Ch. 39 Activity & Exercise & Ch. 28 Immobility

The nurse recognizes that the older adult's progressive lose of total bone mass and tendency to make smaller steps with feet kept closer together will most likely: 1. Increase the patient's risk for falls and injury 2. result in less stress on the patient's joints 3. decrease the amount of work for patient movement 4. allow for mobility in spite of the aging effects on the patient's joints

1. Increase the patient's risk for falls and injury Physical inactivity, hormonal changes, and increased osteoclastic activity contribute to progressive loss of total bone mass in older adults.

Before transferring a patient from the bed to a stretcher, which assessment data of the nurse need to gather? (Select all that apply) 1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment 5. Nutritional intake

1. Patient's weight 2. Patient's level of cooperation 3. Patient's ability to assist 4. Presence of medical equipment By assessing the patient thoroughly you make the correct decision concerning your ability to manage him or her safely, the need for additional personnel, the patient's ability or inability to help you with the transfer, and the proper equipment to use for the transfer.

A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (select all that apply) 1. "I usually go swimming with my family at the YMCA three times a week." 2. "I need to ask my doctor if I need to have a bone mineral density check this year." 3. 'If I don't drink milk at dinner, I'll eat broccoli or cabbage to get that calcium that I need in my diet." 4. "I'll check the label of my multi-vitamin.If it has calcium, I can save money by not taking another pill." 5. "My lactose intolerance should not be a concern when considering my calcium intake."

1. "I usually go swimming with my family at the YMCA three times a week." 2. "I need to ask my doctor if I need to have a bone mineral density check this year." 3. 'If I don't drink milk at dinner, I'll eat broccoli or cabbage to get that calcium that I need in my diet." Patients at risk for or diagnosed with osteoporosis have special health promotion needs. Encourage patients at risk to be screened for osteoporosis and assess their diets for calcium and vitamin D intake. Multivitamins do not always have the needed amount of calcium for every individual. A patient needs to know his or her requirement and make a decision based on that.

A patient is experiencing some problems with joint stability. The doctor has prescribed crutches for the patient to use while still being allowed to bear weight on both legs. Which of the following gaits should the patient be taught to use? 1. 4 point 2. 3 point 3. 2 point 4. Swing-through

1. 4 point four points of support maintains a safe balance.

The body alignment of the patient in the tripod position includes the following: (Select all that apply) 1. An erect head and neck 2. Straight vertebrae 3. Extended hips and knees 4. Axillae resting on the crutch pads 5. Bent knees and hips

1. An erect head and neck 2. Straight vertebrae 3. Extended hips and knees This position improves the patient's balance by providing a wider base of support.

A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continuously assess the patient for the following signs of bleeding: (Select all that apply) 1. Bruising 2. Pale yellow urine 3. Bleeding gums 4. Coffee group like vomitus 5. Light brown stool

1. Bruising 3. Bleeding gums 4. Coffee group like vomitus Because bleeding is a potential side effect of these medications, continually assess the patient for signs of bleeding such as hematuria, bruising, coffee ground-like vomitus or gastrointestinal aspirate, guaiac-positive stools, and bleeding gums.

The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? 1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert 2. Hot dog on whole wheat bun with a side salad and an apple for desert 3. Low-fat turkey chili with sour cream with a side salad and fresh pears for dessert 4. Turkey salad on toast with tomato and lettuce and honey bun for dessert

1. Cream of broccoli soup with whole wheat crackers, cheese, and tapioca for dessert Teach patient and/or caregiver the current recommended dietary allowances for calcium and review foods high in calcium (e.g., milk fortified with vitamin D, leafy green vegetables, yogurt, and cheese).

A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: 1. Decreased peristalsis 2. Decreased heart rate 3. Increased blood pressure 4. Increased urinary output

1. Decreased peristalsis Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? 1. Encouraging use of an overhead trapeze for positioning and transfer 2. Frequent family visits 3. Assisting the patient to a wheelchair once per day 4. Ensuring that there is an order for physical therapy

1. Encouraging use of an overhead trapeze for positioning and transfer The trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed, aid in transfer from bed to wheelchair, or perform upper-arm exercises. It increases independence and maintains upper body strength to help in performing activities of daily living.

