Sim Lab - Moving & Positioning
A resident of a nursing home keeps trying to get out of bed to use the bathroom, despite having a urinary catheter in place. Which intervention will best preserve this client's safety and could be used as an alternative to restraints? A) Investigate the possibility of discontinuing his or her catheter. B) Limit the resident's fluid intake in order to reduce his or her urge to void. C) Collaborate with the resident's health care provider to have his or her diuretics discontinued. D) Increase the resident's physical activity to reduce evening restlessness.
A Discontinuing the catheter, if medically prudent, would eliminate the risks associated with the resident's behavior. Limiting fluid intake or reducing diuretics would be unsafe and ineffective. Similarly, increasing the resident's activity is unlikely to reduce restlessness.
A nurse is placing an infant in a mummy restraint to perform eye care. Which is a recommended guideline for application of a mummy restraint? A) Place the child on the blanket, with the edge of the blanket at or above neck level. B) Position the child's left arm alongside the body and pull the right side of the blanket over the shoulder and chest. C) Leave the lower part of the blanket open and pull the sides of the blanket over the child's body. D) Secure the blanket under the child's body on each side by tucking it in instead of using safety pins.
A Open the blanket or sheet and place the child on the blanket, with the edge of the blanket at or above neck level; position the child's right arm alongside the body; left arm should not be constrained at this time. Pull the right side of the blanket tightly over the child's right shoulder and chest. Secure under the left side of the child's body, position the left arm alongside the child's body. Pull the left side of the blanket tightly over the child's left shoulder and chest. Secure under the right side of the body. Fold the lower part of the blanket up and pull it over the child's body. Secure it under the child's body on each side or with safety pins.
Two nurses are preparing to use a powered full-body sling lift to transfer a client from his bed to a chair. Which nursing diagnosis should the nurse use? A) Risk for Injury B) Risk for Powerlessness C) Risk for Disuse Syndrome D) Risk for Activity Intolerance
A Performing a transfer, especially using a powered lift, poses a significant risk to the safety of the client and must be undertaken with adequate knowledge and preparation. Powerlessness, disuse syndrome, and activity intolerance are not likely consequences of a client transfer.
An older adult client with an unsteady gait has been experiencing urinary urgency after being diagnosed with a urinary tract infection. What is the nurse's best action for reducing the client's risk of falls? A) Provide a bedside commode and ensure adequate lighting. B) Obtain an order for insertion of an indwelling urinary catheter. C) Limit the client's fluid intake during the evening. D) Accompany the client to the bathroom every 4 hours around the clock.
A The use of a commode can often reduce the risk of falls that is associated with ambulating to the bathroom. Falls reduction is not considered a justifiable rationale for catheter insertion. Toileting every 4 hours may or may not be adequate for the client's needs. Fluid intake should never be reduced for the sole purpose of reducing urine output.
A nurse is teaching a client how to use a walker. Which instructions should the nurse provide? Select all that apply. A) "Stand centered between the back legs of the walker." B) "Keep your arms relaxed at the side of the walker." C) "Line up the top of the walker with the crease on the inside of your wrist." D) "Your elbows should be nearly straight when you grasp the walker." E) "Move the walker forward 12 to 18 in with each step and set it down."
A, B, C Regardless of the type of walker used, the client stands between the back legs of the walker with arms relaxed at the side, the top of the walker should line up with the crease on the inside of the client's wrist. When the client's hands are placed on the grips, elbows should be flexed about 30 degrees. Have the client move the walker forward 6 to 8 in and set it down, making sure all four feet of the walker stay on the floor. Then, tell the client to step forward with either foot into the walker, supporting himself or herself on his or her arms. Follow through with the other leg.
A gerontologic nurse is assessing an older adult client's risk for falls. Which aspects of the client's current health status should the nurse identify as increasing the client's risk for falls? Select all that apply. A) Recent changes have been made to the client's medication regimen. B) The client has recently moved to a new assisted living facility. C) The client has recently been diagnosed with hypertension. D) The client had knee replacement surgery 6 weeks ago. E) An occupational therapist has begun working with the client.
