Foundations chapter 8 Adaptive quizzing

Which nursing intervention assists in the prevention of a thrombus?

Applying thromboembolic deterrent (TED) stockings

Which intervention is necessary for a patient who is getting up for the first time in 10 days?

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

Which wheelchair placement reflects best practice for transferring the patient from the bed to a wheelchair?

At a right angle to the bed

Where would the lift sheet be placed under a patient?

Between the upper back and thighs

Which condition would the nurse suspect if a patient in a cast is reporting tingling, burning, and pain in the affected extremity and on assessment the toes are cool to the touch and have sluggish capillary refill?

Compartment syndrome

Which intervention would the nurse implement first before ambulating a patient who has been supine for the past 2 months?

Complete lower extremities range of motion (ROM).

A patient who has decreased mobility is scheduled to be discharged to home. Which action would provide the best indication of the patient's needs and safety concerns in the home environment?

Using the facility checklist to identify standard patient needs and safety

Which instruction will the nurse give to the older patient who reports pain and spasm in the neck with range-of-motion (ROM) exercises?

"Discontinue the exercises until the pain subsides."

Which minimum amount of activity, such as range-of-motion exercises, would the nurse indicate is needed to help prevent disuse syndrome during each 24-hour period for a hospitalized older adult?

2 hours

Which device will the nurse suggest the patient use after a hip replacement to prevent surgery-related complications?

Abductor splint

A nurse is helping with range-of-motion (ROM) exercises. Which term describes the patient's leg being moved back toward the medial position or beyond?

Adduction

Which joint would the nurse identify as a hinge joint if reviewing joint range-of-motion exercises with the unlicensed assistive personnel (UAP)?

Elbow

How frequently will the nurse turn and reposition a patient who is bedridden?

Every 1 to 2 hours

How often will the staff change the position of an immobile patient?

Every 2 hours

Which order would the nurse use to perform full range-of-motion (ROM) exercises with an immobilized patient?

Follow a head-to-toe sequence

For which reason is a lift sheet used to shift the patient's body position?

It requires less effort when shifting the patient.

Which intervention is the most important for prevention of further breakdown of pressure ulcers in the heel area?

Keep the patient's heels in an elevated position.

Which patient position is best when administering medication via the rectal route?

Left lateral recumbent

Which item is essential for the nurse to use in an effort to prevent further damage to the skin while moving a patient with fragile skin up in bed?

Lift sheet

Which movement by the unlicensed assistive personnel (UAP) would reflect abduction?

Movement of an arm or leg away from the body

Which term would the nurse use to refer to the permanent shortening and rigidity of the elbow for a patient who has been cared for the past several years in the home after a stroke?

Muscle atrophy

Which type of exercise would prevent complications related to mobility in a patient who requires a mechanical lift for movement?

Passive range-of-motion

Which documentation would the nurse chart after a patient is transferred from the bed to a bedside chair? Select all that apply. One, some, or all responses may be correct.

Patient's response Unexpected outcomes

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

Place a pillow under the head, neck, and shoulders.

Which aspect of recovery will a continuous passive motion (CPM) machine help with?

Range of motion

Which action reflects proper body mechanics when helping to transfer a patient from the bed to a chair?

Spacing feet a shoulder length apart

Which statement correctly illustrates good posture?

The abdominal muscles are tightened

Which device would be used to prevent the complication of external hip rotation in a patient after a cerebral vascular accident (CVA)?

Trochanter roll

Which instruction would the nurse give to a patient to supinate the forearm?

Turn the lower arm and hand so that the palm is facing up."

Which area of the body would the nurse support when lifting an older patient to minimize pain and stress on the joints?

Upper body

Which information would the nurse provide to a patient regarding how to perform active assisted range-of-motion (ROM) on a joint?

Use your strong limb to exercise your weak limb."

Which action would the nurse take to prevent the development of foot drop?

Which action would the nurse take to prevent the development of foot drop?

Which action ensures proper positioning of a patient in semi-Fowler's position?

Raise the head of the bed to 30 degrees

A patient who is morbidly obese and totally dependent requires more than one nurse for transfer. The patient is scheduled for a bath, but other team members are busy with providing morning care to other patients. Which action would be most effective to ensure that this patient receives the scheduled bath without the nurse sustaining an injury?

Reschedule the bath when adequate help is available.

Which step is essential for the nurse to take before transferring a patient to a wheelchair?

Locking the wheelchair

Which moving technique would be used for turning a patient who has sustained a back injury?

Log-rolling

Which assistive device would the nurse use to prevent external rotation of the legs when positioning an immobile patient in the supine position?

Pillow

Which intervention can the nurse complete to prevent back pain in a patient who is bedridden in the supine position?

Place a pillow under patient's lumbar spine.

A nurse is attempting to transfer a patient from the bed to the chair. Which action indicates that the nurse has a clear understanding of the body mechanics involved in such a transfer?

The nurse stands with their feet shoulder width apart