Adaptive quiz Chapter 8

A patient is scheduled to be discharged to home, and the health care team must assess needs and the safety of the home environment. Which method would provide the best indication of the patient's needs and safety concerns?

A scheduled home visit to assess needs and safety

A patient with a diagnosis of cerebral vascular accident (CVA), which has caused right-sided paralysis and limited mobility, has been admitted to the nursing unit. What device should be used to prevent the complication of external hip rotation in caring for this patient?

A trochanter roll

Which patient problem(s) can occur as a result of immobility?

Anorexia Insomnia Kidney stones Urinary tract infections

Which nursing intervention assists in the prevention of a thrombus?

Applying thromboembolic deterrent (TED) stockings

A patient has been on extended bed rest and is about to ambulate for the first time. What should the nurse do to prevent vertigo and dizziness?

Ask the patient to keep the head up Tell the patient to keep the eyes open Instruct the patient to look straight ahead

A preoperative patient is transferred from the bed to the stretcher. After the patient is on the stretcher, what is the nurse's immediate action?

Assess the patient for proper alignment and comfort.

An elderly patient is placed on a continuous passive-motion (CPM) machine. Which nursing intervention should the nurse make a priority?

Assessing the patient's heel for skin breakdown

A patient has been on bed rest for a few days and is getting up for the first time. What is the best nursing intervention for this patient?

Assist the patient to a sitting position on the edge of the bed

What is proper placement for a lift sheet under the patient?

Between the upper back and the thighs

A patient with a leg cast is complaining of tingling, burning, and pain in the affected extremity. The nurse does an assessment and finds that the patient's toes are cool to the touch and have sluggish capillary refill. What condition should the nurse suspect?

Compartment syndrome

The nurse is caring for a patient who has undergone a hip replacement surgery. Which device does the nurse suggest the patient use to prevent surgery-related complications?

Wedge pillow

A nurse needs to determine range of motion, muscle strength, activity intolerance, gait, and posture for a patient. What will be the best time for the nurse to assess these qualities?

When the patient performs activities of daily living (ADLs)

How does the nurse place a patient in semi-Fowler position?

Elevate the head of bed to 30 degrees.

A patient ambulating in the hallway complains of severe dizziness and begins to fall. Which action should the nurse take first?

Gently lower the patient to the floor

A patient is ambulating in the hall and begins to fall. Which action if taken by the nurse could lead to personal injury?

Holding the patient to prevent the fall from occurring

An elderly patient reports pain and spasm in the neck while performing regular range of motion exercise (ROM). What instruction does the nurse give to the patient?

"Stop the exercise until the spasm subsidies."

A bedridden patient asks a nurse why there is a need to turn every 2 hours if a certain position provides the best comfort. What is the best response the nurse can give?

"Turning every 2 hours will prevent bed sores."

The nurse is teaching a nursing student about body mechanics. What recommendations should the nurse give to the nursing student with regards to moving and lifting objects?

"You should avoid sudden pulling motions when assisting a patient from the chair back to bed." "Do not twist your body trunk while lifting and/or pulling patients up in bed." "Be sure to face the object you intend to move. If you are putting supplies onto shelves, face the objects you are moving."

A nurse is helping with range-of-motion (ROM) exercises. What is it called when the patient's leg is moved back toward the medial position or beyond?

Adduction

A patient living alone will be discharged soon. Which action, if taken by the nurse, will address the self-care deficit the patient may have?

Allow the patient to practice self-care activities that will be carried out at home

The nurse observes that the positioning and alignment of a patient is improper. How should the nurse educate the caregiver regarding possible complications due to improper positioning?

Cramps and contractures Risk of fluid collection in the lungs Risk of development of pressure ulcers

A patient with emphysema tires easily and cannot tolerate an entire session of range-of-motion (ROM) exercises. Which action should the nurse take to address patient fatigue?

Divide the ROM exercises into two or more tolerable sessions.

A patient with fragile skin needs assistance with moving up in bed. Which item is essential for the nurse to use in an effort to prevent further damage to the skin?

Draw sheet

The nurse is caring for a patient who is bedridden for the past two months. The primary health care provider has asked the nurse to ambulate the patient. What intervention does the nurse implement first before ambulation?

Elevate the head end of the bed for some time.

The primary health care provider writes an order to place the patient in Fowler's position. How does the nurse implement this order?

Elevate the patient's head of bed to 50 degrees.

An immobile patient is on the unit. How often should the staff change the position of this immobile patient?

Every 2 hours

The nurse is caring for a dehydrated, debilitated, and bedridden patient. How frequently should the nurse turn and reposition the patient?

Every hour

Which techniques are most appropriate for the nurse to use to prevent self-injury when providing patient care?

Flex knees slightly Keep head erect and chest up Push, pull, or slide heavy objects

A nurse is transferring a patient from a straight chair to the bed using a transfer belt. What should the nurse instruct the patient to avoid during transfer?

Grasping the neck of the nurse for support during the transfer.

The nurse needs to place a patient in a dorsal recumbent position for examination. How does the nurse correctly place the patient for this position?

Knees should be flexed. Feet should be flat on the bed. Patient should lie on the back.

A patient is placed in a dorsal lithotomy position in preparation for a pelvic examination. Which is a correct description of dorsal lithotomy positioning?

Legs are spread apart Feet are placed in stirrups Patient lies on his back

A patient sustained a neck injury in a motor vehicle accident. The unlicensed assistive personnel is providing morning care. Which technique should be used for turning the patient?