Place the following options in the order in which elastic stockings should be applied 1. Identify the patient with 2 identifiers 2. Smooth any creases or wrinkles 3. Slide the remainder of the stocking over the patient's heel and up the leg 4. Turn the stocking inside out until the heel is reached 5. Assess the condition of the patient's skin and circulation of the legs 6. Places toes into foot of stocking 7. Use tape measure to measure patient's let to determine proper stocking size

1. Identify the patient with 2 identifiers 5. Assess the condition of the patient's skin and circulation of the legs 7. Use tape measure to measure patient's leg to determine proper stocking size 4. Turn the stocking inside out until the heel is reached 6. Places toes into foot of stocking 3. Slide the remainder of the stocking over the patient's heel and up the leg 2. Smooth any creases or wrinkles

The effects of immobility on the cardiac system include which of the following? (select all that apply) 1. Thrombus formation 2. increased cardiac workload 3. weak peripheral pulses 4. irregular heartbeat 5. Orthostatic hypotension

1. Thrombus formation 2. increased cardiac workload 5. Orthostatic hypotension The three major changes are orthostatic hypotension, increased cardiac workload, and thrombus formation.

You notice a respiratory change in your immobilized postoperative patient. The changes you note is most consisted with: 1. atelectasis 2. hypertension 3. orthostatic hypotension 4. coagulation of blood

1. atelectasis

Which of the following statements made by an older adult reflects the best understanding of the need to exercise regardless of age? 1. "You are never to old to begin an exercise program." 2. "My granddaughter and I walk around the hight school track 3 times a week." 3. "I purchased a subscription to a runner's magazine for my grandson for christmas" 4. "When I was a child, I exercised more than I see kids doing today."

2. "My granddaughter and I walk around the hight school track 3 times a week." Patient understanding is confirmed when the patient is able to explain information or demonstrate it back. Inability to explain or demonstrate indicates the need for repeat instruction or trying a new approach. Teach back is a way to confirm that a nurse has explained to a patient what he or she needs to know in a manner that the patient understands.

A patient with a right knee replacement is prescribed no weight bearing on the right leg. You reinforce crutch walking known that which of the following crutch gaits is most appropriate for this patient? 1. 2 point 2. 3 point 3. 4 point 4. Swing through

2. 3 point Three-point alternating, or three-point gait requires the patient to bear all of the weight on one foot. In a three-point gait, the patient bears weight on both crutches and then on the uninvolved leg, repeating the sequence.

Which is the correct gait when a patient is ascending the stairs on crutches? 1. A modified 2 point gait (the affected leg is advanced between the crutches to the stairs) 2. A modified 3 point gait (the unaffected let is advanced between he crutches to the stairs) 3. A swing through gait 4. A modified 4 point gait (both legs advance between the crutches to the stairs)

2. A modified 3 point gait (the unaffected let is advanced between he crutches to the stairs) When ascending stairs on crutches, the patient usually uses a modified three-point gait.

To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient who has had an abdominal surgery? 1. Turn, cough, and deep breathe every 30 minutes while awake 2. Ambulate patient to chair in the hall 3. Passive range of motion 4 times a day 4. Immobility is not a concern the firs postoperative day.

2. Ambulate patient to chair in the hall Prevention of complications of immobility begins when the patient becomes immobilized. Every 30 minutes is not necessary and disruptive to the healing process. Active patient participation in exercises is more beneficial to preventing venous stasis.

The nurse evaluates that the NAP has applied a patient's sequential compression device appropriately when which of the following is observed? (Select all that apply) 1. Initial patient measurement is made around the calves 2. Inflation pressure averages 40 mmHg 3. Patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve 4. Stockings are removed every 2 hours during application 5. Yellow light indicated SCD device is functioning

2. Inflation pressure averages 40 mmHg 3. Patient's leg placed in SCD sleeve with back of knee The most effective way to prevent deep vein thrombosis is through an aggressive program of prophylaxis. A properly functioning SCD inflates with a pressure around 40 mm Hg. Inflation pressure averages 40 mm Hg, and the patient's leg should be placed in the SCD sleeve with the back of knee aligned with the popliteal opening on the sleeve. Measurement involves length of leg, not calf. A green light indicates the SCD device is functioning.

