CHP 16 FUNDAMENTALS TEST

A nurse is caring for a patient who is on bed rest and is concerned about the risk of urinary stasis. Which nursing action is most effective in reducing the risk of complications associated with urinary stasis?

Encourage the intake of 3 liters of fluid daily if permitted.

A nurse is caring for a patient who has an order for bed rest. The nurse is concerned about the patient's increased risk for pneumonia. Which nursing action should be implemented by the nurse to minimize this risk?

Encourage the use of an incentive spirometer hourly when awake.

A primary healthcare provider orders active range-of-motion exercises. What nursing action is unique to providing active range-of-motion exercises?

Encouraging the patient to perform the exercises independently

The nurse is caring for a patient who had an appendectomy. What intervention does the nurse perform while assisting the patient with ambulation?

Ensure the patient wears nonskid footwear.

A patient is lying in a lateral position. What site should the nurse assess for tissue ischemia when turning the patient?

Greater trochanter

As the nurse is helping a patient move from a lying to a sitting position, the patient suddenly develops signs of orthostatic hypotension. The nurse should next

Help the patient into a semi-Fowler's position to prevent syncope

Which position is best suited for the bedridden patient during mealtime?

High Fowler's

A nurse plans to teach a patient with hemiparesis to use a cane. What should the nurse teach the patient to do?

Hold the cane in the strong hand when walking

Effects of Immobility on the Respiratory System

Hypostatic pneumonia Atelectasis Hypoxemia

A nurse is planning to assist a patient with active assistive range-of-motion exercises. What should the nurse do first?

Identify any restrictions regarding the type or extent of range-of-motion exercises.

A nurse is transferring a patient from the bed to a chair using a mechanical lift. As the nurse begins to raise the lift off the bed, the patient begins to panic and scream. What should the nurse do?

Immediately lower the patient back onto the bed.

The nurse is aware of the effects of immobility on the musculoskeletal system. What does the nurse teach the patient about the benefits of range-of-motion (ROM) exercises?

It maintains the flexibility and motion of the joints.

When educating a patient about how to prevent musculoskeletal complications, the nurse should emphasize the importance of

Keeping the head, trunk, and hips positioned in a straight line

A healthcare provider orders that a patient with one-sided weakness (hemiparesis) be transferred out of bed to a chair twice a day. In order to promote patient safety during transfer, which nursing action is most important in this situation?

Pivot the patient on the unaffected leg.

nurse is transferring a patient from a bed to a chair. Which principle of body mechanics is important for the nurse to employ?

Place the feet wide apart.

The nurse is caring for a patient who has undergone hip replacement. The nurse instructs the patient to avoid adducting the operative leg to the midpoint of the body for several months. What is the rationale for this instruction?

To avoid joint dislocation

The nurse is preparing the bed of a patient who will be placed in skin traction because of a lower limb fracture. The nurse decides to place a trapeze bar on the overhead frame of the bed. What is the rationale for this nursing intervention?

To facilitate independent patient movement within the bed

The nurse has delegated the task of assisting a patient with walking to a CNA. Which action by the CNA indicates the need for additional teaching?

Tries to hold the patient losing consciousness upright

While a patient is lying in the dorsal recumbent position, the patient's leg externally rotates. What equipment should the nurse use to prevent external rotation?

Trochanter roll

A nurse is positioning a patient in the semi-Fowler position. What action should be implemented by the nurse when positioning this patient?

Use pillows to maintain dorsiflexion of the patient's feet.

Which nursing action is most effective in minimizing tissue ischemia due to shearing forces?

Using a transfer board to move a patient from a bed to a stretcher

A patient who has been mostly immobile for a week complains of feeling weak all over as he sits up with assistance. The nurse correctly understands this weakness to be:

a result of loss of muscle tone and contractures of the muscles.

trochanter roll

a rolled towel or cylinder device placed snugly against the lateral aspect of pts thigh to prevent leg from rotating outward

shearing

a situation in which the skin layer is pulled pulled across muscle and bone in one direction while the skin slides over another surface in the opposite direction

dorsiflexion

when in supine position, toes at 90 degrees pointing toward the ceiling

fowlers position

semi sitting position with various degrees of head elevation with knees slightly elevated

contractures

shortening and tightening of the muscles because of disease

orthopneic position

sitting upright with head of bead elevated 90 degrees or sitting on side of the bed with feet flat on the floor

Nursing Measures to Prevent Respiratory Complications

-Turn the patient from side to side every 2 hours -Elevate the head of the bed 45 degrees -Encourage coughing and deep breathing -Encourage use of the incentive spirometer

how to prevent muscluloskeletal complications

-maintaing proper body alignment, POM, AROM,

nursing intervention to prevent contractures and osteporosis

-perform ROM -support weight of extremity at joints -apply therapeutic devices -assist with ambulation

When caring for a bedridden patient, the nurse recognizes the importance of preventing the formation of a venous thromboembolism (VTE). To prevent a VTE, the nurse should

3) Assist the patient in performing passive range-of-motion exercises. 4) Apply antiembolism stockings to prevent pooling of blood in the legs.