Moving the patient using log rolling

A patient with chronic obstructive pulmonary disease is experiencing difficulty breathing. The nurse places a pillow on the bedside table and instructs the patient to tilt forward and rest the head on the pillow. The patient has assumed which position?

Orthopneic

What type of exercise would a patient who requires a mechanical device for movement require from staff for prevention of complications related to immobility?

Passive range-of-motion (ROM) exercises

What should be documented as an unexpected outcome for a patient receiving passive range-of-motion exercises?

Patient experienced dyspnea during ROM exercises.

Documentation is essential in patient care. What documentation should the nurse chart after a patient is transferred from the bed to a bedside chair?

Patient's response Unexpected outcomes

The nurse understands that a bed-ridden patient in a supine position may develop back pain if not positioned correctly. How can the nurse prevent back pain in this patient?

Place pillow under patient's lumbar spine.

A nurse is assisting a postsurgical patient to dangle. Which essential action should the nurse take to ensure patient safety?

Place the bed in the lowest position before dangling

An unlicensed assistive personnel (UAP) is preparing to make a bed. Which action would reduce strain on the back muscles of the UAP?

Raising the bed to a comfortable working height

A patient on fall precautions is being discharged to home. What instructions regarding safety should the nurse discuss with the patient?

Removing throw rugs and moving electrical cords out of pathways

A patient arrives at the clinic with complaints of chronic constipation. The primary health care provider recommends the patient undergo a rectal examination. The nurse places the patient in which position in preparation for a rectal examination?

Sim's position

The nurse is preparing to administer a drug to a patient via the rectal route. Which is the best way to position the patient for the procedure?

Sims'

Which intervention does the nurse perform to prevent external rotation of the hips in the patient placed in a supine position?

Support the lateral aspect of the thigh with a sand bag.

The job of the nurse is physically demanding. To prevent injury to the muscles and bones, the nurse assumes good posture. Which statement correctly illustrates good posture?

The abdomen muscles are pulled inwards.

A nursing student assists a patient into a chair. Which posture indicates the patient has correct body alignment?

The head is centered and erect. Knees and ankles are slightly flexed. Arms are hanging comfortably by the patient's sides.

The nurse is helping a patient achieve a knee-chest position for rectal examination. How is the patient placed in a knee-chest position?

The knees are bent, with the lower legs flat on the bed The patient's thighs are perpendicular to bed The chest, elbows and knees are on bed

The primary health care provider has prescribed continuous passive motion (CPM) therapy for a patient who has undergone knee arthroplasty. What could be the reason for this prescription?

To avoid active exercises To prevent skin breakdown To improve mobility of joint

A patient has returned to the surgical floor after hip replacement surgery. What assistive device is used for proper body alignment?

Wedge pillow

When planning the care for a patient with mobility concerns, what is essential for the nurse to consider?

he patient's immediate mobility needs

A patient needs to be placed in a semi-Fowler's position for a medical examination. How does the nurse ensure proper positioning of the patient?

Raise the head of the bed to 30 degrees

The nurse asks the patient's caregiver to frequently change the patient's position, because the patient is bedridden. What could be the possible reasons behind the nurse's instruction?

Repositioning may provide comfort to the patient. Repositioning relieves constant pressure on body parts. Repositioning may prevent deformities and respiratory problems.

A totally dependent, morbidly obese patient who requires more than one nurse for transfer is scheduled for a bath. Other team members are busy giving morning care. What would be the most effective method to ensure that the patient receives the scheduled bath without the nurse sustaining an injury?

Secure a mechanical lift to transfer the patient into the bath.

Two nurses use a lift sheet to shift the position of a bedridden patient. What is the reason for using a lift sheet to shift the patient's body position?

It requires less effort when shifting the patient.

A patient is being transferred from the bed to the wheelchair. What step is essential for the nurse to take before allowing the patient to sit in the wheelchair?

Locking the wheelchair

A patient is lying in a supine position. How does the nurse prevent internal rotation of the shoulder?

Maintain arms parallel to the body. Place a pillow under the pronated forearms.

What action should the nurse take to prevent the development of foot drop in a bed-ridden patient who remains in a supine position most of the time?

Maintain the patient's foot in dorsiflexion

A patient has sustained an injury to the shoulders. Which exercises does the nurse teach the patient to help promote joint movements and exercise the shoulder muscles?

Performing the internal rotation of the shoulders Performing the external rotation of the shoulders Raising and lowering the arms above the head

Which intervention should the nurse perform to prevent flexion contractures of neck in the patient who is placed in the supine position?

Place a pillow under the head, neck, and shoulders

What interventions does the nurse perform while caring for a patient with pressure sores?

Provide proper support to the limbs. Check the skin frequently for redness. Change the patient's position frequently.

A nurse is attempting to transfer a patient from the bed to the chair. Which position, if assumed by the nurse during the transition, demonstrates that the nurse has a clear understanding regarding body mechanics?

The nurse stands with the feet shoulder width apart.

A patient recovering from a spinal injury tells the nurse, "I would like to get to my wheelchair so I can move around in my room." Which assistive device does the nurse use to facilitate safe transfer for the patient?

Trapeze bar

The nurse is caring for a patient who is in hypovolemic shock due to ruptured ectopic pregnancy. What patient position helps to prevent complications while shifting the patient to the operating room?

Trendelenburg's