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while laying flat. Which of the following assessment data support a possible pulmonary problem related to impaired mobility? (Select all that apply) 1. B/P = 128/84 2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation 5. Pain reported a 3 on a scale of 0 to 10 after medication

2. Respirations 26/min on room air 3. HR 114 4. Crackles over lower lobes heard on auscultation Patients who are immobile are at high risk for developing pulmonary complications. The most common respiratory complications are atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from stasis or pooling of secretions). Ultimately the distribution of mucus in the bronchi increases, particularly when the patient is in the supine, prone, or lateral position.

Which of the following most motivates a patient to participate in an exercise program? 1. providing a patient with a pamphlet on exercise 2. providing information to the patient when he or she is ready to change behavior 3. explaining the importance of exercise at the time of diagnosis of a chronic disease 4. providing the patient with a booklet of examples of exercises 5. providing the patient with a prescribed exercise program

2. providing information to the patient when he or she is ready to change behavior Patients are more open to developing an exercise program when they are at a stage of readiness to change their behavior.

A nursing assistive personnel asks for help to transfer a patient who s 125 lbs from the bed to a wheelchair. The patient is unable to help. What is the nurse's best response? 1. "As long as we use the proper body mechanics, no one will get hurt." 2. "The patient only weighs 125 lbs. You don't need my assistance." 3. "Call the lift team for additional assistance." 4. "The two of us can lift the patient easily."

3. "Call the lift team for additional assistance." Body mechanics alone are not sufficient to prevent musculoskeletal injuries when positioning or transferring patients. Teaching the use of patient-handling equipment or a lift team in combination with proper body mechanics is more effective.

Which of the following are physiologic outcomes of immobility? 1. Increased metabolism 2. Reduced cardiac workload 3. Decreased lung expansion 4. Decreased oxygen demand

3. Decreased lung expansion

Which of the following is a principle of proper body mechanics when lifting or carrying objects? (Select all that apply) 1. Keep the knees in a locked position 2. Bend at the waist to maintain a center of gravity 3. Maintain a wide base of support 4. Hold objects away from the body for improved leverage 5. Encourage patient to help as much as possible

3. Maintain a wide base of support 5. Encourage patient to help as much as possible Patient assistance promotes independence and strength while minimizing workload. A broad base of support increases stability.

A patient on prolonged bed rest is at increased risk to develop this common complication of immobility if preventative measures are not taken. 1. Myoclonus 2. Pathological fractures 3. Pressure ulcers 4. Pruritus

3. Pressure ulcers Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative.

Musculoskeletal disorders are the most prevalent and debilitating occupational health hazards for nurses. To reduce the risk for these injuries, The ANA advocates which of the following? 1. Mandate that physical therapists do all patient transfers 2. Require adequate staffing levels in health care organizations 3. Require the use of assisted equipment and devices 4, Require an adequate number of staff to be involved in all patient transfers

3. Require the use of assisted equipment and devices Musculoskeletal disorders are the most prevalent and debilitating occupational health hazards for nurses. Preventive interventions are needed to avoid the hazards and economic burdens associated with patient-handling tasks. The American Nurses Association (ANA, 2010) position statement calls for the use of assistive equipment and devices to promote a safe health care environment for nurses and their patients.

Which of the following indicates that additional assistance is needed to transfer the patient from the bed to the stretcher? 1. The patient is 5 feet 6 inches and weighs 120 pounds 2. The patient speaks and understands english 3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation 4. The patient received analgesia for pain 30 minutes ago

3. The patient is returning to unit from recovery room after a procedure requiring conscious sedation The morphine injection would change the patient's ability to safely follow directions and participate in the transfer; therefore additional help would be needed to safely transfer the patient from the bed to the stretcher.

A nurse is instructing a patient who has decreased leg strength on the left side how to use a cane. Which action indicates proper cane use by the patient? 1. The patient keeps the cane on the left side of the body 2. The patient slightly leans to one side while walking 3. The patient keeps two points of support on the floor at all times 4. After the patient places the cane forward, he or she then moves the right leg forward to the cane

3. The patient keeps two points of support on the floor at all times Two points of support on floor maintains a safe balance.