A patient has limited mobility because of a stroke. When the nurse responds promptly to his call button, he snaps, "What the heck took you so long to get here! You people are so lazy." An appropriate response would be:

"You sound frustrated. What is the thing you are most concerned about?"

An immobile patient who has been alert; coherent; and oriented to time, place, and person says, "I keep hearing a cat crying, but I know there can't be a cat in here, can there?" Which of the following would be an appropriate response?

"You're right—there's no cat here. Sometimes when people don't have much to do, the brain tries to keep busy by making up stimuli. Let's talk about how we can keep your brain busier."

A nurse must transfer a patient from a bed to a wheelchair. Place the following nursing actions in the order that they should be performed.

- 4,2,1,6,5,3 Lock the brakes on the wheelchair. Place the wheelchair parallel to the patient's bed. Stand up and pivot the patient toward the wheelchair. Inform the patient how the transfer will be performed. Bend your knees and place your arms under the patient's axillae. Allow the patient to sit on the side of the bed for several minutes.

Nursing Measures to Prevent Cardiovascular Complications

-Encourage the movement of extremities ROM -Apply ordered devices to prevent pooling of blood in the legs -Gradually move the patient from lying to sitting or to a standing position -Change the patient's position frequently -Remain with the patient the first few times getting out of bed and dangling

effects of immobility on the cardiovascular system

-venous thromboembolism -DVT -orthostatic hypotension -syncope

An immobile patient has not had a bowel movement for 3 days and reports not feeling hungry. The nurse should consider the possibility that:

1) A lack of activity has caused a decline in peristalsis.

A physician has written an order to instruct the patient to turn, cough, and deep breathe. When teaching the patient to turn, cough, and deep breathe, the nurse explains that these actions will help to prevent

1) Atelectasis

A nurse is writing a procedure for logrolling a patient. Which of the following should be included in the procedure? Select all that apply

1) Three staff members are required to logroll a patient. 2) A draw sheet is used to keep the patient's head, neck, and shoulders in alignment during the turn. 4) The staff person standing at the patient's head is responsible for giving directions and counting to 3 before each movement of the patient. 5) Logrolling is appropriate for a patient with a spinal injury or who has had spinal surgery.

When reviewing with student nurses at a nursing home about the potential neurological complications of immobility, the instructor correctly includes which of the following? Select all that apply.

3) Compression neuropathy 4) Compromised coordination 5) Less mental alertness

The nursing instructor knows a student needs further review when the student describes position of function as:

the greatest range of motion a joint can move.

log roll

turning the patients body as one unit after the patient has spinal surgery or spinal injury

What is the most therapeutic exercise that a patient confined to bed can do?

Active range of motion

What is the action of moving a patient's lower extremity toward the midline and beyond during range-of-motion exercises called?

Adduction

When educating a class of nursing students, the nursing instructor emphasizes the importance of recognizing preventable causes of death. The nursing instructor teaches that the most preventable cause of death during hospitalization is

An embolism

A patient's chart shows orders to wear sequential compression devices and to receive range-of-motion exercises every 8 hours. The nurse correctly understands that:

Both treatments can help prevent the formation of venous thrombosis.

The nurse is caring for a patient who has undergone hip surgery. How might the nurse prevent dislocation of the head of the femur?

By instructing the patient to avoid leaning forward with a hip angle greater than 90 degrees

sims position

lying on back with arms at sides

A nurse is educating a patient about her diagnosis of osteoporosis. The nurse recognizes that osteoporosis

Can cause a patient to become hypercalcemic

The nurse is aware that atelectasis or hypostatic pneumonia may occur in a patient who is confined to the bed. Which factor does the nurse relate to atelectasis?

Collapse of the lung tissue

A nurse is caring for a patient who is ordered out of bed in a chair for 1 hour twice a day. The nurse is concerned about the complication of orthostatic hypotension. What nursing action employed by the nurse will help to minimize the risk of orthostatic hypotension?

Dangle the patient on the side of the bed for 1 minute before standing.

A nurse is repositioning a patient who is on bed rest to the orthopneic position. What action should the nurse implement when repositioning this patient?

Elevate the head of the bed to a high-Fowler position.

A nursing instructor educates a class of student nurses about how to prevent respiratory complications of immobility. The instructor properly emphasizes the importance of

Elevating the head of the patient's bed 45 degrees

A nurse is transferring a patient from the bed to a chair and sits the patient on the side of the bed for several minutes. What is the primary rationale for this action?

Enable the body to adapt to a drop in blood pressure

A bed-bound older adult has a stage I pressure ulcer in the sacral area. In which position should the nurse place the patient to relieve pressure and promote circulation to the sacral area?

Lateral

A patient has fallen onto the floor and is too weak to stand up without assistance. Which of the following types of equipment is best suited to this situation?

Lift

What is the most important principle of body mechanics when the nurse positions a patient?

Maintaining the patient in functional alignment

Which posture or movement would increase the risk of injury to the nurse in the scenarios described?

Misaligning the back when moving patients

Where should the nurse stand when assisting a blind patient to walk?

Next to the patient while the patient holds the nurse's arm.