A, B, D Polypharmacy and changes to medications can contribute to falls. Similarly, new environments and recent surgery can increase the risk for falls. Hypertension and the involvement of an occupational therapist do not likely increase the client's risk for falls.
The nurse is caring for an older adult client. Which situational assessment findings establish the need for interventions? Select all that apply. A) Bedside table with client's personal items is at the foot of the bed. B) Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L. C) Bed is in low position and brakes are in place. D) Call light is at top of bed under the pillow. E) Trash bag on side rail for used tissues.
A, B, D The nurse performs the situational assessment observing the client, family, and environment to identify and solve any potential problems before they can lead to safety concerns. The nurse should assess the need to place the bedside table by the client to provide items at close reach and decreases risks for falls. The nurse should establish that the oxygen tubing needs to be connected to the flow meter. The nurse determines that the bed is in its safest position. The trash bag secured on the side rail provides a convenient location for used tissues, decreasing clutter. The nurse determines that the call light needs to be secured and within reach for the client to use it.
The nurse is caring for an infant after cleft lip repair surgery. The primary care provider ordered bilateral infant elbow immobilizers. Which considerations should the nurse make when applying the elbow restraints? Select all that apply. A) Ensure that the elbow restraint is just below the axilla and right above the wrist. B) Apply the elbow restraints before placing the long sleeve shirt over the infant. C) Assess skin color, temperature, and presence of breakdown at baseline and every 2 hours. D) Check the capillary refill at baseline and every 2 hours. E) Apply elbow restraint so one finger can fit under the restraint.
A, C, D The nurse should make sure that the elbow restraint is below the axilla and above the wrist. The clothing should be placed on the infant before applying the elbow restraints, which will help pad and protect the skin below. The nurse should assess at baseline and every 2 hours skin color, temperature, and for the presence of skin breakdown. The nurse also assesses circulation by assessing capillary refill in the hand. The elbow restraints must be applied so two fingers can fit under the restraint to prevent from making them too tight.
When teaching range-of-motion exercises to a dependent client's caregiver, a nurse moves the arm of the client laterally to an upright position above the client's head, and then returns it to the original position. What anatomic movements has the nurse utilized during this exercise? Select all that apply. A) Abduction B) Rotation C) Extension D) Flexion E) Adduction
A, E Abduction is lateral movement of a body part away from the midline of the body; adduction is movement toward the center or median line of the body. Rotation occurs when a body part turns on its axis toward or away from the midline of the body. Extension is the state of being in a straight line and flexion is the state of being bent.
A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client? A) Powered stand assist B) Transfer chair C) Repositioning lift D) Gait belt
B Chairs that can convert into stretchers are available. These are useful with clients who have no weight-bearing capacity, cannot follow directions, and/or cannot cooperate. The back of the chair bends back and the leg supports elevate to form a stretcher configuration, eliminating the need for lifting the client. Powered stand-assist and repositioning devices require the client to have weight-bearing capacity in one leg. Gait belts are used to assist clients to ambulate safely.
Which client would be the most appropriate candidate to move by using a powered stand-assist device? A) A comatose client who is being taken for x-rays B) An alert client after knee replacement surgery who is being assisted to ambulate C) An obese client who has Alzheimer's disease and is being escorted to the shower room D) A car accident victim with fractures in both legs who is being moved to another room
B Powered stand-assist devices can be used with clients with weight-bearing ability on at least one leg, who can follow directions, and who are cooperative. Clients who are unable to bear partial weight or full weight or who are uncooperative should be transferred using a full-body sling lift.
A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? A) Apply restraints to the hands or wrists, never to the ankles. B) Ensure that two fingers can be inserted between the restraint and the client's extremity. C) Use a quick-release knot to tie the restraint to the side rail. D) Remove the restraint at least every 4 hours, or according to facility policy.