An older adult patient has been bed-ridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility 1. Loss of appetite 2. Gum soreness 3. Difficulty swallowing 4. Left ankle joint stiffness

4. Left ankle joint stiffness Patients whose mobility is restricted require range-of-motion (ROM) exercises daily to reduce the hazards of immobility. Temporary immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness. Two weeks of joint immobilization without ROM can quickly result in contractures.

A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess: 1. posture 2. activity tolerance 3. body mechanics 4. range of joint motion

4. Range of joint motion

The nurse encourages a patient with type 2 diabetes to engage in a regular exercise program primarily to improve the patient's: 1. Gastric motility, thereby facilitating glucose digestion 2. Respiratory effort, thereby decreasing activity intolerance 3. Overall cardiac output, thereby resuming resting heart rate 4. Use of glucose and fatty acids, thereby decreasing blood glucose level

4. Use of glucose and fatty acids, thereby decreasing blood glucose level Recent data in the United States show the prevalence of diabetes among adults aged 65 years and older to average around 28%. Obesity and a sedentary lifestyle are consistent contributing factors across all ethnic groups diagnosed with type 2 diabetes.

Which of the following nursing interventions should be implemented to maintain a patient airway in a patient on bed rest? 1. Isometric exercises 2. Administration of low-dose heparin 3. Suctioning every 4 hours 4. Use of incentive spirometer every 2 hours while awake

4. Use of incentive spirometer every 2 hours while awake Incentive spirometry opens the airway, preventing atelectasis.

When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? A. To identify the potential risk for deep vein thrombosis (DVT) B. To identify improper patient positioning C. To select the proper stocking size D. To determine whether a sequential compression device is needed

A. To identify the potential risk for deep vein thrombosis (DVT) The nurse assesses for skin discoloration because it is one possible indicator of deep vein thrombosis (DVT).

When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first? A.Assesses the patient for weakness, dizziness, or postural hypotension B. Arranges for at least three healthcare personnel to assist in the transfer C. Makes sure the patient agrees to the intervention D. Applies clean gloves

A.Assesses the patient for weakness, dizziness, or postural hypotension Assessing the patient for weakness, dizziness, or postural hypotension will help ensure the patient's safety.

Which patient is most at risk of developing permanently impaired mobility? A: A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) B: A 55-year-old woman with mental illness who had become malnourished C: An 11-year-old boy who sustained a fractured pelvis during a fall from his tree house D: A 79-year-old man recovering from surgery to release a contracture of the connective tissue in his hand

A: A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) Rationale: Although this patient's anemia will not affect her mobility, she is the patient most at risk of mobility impairment. The fact that she has diabetes, a serious chronic condition, puts her at high risk of mobility impairment. In addition, her age is a risk factor, since mobility impairment is more prevalent among older adults.

The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk? A: Ask the patient how far she would like to go. B: Review the health care provider's order. C: Review the medical record to see how far the patient has walked during the past several therapeutic ambulations. D: Review the records of other patients who are at a similar point in their stroke rehabilitation.

A: Ask the patient how far she would like to go. Rationale: Setting mutual goals increases the likelihood of success in achieving the goal of ambulation.

When turning a patient to place a slide board, where do the assistants stand? A: At the side of the bed to which the patient will be turned B: At the side of the bed from which the patient will be turned C: At the head and foot of the bed D: At the foot of the bed only

A: At the side of the bed to which the patient will be turned Rationale: When turning a patient to place him or her on a slide board, the assistants stand on the side of the bed to which the patient will be turned.

The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move? A: Hold the slide board stationary in place. B: Pull the draw sheet. C: Hold the patient's head stationary. D: Lock the brakes on the stretcher.

A: Hold the slide board stationary in place. Rationale: The nurse, standing alone, will hold the slide board in place as the two assistants pull the draw sheet.

The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do? A: Return the patient to the bed or chair (whichever is closer). B: Encourage the patient to complete the distance of ambulation. C: Help him to the restroom. D: Ease him to the floor.

A: Return the patient to the bed or chair (whichever is closer). Rationale: This action allows patient to rest, and the nausea may subside.

