ATI Testing Ambulation, Transferring, Range of Motion Pretest

Which instruction is appropriate regarding ambulation with a cane? A. Hold the cane on your stronger, unaffected side. B. First move the cane forward about 12 to 15 inches. C. While moving the cane forward, keep your weight on your unaffected side.

A. Hold the cane on your stronger, unaffected side.

A nurse is about to transfer to a chair a pt who has a weak left leg. Which of the following actions by the nurse demonstrates correct transfer technique?

Aligning the nurse's knees with the pt's knees just before the transfer. This is a correct strategy that helps the nurse safely the patient while moving to a standing position.

What should I assess when ambulating a patient who has previously been immobile?

Assess the patient's activity tolerance, strength, coordination, and baseline vital signs. Also, determine how much assistance the patient will need. Consider consulting physical therapy to assist in the development of a mobility plan. Assist the patient to a sitting position and allow her to dangle the legs over the bed for 1 to 2 minutes before standing. Assess the patient for signs and symptoms of orthostatic hypotension, including dizziness, light-headedness, nausea, tachycardia, pallor, or fainting.

To assist the patient in transferring from the bed to the chair, you A.position the chair at a 90° angle to the head of the bed. B. keep your feet together while rocking the client up to a standing position. C.flex your hips and knees while lowering patient to the chair

C. flex your hips and knees while lowering patient to the chair. Flexing the hips and knees while lifting weight reflects good body mechanics as this prevents injury due to poor body alignment. Flexion of the knees and hips lowers your center of gravity in relation to the object you are raising or lifting.

A nurse ambulates an unsteady patient, the pt becomes light-headed and begins to fall. Which of the following interventions by the nurse is appropriate in this situation?

Extend one leg and allow the pt to slide down it. This is a correct procedure that prevents injury to the patient. As the patient gets close to the floor, the nurse bends both legs, continuing to support the patient.

A nurse is caring for a hospitalized patient who is performing active range of motion exercises. Which of the following body movements should indicate the nurse that the patient has full range of motion in the shoulder?

Flexing the shoulder by raising the arm from a side position to a 180 degree angle. The demonstrates full range of motion of the shoulder. The patients fingers would be pointing directly upward.

A nurse stands facing a pt to demonstrate AROM exercises. which of the following should the nurse do when demonstrating hyperextension of the hip?

Move the leg behind the body. The movement demonstrates hyperextension of the hip.

Which of your four patients should you see first? A.The patient who had a fractured femur repaired and must demonstrate proper crutch walking B.The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair C.The patient who had a lumbar repair and is on strict bed rest D.The patient with quadriplegia who had sacral redness when last turned 2 hours ago

The patient with quadriplegia who had sacral redness when last turned 2 hours ago.

Which of the following nursing actions will help improve your patient's tolerance of getting out of bed? select all that apply- A. Administer the prescribed oral pain medication to your patient about 20 minutes before she gets out of bed. B. Have your patient dangle her legs at the side of the bed first for a few minutes before getting out of bed. C. Assign the nursing assistant on your team to help your patient get out of bed. D. Explain the steps involved in getting out of bed to your patient prior to the procedure. E.Have the patient use crutches to help her get out of bed.

A. Administer the prescribed oral pain medication to your patient about 20 minutes before she gets out of bed. B. Have your patient dangle her legs at the side of the bed first for a few minutes before getting out of bed. D. Explain the steps involved in getting out of bed to your patient prior to the procedure.

Which action is appropriate when transferring the patient to the gurney using a slide board and three team members? A. Have one person hold the slide board steady while the other two pull the patient onto the gurney. B. Position the slide board under the patient and over the draw sheet. C. Adjust the height of the gurney so it is slightly higher than the height of the bed

A. Have one person hold the slide board steady while the other two pull the patient onto the gurney. Using this method, the slide board remains stationary as two team members pull the draw sheet and move the patient. This slippery surface reduces friction and makes it easier for the staff to pull the patient onto the gurney.

Which data may help to explain the patient's extreme fatigue? A. Hemoglobin and hematocrit B. Heart rate and blood pressure C. Temperature and white blood cell count D. Respiratory rate and oxygen saturation

A. Hemoglobin and hematocrit These values are a reflection of the patient's capacity to carry oxygen in the blood. This patient's results are below the normal range, possibly as a result of blood loss during surgery. A hemoglobin and a hematocrit below normal indicate anemia, which causes the manifestations of extreme fatigue, pallor, and weakness.

After the G-tube feeding is complete, which action will you direct the nursing assistant to perform next? A. Range-of-motion exercises B. Assistance out of bed via a mechanical/hydraulic lift

A. Range-of-motion exercises

You decide that both patients should get out of bed and plan to delegate assisting one of the patients to the nursing assistant. Which patient will you delegate to him? A. The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair B. The patient who had a lumbar repair and has a new activity order to ambulate with a walker

A. The patient who had hip arthroplasty and needs one person to help him get out of bed to the chair. In report, you learned that this patient is moving well and needs only the assistance of one person to get out of bed. Assisting patients with ambulation is a task you can delegate to nursing assistants, and, of the two patients, this one is the most appropriate choice.