B Restraints should be sufficiently loose for two fingers to be inserted between the restraint and the extremity. Restraints can be placed on ankles; quick-release knots should be tied to the bed frame, not the side rail. Restraints should be removed every 2 hours.
A client with impaired mobility following recent knee replacement is being discharged to her home with continuing care from a community health nurse. What client teaching regarding safety and falls prevention should the nurse share with this client? A) Abstain from exercising until the knee is completely healed. B) Keep home temperature at a moderate level to prevent dizziness. C) Wear socks around the house to avoid catching a heel in a rug. D) Stand up quickly from a sitting or lying position to allow blood to move to the head.
B Temperatures too hot or too cold can contribute to dizziness and falls. Regular exercise helps maintain strength and flexibility, and can help slow bone loss. Shoes with rubber soles should be worn around the house. Standing too quickly can cause fainting or dizziness.
The nurse is caring for a postoperative client with confusion, and a weak and unsteady gait and a history of falls. The chart has an order for a waist restraint. What is the nurse's best next action? A) Apply the waist restraint over the gown and abdominal dressing. B) Notify the primary care provider and obtain an order for a client sitter. C) Apply bilateral wrist restraints and secure to the bed frame with a quick-release knot. D) Call the out-of-state family and ask if they can take turns watching the client.
B The nurse's best next action is to call the primary care provider for a client sitter, an alternative way to provide around-the-clock safety. Alternatives to restraints should be explored first. The client has a postoperative abdominal incision, which is a contraindication for the application of a waist restraint because it would increase intra-abdominal pressure and place strain on the wound. The primary care provider did not order wrist restraints, so the nurse would have to get an order for them, if they were needed. Wrist restraints are applied when a client may try to pull out an intravenous line and harm self from such action. It is not used to help keep the client in bed. The family is out of state and may not be able to come and watch the client around the clock or arrive in a timely manner to be able to help.
A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? A) "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." B) "Your elbows will be slightly bent when you are using your crutches." C) "When your crutches fit right, most of your body weight will be supported by your armpits." D) "We'll have the nursing assistant watch you while you walk around the unit the first time."
B When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.
A nurse is caring for an acutely confused hospital client who is ordered to remain on bed rest for medical reasons. The nurse asks the health care provider for an order for restraints. Which guidelines for the use of restraints should the nurse follow? Select all that apply. A) Restraints may be used to prevent a client from falling if the facility is short-staffed. B) The client's family must be involved in the decision and care plan. C) Alternatives to restraints and less restrictive interventions must have been implemented and failed. D) The benefit gained from using a restraint must outweigh the known risks for that client. E) A physician or licensed independent practitioner must reevaluate and assess the client every 48 hours. F) The client's vital signs must be assessed and the medical client must be visually observed every 4 hours.
B, C, D The client has the right to be free from restraints that are not medically necessary. Restraints are not used for the convenience of staff or to punish a client. The client's family must be involved in the care plan, and must be consulted when the decision is made to use restraints. Alternatives to restraints and less restrictive interventions must have been implemented and failed and all alternatives used must be documented. The benefit gained from using a restraint must outweigh the known risks for that client. A physician or licensed independent practitioner must reevaluate and assess the client every 24 hours. The client's vital signs must be assessed and the medical client must be visually observed every 2 hours.
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? A) Apply the stockings at night when the client is going to bed. B) Apply the stockings after the client has been sitting up for an hour. C) If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. D) Avoid the use of powders on the legs before applying stockings.
C Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.
Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer? A) To ensure safety, do not allow the client to assist with the transfer. B) Use assistive devices if either nurse will have to lift more than 60 lb. C) If the client is in pain, administer analgesics in advance of the transfer. D) Avoid using handling aids unless absolutely necessary.