The nurse has applied a gait belt to a postoperative patient to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse's initial response? A: Slowly lower the patient to the floor. B: Attempt to sit the patient down on a chair just a few steps away. C: Try to hold the patient up until the dizziness passes. D: Call for assistance in a loud but calm voice.

A: Slowly lower the patient to the floor. Rationale: The safest action would be for the nurse to slowly lower the patient to the floor. The patient is already leaning heavily on the nurse, and attempting to ambulate him or her even a few steps may injure the patient, the nurse, or both.

The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer? A: Four B: Two C: One D: None

B: Two Rationale: The nurse will need two additional people to help move this patient. Three nurses are recommended for a slide board transfer.

When preparing to move a patient in bed, what will the nurse do first? a. Assemble adequate help to move the patient. B. Assess the patient's ability to help with moving. C. Determine the patient's weight. D. Decide on the most effective means of moving the patient.

B. Assess the patient's ability to help with moving. CORRECT. Assessing the patient's ability to help is the first thing the nurse must do, since the answer determines how much help is needed with the move.

After determining the proper size stocking and assessing the patient's circulatory status, a nurse delegates the application of elastic stockings to nursing assistive personnel (NAP). The nurse discovers that the NAP has been using moisturizer on the patient's legs before applying the stockings. What is the best action by the nurse? A.Explain that moisturizer may cause excessive skin softening, which can lead to skin breakdown. B. Instruct NAP to use a small amount of cornstarch or powder. C. Ask the patient if she is allergic to the moisturizer. D. Inspect the patient's skin for color variations.

B. Instruct NAP to use a small amount of cornstarch or powder. Using a small amount of cornstarch or powder will decrease friction and make the stockings easier to apply.

When re positioning a patient, what can the nurse do to prevent the patient's hips from rolling outward? A. Apply therapeutic boots to the feet. B. Place sandbags along the legs. C. Place a small pillow at the lumbar region of the back. D. Place a pillow under the calves.

B. Place sandbags along the legs. CORRECT. Placing sandbags along the legs will prevent the hips from rolling outward.

When positioning a hemiplegic patient in the supported Fowler's position, what is the primary reason a trochanter roll is placed alongside the patient's legs? A. To reduce the risk of a fall while the side rails are down B. To reduce the risk of contracture C. To control pain D. To cushion the legs

B. To reduce the risk of contracture CORRECT. A trochanter roll is placed alongside the patient's legs to prevent external rotation of the hips, which contributes to contracture.

The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up? A: "I will be sure to put nonskid slippers on the patient before getting him up to ambulate." B: "I will use the under-axillae technique to help him up to a standing position." C: "Rocking the heavier patient into a standing position seems to work really well for me." D: "I will grasp the gait belt in the middle of the patient's back."

B: "I will use the under-axillae technique to help him up to a standing position." Rationale: This is not a safe lifting technique, so this statement requires the nurse to follow up.

The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient? A: On the patient's strong side B: On the patient's weak side C: Behind the patient D: In front of the patient

B: On the patient's weak side Rationale: The patient's weak side would need support if the patient begins to fall.

The nurse notes that a patient's left elbow is resistant to extention and flexion while performing range of motion exercises. What is the appropriate nursing action? A: Move joint through full range of motion exercises. B: Perform range of motion to the left elbow until resistance is met. C: Omit all range of motion exercises until the health care provider is notified. D: Inform the health care provider that the patient is uncooperative with exercising.

B: Perform range of motion to the left elbow until resistance is met. Rationale: The nurse would stop the range of motion exercises because resistance is met. The range of motion exercises should not continue until pain is felt by the patient.

A patient lying supine in bed is being transferred to a wheelchair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed? A: Help the patient put on skid-resistant footwear. B: Raise the head of the bed 30 degrees. C: Place the transfer belt over the patient's clothing. D: Position the chair so that the patient will move toward his or her stronger side.

B: Raise the head of the bed 30 degrees. Rationale: The nurse would raise the head of the bed 30 degrees right before moving the patient to the side of the bed.

Which of the following are basic guidelines when assisting a patient with passive range of motion? A: Exercises should be continued until the point of fatigue and pain. B: Exercises should be done frequently to lessen pain for the patient. C: Each joint is exercised to the point of resistance but not pain. D: Exercises should be performed without the support to each joint.