Which action is appropriate when getting a patient out of bed via a mechanical/hydraulic lift? A.Place the sling under the patient's center of gravity and greatest portion of body weight. B. Position the patient's wheelchair alongside the foot of the bed, facing the head of the bed. C. Remove the sling from under the patient once he is safely positioned in the chair.

A.Place the sling under the patient's center of gravity and greatest portion of body weight. The sling (or hammock) is supplied with the lift. Hammocks that provide neck support are best for patients who are flaccid or have poor muscle tone. This helps ensure the patient's safety.

When teaching the patient how to ambulate with a cane, you say, A."When properly fitted, the cane length is twice the distance between the greater trochanter and the floor." B."Place the cane on your stronger side for support." C."After moving the cane, bear weight on the stronger side and swing yourself forward."

B."Place the cane on your stronger side for support." Patients who use a cane should place the cane in the hand on the stronger side so that the cane and the stronger leg provide support and balance when ambulating.

A nurse is performing a physical assessment on a patient and instructs the pt to stat with his feet together and arms at his sides. The purpose of positioning the pt in this manner is to test which of the following?

Balance This maneuver, the Romberg test, assesses balance. The nurse watches the swaying and stands near the patient to protect him from falling.

Prior to morning therapy, the patient requires several nursing interventions. Which nursing action do you and the nursing assistant perform first? A. Range-of-motion exercises B. Assistance out of bed via a mechanical/hydraulic lift C. Morning hygiene care and assessment

C. Morning hygiene care and assessment Patients who need total care are at increased risk for skin breakdown due to impaired mobility, and increased risk for other complications of immobility, including respiratory failure, impaired circulation, and sluggish digestion. It can be helpful to use the nursing process when deciding the order of nursing actions, Assessment is first; it guides your subsequent actions, and performing the morning assessment while providing hygiene care is an efficient use of your nursing time.

Based on the patient's condition, which type of range of motion (ROM) exercises should the nursing assistant initiate? A.active ROM. B.active-assisted ROM. C.passive ROM.

C. passive ROM Passive ROM exercises are performed without the patient's assistance to prevent joint contracture. These are most appropriate for a patient who is totally dependent and unable to follow instructions.

You determine that the patient performs the prescribed three-point gait appropriately when using his crutches because he... A.positions each upper crutch pad centered in the axilla. B. leans his upper torso forward slightly in the tripod position. C. advances the crutches first, followed by the unaffected leg.

C.advances the crutches first, followed by the unaffected leg.

You stop to see a patient who had arthroplasty on her left knee yesterday. You ask the patient how she is feeling and explain that her care plan calls for her to get out of bed to a chair today for the first time. The patient responds as follows: "I guess I am doing as well as can be expected, but I really don't think I am doing well enough to get out of bed. I am sure that it will be very painful." Which of the following should be your therapeutic response to this patient? A."Your doctor's orders call for you to get out of bed today." B."Everyone is a bit nervous about getting out of bed for the first time." C."Why don't you think you aren't able to get out of bed?" D."It sounds like you are concerned that getting out of bed will be painful."

D."It sounds like you are concerned that getting out of bed will be painful." When responding therapeutically to patients' questions, always remember that you must use communication skills and avoid communication blocks. In general, therapeutic responses are open-ended, patient-centered, and focused on the patient's feelings. This response meets all of these criteria. By acknowledging that you have heard the patient's message, this response encourages further communication.

A nurse in the emergency department is caring for a pt who has a knee injury. The pt will be discharged and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include when discharging this pt?

Hold the cruthces on the unaffected side when preparing to sit in a chair. The crutches should be held on the unaffected side when preparing to sit in a chair.

A nurse is observing an assistive personnel (AP) who is using a mech lift with a hammock sling to transfer a pt from the bed to a chair. The nurse should intervene if the AP

Leaves the bed in the lowest position throughout the procedure. The bed should be raised to its highest position in order to prevent injury to nursing staff and to properly position the lift under the patients bed.

Which patient will you see second? A.The patient who had a fractured femur repaired and must demonstrate proper crutch walking. B.The patient who had a hip arthroplasty and needs one person to help him get out of bed to the chair. C.The patient who had a lumbar repair and is on strict bed rest. D.The patient with quadriplegia who had sacral redness when last turned 2 hours ago.

The patient who had a fractured femur repaired and must demonstrate proper crutch walking. The patient's discharge is written, his escort has arrived, and you need to evaluate his ability to ambulate appropriately with crutches before he leaves. Although this is not an urgent situation from a medical standpoint, it is inappropriate to keep this patient waiting if your other two patients' needs are not urgent, either.

Can assistive personnel transfer patients?

You may delegate the task of transferring a patient to an AP who has demonstrated competency in transferring patients. You remain responsible for the delegation of this task, so you must be sure that the AP understands the procedure including the use of any necessary devices, determines how much the patient can participate if at all, and enlists the aid of other staff members as needed.