ch 18 and 39

The nurse assesses an elderly patient as having delayed capillary refill if the blanching lasts longer than _____ second(s).

5

A physician orders the nurse to place a patient in Fowler's position. The nurse should elevate the head of the patient's bed _____ degrees.

60 to 90

The patient for whom passive range-of-motion exercises would be most beneficial would be the

66-year-old patient with loss of mobility related to a recent cerebrovascular accident (CVA).

The nurse, in order to prevent the cast from chafing, will instruct the patient for home care to _______ the rough edges with adhesive tape.

Adhesive tape may be used to "petal" around the rough, crumbling edges of a cast to prevent chafing.

Complications from incorrect alignment and positioning include which of the following?

Pressure ulcers, Contractures, Fluid in the lungs

The nurse uses professional knowledge about body mechanics to prevent the most common occupational disorder in nurses, which is:

back injuries from lifting and twisting.

A nurse applying a pressure bandage for a patient should terminate the wrap by a _____ turn.

circular

When cleaning the pins on a patient in skeletal traction, the nurse should:

clean closest to the skin puncture site in a circular motion.,secure ends of wire with cork or adhesive tape.

The nurse explains that range-of-motion exercises are necessary so that movement improves venous circulation by:

compression of muscles on venous walls.

A patient who fractured a leg several weeks ago is scheduled for cast removal after he returns home. The nurse should explain to the patient to expect the skin underneath the cast to appear:

dry and dirty.

A patient has just had a leg cast applied with plaster of Paris. The nurse can best reduce the incidence of edema by:

elevating the leg on one to two pillows.

The nurse points out that the major advantage of the low-air-loss mattress is that it reduces the incidence of:

friction.

The nurse directs the immobilized patient in frequent deep breathing exercises during the day in order to combat:

hypostatic pneumonia

An example of the principles of good body mechanics applied to patient care occurs when the nurse:

keeps his feet fixed, spread one in front of the other, and turns his upper body to move the patient up in bed with a rocking movement.

A nurse is applying an elasticized bandage to the leg of a patient. To perform this procedure correctly, the nurse should:

overlap turns of the bandage equally.

When handling a freshly applied plaster cast while assisting a patient from stretcher to bed, the nurse should handle the cast using:

palms and flat parts of fingers.

An emaciated semiconscious bed-bound patient does not remain in a side-lying position and repeatedly turns onto her back, where she is developing a pressure area over her sacrum. The nurse should add to the nursing care plan to:

place the patient on her stomach (prone position) using a small pillow below her diaphragm.

The nurse caring for a patient with a nursing diagnosis of Injury, risk for, related to right-sided weakness as evidenced by unsteady gait, would accommodate the patient by:

placing the wheelchair on the left side of the patient before transfer.

The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include:

pressure injuries.loss of bone mass.pneumonia.permanent loss of function.

When the post-stroke patient complains to the nurse, "I don't see why you are wasting your time doing the passive range-of-motion exercises on my legs," the nurse's most informative response would be based on the knowledge that the exercises:

prevent contractures of the hips.

To place a patient in the Sims' or lateral-lying position, the nurse would initially:

raise the bed to a waist-high working level.

The daughter of an elderly woman with a diagnosis of a fractured tibia asks why her mother is in Buck's traction. The nurse's most informative response would be that Buck's traction:

reduces muscle spasm that accompanies fractures.

The nurse assisting a weak patient from a bed to the wheelchair to go to physical therapy would:

seat the patient on the side of the bed with feet touching the floor.

The nurse explains to the unlicensed assistive personnel (UAP) that a shearing force is applied to the patient when:

the patient is pulled up in bed without being lifted.

The nurse demonstrates a crutch walking technique by advancing the left crutch and the right foot and then the right crutch and the left foot. This is the _____ gait.

two-point

The nurse is aware that the maximum weight that can be applied with a skin traction is ______ pounds.

15

A nurse is observing a patient in a skilled nursing facility using a walker. The nurse concludes that the walker is at proper height if the patient's elbows are bent to which angle while the patient is upright and grasping the handgrips?

15 to 30 degrees

A nurse enters the room of a patient who is in Buck's traction (skin traction). An error in the traction setup observed would be:

feet resting against the foot of the bed.

A nurse performing a head-to-toe neurovascular check on a patient in a long leg cast notes an indication of altered perfusion as evidenced by:

numbness of distal limb.