C If the client is in pain, administer the prescribed analgesic sufficiently in advance of the transfer to allow the client to participate in the move comfortably. Clients should be encouraged to assist in their own transfers. During any client-transferring task, if any caregiver is required to lift more than 35 lb of a client's weight, then the client should be considered to be fully dependent and assistive devices should be used for the transfer. Handling aids should be used whenever possible to help reduce the risk of injury to the nurse and client.
An order for a waist restraint has been obtained for a client who is a threat to her own safety. The nurse should perform which action? A) Place the client in a prone position to apply the restraint. B) Remove the client's upper body clothing and reapply it over the restraint. C) Insert a fist between the restraint and the client to ensure that her breathing is not constricted. D) Assess the client at least every 2 hours or according to facility policy, as required.
C The client should be in a sitting position. Apply the restraint over the clothing and insert a fist between restraint and the client to ensure that breathing is not constricted. Assessments should be made every hour to ensure respirations are not obstructed.
A health care provider has ordered restraints for an older adult client who is delirious from the pain medication she was administered. Which guideline is appropriate for utilizing restraints? A) Chemical restraints should be tried before using physical restraints. B) The restraints can be ordered by the nursing supervisor in emergency situations. C) The client's vital signs must be assessed every hour. D) The client's order for restraints must be renewed by the health care provider every 4 hours.
C The client's vital signs must be assessed every hour when restrained. Restraints must be ordered by a health care provider. Orders for restraints may be renewed every 4 hours for adults 18 years of age or older but must be renewed every 24 hours. Chemical restraints do not necessarily have to precede the use of physical restraints.
A nurse enters a client's room and finds that the client has fallen on her way to the bathroom. Which is the best nursing intervention for this client? A) Briefly leave the client in order to call the primary health care provider to assess the client's condition. B) Assist the client back to bed and teach her about falls-prevention measures. C) Assess the client and document the incident and interventions in the client's medical record. D) Perform a head-to-toe assessment to determine whether an incident report is necessary.
C The nurse is responsible for documenting the incident in the client's record. Assess the client immediately and provide appropriate care and interventions based on the client's status, and ensure prompt follow-through for any physician orders for diagnostic tests. An event report must be filed in the case of a fall, as per facility policy. It would be unsafe to leave the client. Teaching may be necessary, but immediate care and follow-up are the priorities.
A nurse is providing care for a client who is in skin traction following multiple trauma. Which action should be included in the client's care plan? A) Ensure the traction apparatus is not attached to the bed. B) Check that all knots are tight and are positioned near the pulleys. C) Place the client in a supine position with the foot of the bed elevated slightly. D) Place the bed in the lowest position, allowing the weights to touch the floor.
C The nurse should place the client in a supine position with the foot of the bed elevated slightly and ensure the traction apparatus is attached securely to the bed. The nurse should also check that all knots are tight and are positioned away from the pulleys, and place the bed in the lowest position that still allows the weights to hang freely.
A client injured her shoulder in a fall and requires a sling. Which action should the nurse perform during and after application of the client's sling? A) Ensure that the client's wrist is not enclosed in the sling. B) Remove the sling every 2 hours for the first 6 hours to assess circulation. C) Position the sling so the client's arm is at a right angle to his or her body. D) Assess the client's active and passive ROM before applying the sling.
C The sling and forearm should be slightly elevated and at a right angle to the client's body. The wrist should be enclosed in the sling. Assessment of passive ROM is likely to cause further injury. It is unnecessary to remove the sling to assess the client's circulation.
A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? A) Stand at the top of the bed and have a colleague stand at the bottom of the bed. B) Place the bed in its lowest position to reduce the client's risk for falls. C) Position a friction-reducing sheet under the client to facilitate movement. D) Use back muscles to gently and gradually pull the client to the side.
C After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, place a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side.