C: Each joint is exercised to the point of resistance but not pain. Rationale: Joints should be exercised slowly, smoothly, and rhythmically to the point of resistance but pain should not be felt by the patient. Uncomfortable reactions should be reported.

Which condition is not associated with venous stasis, part of Virchow's triad? A. Pregnancy B. Obesity C. Anxiety D. Immobility

C. Anxiety Pregnancy, obesity, and immobility can all cause pooling of blood in the lower extremities. Anxiety is not associated with blood stasis.

A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? A. A minimum of two B. None, since the device does all the lifting during the move. C. At least three D. The nurse can carry out this move without assistance.

C. At least three CORRECT. Since a friction-reducing device will be used and the client weighs more than 157 lbs., a minimum of three to four people are needed to move this patient safely.

When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety? A. Stand with the knees locked. B. Stand with the feet together. C. Flex the hips and knees. D. Shift the body weight from the back leg to the front leg.

C. Flex the hips and knees. CORRECT. Flexing the hips and knees is the safest posture for both caregivers to assume when moving a patient in bed.

To which position would the nurse assist the patient who is experiencing difficulty breathing? A. Sims' position B. 30-degree lateral position C. Fowler's position D. Prone position

C. Fowler's position CORRECT. In the Fowler's position the head of the bed is elevated and maximal breathing space in the thoracic cavity is promoted. Fowler's is the position of choice for a patient having breathing difficulties.

The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side? A. Place a small pillow under the shoulder. B. Use the affected arm as a guide during rolling. C. Place a pillow on the abdomen. D. Place rolled bath blankets along the dependent leg.

C. Place a pillow on the abdomen. CORRECT. When rolling a patient with hemiplegia onto her side while moving into the prone position, the nurse should place a pillow on the patient's abdomen.

A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient? A. Lift the patient to place the device directly under him or her. B. Remove the draw sheet, and replace it with the device. C. Roll the patient from side to side, and place the device under the draw sheet. D. Sit the patient up in the bed, and place the device behind the shoulders.

C. Roll the patient from side to side, and place the device under the draw sheet. CORRECT. The patient will be rolled from side to side and the device placed under the draw sheet.

In which position will the nurse place the patient to move him or her up in bed? A. Supine with the head of the bed at a 30-degree angle B. Sitting in the bed C. Supine with the head of the bed flat D. Prone with the head of the bed flat

C. Supine with the head of the bed flat CORRECT. Placing the patient in the supine position with the head of the bed flat is the recommended position to use to move a patient up in bed.

Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient's legs? A. The patient will have a scheduled bath in a few hours. B. The patient says they are too tight. C. The patient's skin is irritated. D. The patient has become fully ambulatory.

C. The patient's skin is irritated. Elastic stockings should not be applied if the skin of the legs is irritated.

The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned? A. To position the pillows B. To keep the spine in alignment C. To roll the patient as a unit D. To ease the patient back onto the support pillows

C. To roll the patient as a unit CORRECT. Two assistants are needed to roll the patient as a unit, using one smooth, continuous motion. One assistant grasps the draw sheet at the lower hips and thighs, and the other assistant grasps the draw sheet at the patient's shoulders and lower back.

Which action would decrease a patient's pain before a transfer with a hydraulic lift? A: Stop the transfer if the patient expresses or displays physical signs of pain. B: Explain the procedure to the patient before beginning the transfer. C: Administer a prescribed analgesic 30 to 60 minutes before the transfer. D: Postpone the transfer if the patient reports having physical pain or anxiety before the transfer.

C: Administer a prescribed analgesic 30 to 60 minutes before the transfer. Rationale: Administering a prescribed analgesic 30 to 60 minutes before the transfer helps prevent unnecessary pain during transfer by allowing time for the medication to take effect before the patient is moved.

When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve? A: After the patient crosses the arms over the chest B: After the patient's eyeglasses are removed C: As soon as the patient has been placed in the chair D: When the nurse removes the straps

C: As soon as the patient has been placed in the chair Rationale: The nurse turns off the check valve as soon as the patient has been placed in the chair.

When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first? A: Coordinate extra help. B: Assess the patient's vital signs. C: Assess the patient's physiological capacity to transfer. D: Determine whether to transfer the patient to a wheelchair or chair.

