Sherpath: Activity and Movement: Implement and Take Action; Evaluate

Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse?

Places a gait belt on a patient with osteoporosis to assist with ambulation Allows the patient's elbows to be bent at a 45-degree angle when using a cane Tells the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg

Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement?

Promotes muscle strength

Place the steps in the order the nurse would follow to teach a patient how to use a cane.

Place cane on the patien'ts stronger side Move the cane Move the weaker leg Move the stronger leg

Which actions would the nurse take for a patient who is immobile?

Suggest drinking at least 2000 mL during a 24-hour period. Encourage passive range-of-motion exercises Place high-top tennis shoes on feet.

Which instruction would the nurse share with the patient about coughing techniques?

Take two deep breaths in and out to start.

Kegel exercises

Isometric

Ambulating

Isotonic

When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient?

Leave top side rails up. Bend at the knees. Carry weight close to the body. Use mechanical lift equipment.

The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? Record your answer as a whole number.

2

Repeated stair-climbing

Aerobic

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair?

Allow the patient to dangle.

Which action would the nurse take to improve an immobile patient's nutritional intake?

Allow the patient to make food choices.

Heavy weight-lifting

Anaerobic

Which actions would the nurse take if the patient falls while ambulating in the hall?

Call for help. Assess the patient's physical and neurologic status. Notify charge nurse and primary health care provider Complete occurrence report.

Which cues alert the nurse that the patient with Paralysis is declining?

Develops disuse osteoporosis Does not participate in physical therapy

Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating?

Experiences a pulmonary embolus Has dusky toes Has coagulation laboratory results that indicate the patient is clotting too fast

In which position would the nurse place the patient to perform coughing and deep breathing?

Fowler's

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining?

Has a Braden Scale score that indicates a high risk for skin breakdown Develops a Stage 1 pressure injury on the buttocks Develops a Stage 2 pressure injury on the left hip

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving?

Has a pulse oximetry reading of 94% when standing to brush teeth

Which interventions would the nurse select for a patient who is on bed rest?

Have the patient shift weight every 15 minutes while awake. Reduce hallway light at night. Apply a pressure-relief ankle-foot orthotic (PRAFO) boot.

Which action would the nurse take for a patient on bed rest who is concerned about developing constipation?

Increase the patient's dietary fiber and fluid intake.

Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed?

Initiate a fall prevention plan for the patient.

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)?

Monitor the patient's toes for impaired circulation.

Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving?

Needs no assistance to transfer Ambulates unassisted down the corridor and back Ambulates with no slips on the floor

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills?

Notify the health care provider that the patient may have pneumonia.

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility?

Obtains two unlicensed assistive personnel to help

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle?

Open the window blinds during the day.

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed?

Trapeze bar

Which interventions would the nurse implement for a patient with lower extremity Paralysis?

Turn every 2 hours. Arrange for a special bed. Perform range-of-motion (ROM) exercises at least two times per day.

In which area would the nurse place a pillow for a patient in the supine position?

Under the calves

To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity?

Unlicensed assistive personnel

Which safety measures would the nurse implement for a patient who is a fall risk?

Use a low bed. Frequently orient the patient. Place floor mats beside the bed.

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility?

Use the incentive spirometer 5 to 12 times every 1 to 2 hours. Deep breathe 10 times every hour. Cough two to three times every 2 hours. Move each joint three to five times during range-of-motion exercises.

Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation?

Walker