A nurse is providing range-of-motion exercises for an immobilized client. Which guidelines should the nurse employ? Select all that apply. A) Perform the exercises swiftly with as much force as can be comfortably tolerated by the client. B) Repeat each exercise five to ten times, moving each joint in a smooth and rhythmic manner. C) While performing the exercises, begin at the head and move down one side of the body at a time. D) Encourage the client to do as many of these exercises by himself or herself as possible. E) Stand on the opposite side of the bed to where the joints are to be exercised. F) Lower the side rail and uncover only the limb to be used during the exercise.
C, D, F While performing the exercises, begin at the head and move down one side of the body at a time. Encourage the client to do as many of these exercises by himself or herself as possible. Lower the side rail and uncover only the limb to be used during the exercise. Perform the exercises slowly and gently, providing support by holding the areas proximal and distal to the joint. Repeat each exercise two to five times, moving each joint in a smooth and rhythmic manner. Stand on the side of the bed where the joints are to be exercised.
The registered nurse is caring for a client with a waist restraint. Which tasks should the nurse delegate safely to the unlicensed assistive personnel (UAP)? Select all that apply. A) Assess the client's need to continue the waist restraint. B) Chart the skin findings during the 2-hour check. C) Provide a bedpan and pericare. D) Determine if the waist restraint is too tight. E) Obtain, record, and report vital signs.
C, E The registered nurse (RN) cannot delegate the nursing process, so the RN should assess the client's continued need for the waist restraint, and perform the ongoing assessment including the condition of the client's skin, circulation, and if the restraint is too tight. The nurse may safely delegate providing a bedpan and pericare, and obtaining, recording, and reporting vital signs to the RN.
A registered nurse is overseeing the care of numerous residents in a care facility. Which tasks can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. A) Assessing a new resident's risk for falls B) Assessing the circulation of a resident in extremity restraints C) Removing items that have been deemed a risk for falls from a resident's room D) Helping a resident safely ambulate to the bathroom from her bed E) Applying a waist restraint that has been ordered for a resident
C,D Activities related to the prevention of falls may be delegated to UAP. Applying restraints, assessing a client in restraints, or assessing a person's risk for falls would be beyond the scope of UAP.
For which client might skeletal traction be indicated? A) A client with a fractured arm B) A client with a dislocated shoulder C) A client with a skull fracture D) A client with a fractured cervical spine
D Skeletal traction provides pull to a body part by attaching weight directly to the bone using pins, screws, wires, or tongs. It is used to immobilize a body part for prolonged periods. This method of traction is used to treat fractures of the femur, tibia, and cervical spine.
A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? A) Respond to the past history of the client (including previous falls) to determine the need for restraints. B) Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. C) Individualize the use of restraints and choose the most easily used device. D) Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.
D The client should be released from the restraint as soon as he or she is no longer a risk to self or others. Decisions should be based on the client's present status, not on his or her history. Restraints must be ordered by a health care provider and the least restrictive device should be used.
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? A) The nurse should place his or her feet close together with one foot in front of the other. B) The nurse should rock his or her pelvis out on the opposite side of the client. C) The nurse should grasp the gait belt and pull the client's body backward away from his or her body. D) The nurse should gently slide the client down his or her body to the floor.
D The nurse should place feet wide apart, with one foot in front and rock pelvis out on the side nearest the client. The nurse should grasp the gait belt and support the client by pulling his or her weight backward against his or her body and then gently sliding the client down his or her body to the floor, protecting the client's head.
For which client would a pneumatic compression device (PCD) be most clearly indicated? A) A postoperative client who has had bowel surgery B) A client with severe edema following a hip replacement C) A postoperative client with osteoarthritis and arterial occlusive disease D) A postoperative client suspected of having deep vein thrombosis (DVT)
A PCDs are contraindicated in clients with suspected or existing DVT. They should not be used for clients with arterial occlusive disease, severe edema, cellulitis, phlebitis, a skin graft, or an infection of the extremity.