A nurse places a patient with a sacral pressure ulcer in the left Sims position. How should the nurse position the patient's right arm?

On a pillow

. A patient is admitted to an extended-care facility after initially recovering from a cerebrovascular accident, resulting in left-sided hemiplegia. The nurse begins passive range-of-motion exercises on the patient's left upper and lower extremities. Which movement is indicated in the illustration?

Opposition

Which is the range-of-motion exercise being performed in the following illustration? pinky and thumb move together

Opposition

The nurse is caring for a patient who has a history of orthostatic hypotension. When providing patient education, the nurse emphasizes the importance of

Performing dorsal and plantar flexion of the feet

patient is afraid of falling and becomes anxious when it is time to get out of bed and move to a chair. What is the best action by the nurse to reduce the patient's anxiety?

Permit the patient to set the pace of the transfer.

prone position

lying on ones stomach with head turned to the side

A nurse is instructing unlicensed assistive personnel how to position an immobile patient. What should the nurse teach the unlicensed assistive personnel to do?

Position a pillow between the patient's legs when in the side-lying position.

A patient prefers and excessively maintains the supine position. For what potential problem associated with this position should the nurse assess the patient?

Pressure on the heels

The nurse turns the palm of a patient's hand downward when performing range-of-motion exercises. What word should the nurse use when documenting exactly what was done?

Pronation

Normally bedridden patients are turned every two hours unless they are placed in which position that requires more frequent turning?

Prone

A nurse is caring for a patient who recently sustained a cerebrovascular accident (CVA) which caused left-sided hemiparesis. The nurse is concerned about the patient developing contractures related to immobility. Which action is most important for the nurse to implement?

Providing active and passive range-of-motion exercises

A patient is 1 day post-op, and the physician has written an order for the patient to ambulate. When the patient asks why it is important to ambulate, the nurse explains that ambulation prevents complications related to immobility, which include:

Renal calculi

The nurse is caring for a hospitalized diabetic patient who is confined to the bed. Which nursing intervention helps to maintain the skin integrity in the patient?

Reposition the patient in bed every 2 hours.

A nurse is caring for an immobilized patient. Which nursing action will most effectively prevent occlusion of the blood supply in areas where bony prominences rest on a mattress?

Repositioning the patient every 2 hours

A male patient on bedrest tells the nurse he thinks he could empty his bladder more completely if he could stand while urinating. The nurse should:

Request an order from the physician to permit the patient to stand while urinating.

What should the nurse do first before moving a patient?

Review the primary healthcare provider's activity order.

A nurse is performing range-of-motion exercises to prevent contractures for a patient who had a cerebrovascular accident. How should the nurse move the patient's hip when performing internal rotation?

Rotate the leg and foot pointing inward toward the other leg.

A nurse identifies that a patient is walking with a propulsive cogwheel gait. Which patient behavior observed by the nurse supports this conclusion?

Small, shuffling steps with involuntary acceleration

A nurse is assisting a patient with range-of-motion exercises. What exercise is the nurse performing when the palm of the patient's hand is turned up toward the ceiling?

Supination

The nurse is repositioning a bedridden obese patient. Which position should the nurse avoid?

Supine

A nurse is providing passive range-of-motion exercises. Which principle is most important?

Support above and below the joint being moved.

When educating a patient about nursing measures to prevent gastrointestinal complications, the nurse should teach the importance of

Taking a stool softener as needed

A patient had a cerebrovascular accident with right-sided hemiparesis. What should the nurse do to best prevent this patient from developing contractures?

Teach the patient to perform range-of-motion exercises.

During shift report, a nurse is informed that a patient is using an incentive spirometer. The nurse correctly understands that:

The incentive spirometer helps to prevent atelectasis.

A patient is on bedrest. To prevent pressure ulcers, the patient is provided a gel-filled mattress overlay, and:

The nurse inspects the patient's bony prominences for redness at least every 2 hours.

The nurse is assessing a patient who previously received a plaster of Paris cast. During the assessment, the nurse observes malodorous discharge. What should the nurse interpret from this observation?

There is an infection beneath the cast.

lateral position

lying on the right or left side to relieve pressure on the back and on the saccral and coccygeal areas

supine position

lying on your back

hazards of immobility

blood clots pneumonia none demineralization kidney stones constipation pressure ulcers urinary retention depression

transfer

movement of pt from one place to another

effects of immobility

muscle atrophy contractures osteoporosis foot drop

body systems affected by immobility

musculoskeletal cardiovascular respiratory gastrointestinal urinary integument neurological psychological facts

footdrop

permanent plantar flexion of the foot

position of function

placement of extremeties in an alignment to maintain the potential for their use and movement

orthostatic hypotension

decrease in blood pressure that occurs when a patient changes from a reclining position or flat position to a upright position, common in pts on bedrest

plantar flexion

downward pointing of the foot

syncope

fainting

semi fowlers position

head of the bed is elevated 45 degrees

24. A patient in a nursing home has had a stroke and is largely immobile. When explaining the potential complications of immobility to the patient's family, the nurse would not include:

increased urine volume.