiving a report on a patient. The nurse giving the report states that the patient has door drop. The nurse receiving the report knows that which is the correct terminology for foot drop?

"I will not sleep lying on my left side", "I will sit at the table to eat breakfast", "I will sit in my recliner with my feet elevated", "I will not lift anything heavier than 10 pounds"

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understand of the instructions? (Select all that apply)

Keep the knees slightly bent

The nurse is working with a patient who has poor balance to move from the bed to the chair. What is included in the correct technique for assisting the patient to stand and pivot to the chair?

The nurse lowers the body by flexing the knees and bending the hips

The patient accidentally knocks the enemies basin to the floor. When picking up the emesis basin, which movement demonstrates proper body mechanics by the nurse?

Footboard

The patient experienced a stroke that left her with severe left-sided paralysis and very limited mobility. Which device would prevent plantar flexion?

Pull the patient close and lower him gently to the floor

The patient had a surgical procedure and is getting up to ambulate for the first time. While ambulating down the hallway, the patient says "I'm going to faith." What should the nurse do first?

Assess skin color, temperature, movement, sensation, pulses, capillary refill, and pain.

The patient has a cast on the left lower leg. Which assessment is performed to prevent compartment syndrome?

Encourage deep-breathing and coughing every hour

The patient will be immobilized for an extended period due to extensive injuries. Which intervention will the nurse use to prevent respiratory complications?

Maintaining a wide base of support and bending at the knees

The student nurse demonstrated principles of good body mechanics with which activity? (Select all that apply)

Ensure that the patient wears shoes with a nonslip sole during ambulation and transfer, assist the patient to make slow, gradual position changes, if the patient becomes faint or dizzy when walking, ease him to the floor or a chair, be sure the home is free of clutter, wet areas, or rugs that may slide.

What instructions should the nurse give to a new home health aide about helping the patient who has problems with immobility? Select all that apply

Preventing contractures, maintaining joint movement and mobility, preventing atrophy of muscle near the joints, increasing the patients self-esteem and motivation

What is a major benefit of active ROM exercises? (Select all that that apply)

Have patient wear well-fitting nonskid shoes or slippers, have at least two people present to assist the patient, use a gait belt when assisting the patient to stand and to ambulate

What is a necessary safety precaution when helping a patient who has an unsteady gait to ambulate? (Select all that apply)

Pain upon stretching

What is an early sign of acute compartment syndrome?

Shearing or tearing of the skin

What is the most likely complication when an older adult patient gets pulled across the bed when changing wet linens?

Pulses strong and easily palpated

When assessing the neurovascular status of a patient, what is an expected finding?

Maintain good body alignment

When using a lift sheet to assist in moving a patient up in bed, what should the nurse ask the patient to do? (Select all that apply)

Trapeze bar

Which assistive device allows patients to pull with the upper extremities to raise their trunk off the bed, to assist in transfer from bed to wheelchair, and to perform upper arm exercises?

Has mechanical lifts available for use; there is at least an 80% compliance rate and nurses and UAP are trained in the use of devices

Which health date facility is using evidence based practice to protect patients and health care workers from musculoskeletal injuries?

Medications used to reduce high blood pressure

Which medications are most likely to contribute to orthodontic hypotension?

Nurse D keeps head erect and aligns and balances weight on both feet when assisting a patient to stand up

Which nurse is using the key factor in body mechanics?

The patient sits in chair and crosses legs while reading a book

Which patient behavior should be corrected to reduce risk of thrombophlebitis?

Patients wrist is abnormally flexed and joint is fixed

Which patient has a contracture?