A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home teaching plan information relative to:

protecting the cast from soiling,grasping the cast over the leg to help in turning.turning frequently to the prone position.

The nurse placing a patient following knee replacement surgery into a continuous passive motion (CPM) machine has the responsibility to:

set the proper flexion and extension limits.

There are two main factors in the development of pressure ulcers. One is pressure and the other is _________________.

shearing force

The nurse plans for an immobilized patient who suffered a cerebrovascular accident to be protected from skin disruption by the use of:

sheepskin pads.,water mattresses.,pulsating air pads.

As the nurse is helping an 85-year-old man to stand and ambulate, he complains that he feels that he has lost all of his strength in the last several years and cannot do the things he could do when he was 80. The nurse's most informative response would be:

"As we age our muscle cells are lost and replaced by fat, which leads to loss of strength."

A nurse giving instructions to a patient who will be using stairs while ambulating with crutches will instruct the patient:

"Bring the good leg up first when going up stairs."

A patient who just underwent a left arm cast change to a synthetic fiberglass cast asks when the cast should be dry. The best response is that it should be hardened enough to be durable within:

30 minutes.

A patient needs to have a triangular bandage applied. The nurse should position the sling so that the hand is _____ inches below the elbow.

4

A patient in the skilled nursing facility has left-sided paralysis from a stroke several years before, as well as generalized weakness. The nurse should ensure that which of the following devices is in place to prevent flexion contractures?

A rolled washcloth in the palm of her left hand or a hand splint

A 70-year-old immobile patient, who has right-sided weakness caused by a recent stroke, weighs approximately 250 pounds and needs to be moved up in bed. Which of the following actions should the nurse take?

Summon at least one other person to assist., Obtain a lift sheet, Place the patient flat on her back.

The nurse explains that an air-fluidized mattress would not be advocated for the patient with:

a spinal cord injury.

A patient who is weak from inactivity following a car accident benefits most if the nurse provides for:

active ROM exercises to arms and legs several times a day.

A nurse and an assistant are preparing to get a patient out of bed for the first time after a week of bed rest. They begin by having the patient dangle on the edge of the bed. The nurse should:

assess the patient's response to the changed position, looking for orthostatic hypotension, nausea, or dizziness before proceeding.

The nurse reminds a patient that one of the anatomic parts of a joint that allows the joint to move freely is the fluid-filled ___________.

bursa

A certified nursing assistant (CNA) is assisting a patient into a wheelchair. The nurse intervenes if the CNA has:

left the brakes of the wheelchair unlocked.

A nurse is instructing one of the facility's unlicensed assistive personnel (UAPs) regarding body mechanics for moving and lifting. The nurse recognizes that further instruction is warranted when the UAP states, "I will:

lift using my back muscles."

The primary function of a joint is to provide ______________ to the skeleton.

movement

To provide correct body alignment for a physically immobile patient in bed in the supine position, the nurse:

uses a footboard or places high-top sneakers on the patient's feet to maintain dorsiflexion.

The charge nurse on the night shift of a skilled nursing facility is orienting a new aide to the unit. The LPN's most accurate information relative to moving patients is:

"Get one other aide to help and use the mechanical lift when you get Mr. A out of bed in the morning. He is heavy and doesn't assist at all."

A frail older patient is able to stand but not to ambulate. She has an order to be up in a wheelchair as desired during the day. A safe and appropriate way to assist her up to a chair is to:

assist her to stand and pivot to a chair at right angles to the bed, using a transfer belt.

An anxious patient in skeletal traction is distressed by the clear fluid drainage that is oozing from the pin sites. The nurse's best intervention would be to:

assure the patient that such drainage is expected.

A nurse is ambulating an unsteady patient from the bed to a chair in the patient's home. To do so safely, the nurse applies a gait belt and:

slides his hand from the bottom under the gait belt at the middle of the patient's back.

While the nurse is assisting a patient to ambulate, the patient suddenly says, "I'm dizzy. I can't stand up." As the patient begins to fall, the nurse should:

step behind the patient, grasp her around the waist or chest, and slide her down his leg gently to the floor.

A patient who has had spinal surgery is not permitted to bend at the waist or to sit in a chair. To position the patient correctly in bed, the nurse:

uses logrolling to accomplish position changes from side to side.

When transferring a patient from bed to chair using a mechanical lift, the nurse should:

widen the stance of the lift's base and lock it.