C: Assess the patient's physiological capacity to transfer. Rationale: Assessing the patient's physiological capacity to transfer determines the patient's ability to tolerate and assist with the transfer and whether special adaptive techniques are necessary.

A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair? A: Remove the wheelchair leg rests. B: Ask the patient to rate his or her pain level. C: Lower the foot rests, and place the patient's feet on them. D: Remove the transfer belt.

C: Lower the foot rests, and place the patient's feet on them. Rationale: The nurse lowers the foot rests and places the patient's feet on them once the patient has been positioned in the wheelchair. Doing so supports the patient's feet and keeps them from dragging and creating a falling hazard when the chair is moved.

The nurse is preparing to move a patient from a bed to a stretcher. What is the first action of the nurse? A: Cross the patient's arms over his or her chest. B: Lower the side rails of the bed. C: Make sure the bed brakes are locked. D: Fanfold the draw sheet.

C: Make sure the bed brakes are locked. Rationale: The nurse's first action would be to verify the bed brakes are locked prior to moving the patient.

After moving a patient from the bed to a stretcher, the nurse raises the head of the stretcher. What will the nurse do next? A: Lock the wheels on the stretcher. B: Cover the patient with a blanket. C: Raise the side rails on the stretcher. D: Unlock the wheels of the bed.

C: Raise the side rails on the stretcher. Rationale: The nurse will raise the side rails after adjusting the head of the stretcher.

Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift? A: Prone B: Side-lying C: Supine D: Sims

C: Supine Rationale: The patient is placed in the supine position before he or she is transferred from the bed to a chair with a hydraulic lift.

Why would the nurse ask a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash? A: The patient is an older adult or has a chronic condition. B: The patient is reluctant to perform the exercises because he is worried about reinjury. C: The patient has orthopedic trauma. D: The patient has pain exacerbated by exercise.

C: The patient has orthopedic trauma. Rationale: Specialized expertise is usually required to perform passive ROM exercises for a patient with orthopedic trauma or spinal cord injury.

A nurse plans to provide education to the parents of school-age children, which includes the increased prevalence of _____________ as a result of children being less physically active outside of school.

Childhood obesity

Why does the nurse remove the patient's elastic stockings at least once per shift? A. To permit the skin to breathe. B. To wash the legs with a disposable bath product. C. To air out the stockings and allow sweat to evaporate. D. To check the skin for irritation or breakdown.

D. To check the skin for irritation or breakdown. The nurse removes the patient's elastic stockings at least once per shift to check the skin for irritation or breakdown.

Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt? A: "When I count to three, please rock yourself into a standing position." B: "Please hold on to my waist while I help you stand." C: "Please tell me how I can best help you get up off the bed and stand up." D: "Please push down onto the mattress with both hands and stand when I count to three."

D: "Please push down onto the mattress with both hands and stand when I count to three." Rationale: Telling the patient to push against the mattress is the best instruction the nurse can give because it teaches the patient how to help achieve a standing position during the transfer.

What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? A: Lower the head of the bed. B: Remove the patient's eyeglasses. C: Have the patient cross the arms over the chest. D: Elevate the head of the bed.

D: Elevate the head of the bed. Rationale: The head of the bed is elevated immediately after the hooks are attached to the sling.

The nurse is preparing to transfer a patient with left-sided weakness from the bed to a wheelchair using a transfer belt. Which position would the nurse instruct the patient to assume? A: Place both feet together on the floor. B: Place your weaker foot forward and your stronger leg toward the back. C: Extend both of your legs and feet. D: Place your stronger leg forward and your weaker leg toward the back.

D: Place your stronger leg forward and your weaker leg toward the back. Rationale: The nurse will instruct the patient to place the stronger leg forward, with the weaker foot toward the back, allowing the stronger leg to support most of the patient's body weight.

The nurse is performing passive shoulder and elbow exercises for a patient who is recovering from surgery to remove a soft-tissue tumor in her upper arm. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises? A: To keep the arm above the level of the heart B: To assess the patient's muscle tension C: To listen for crepitus in the joint D: To ensure stability while exercising the joint

D: To ensure stability while exercising the joint Rationale: The nurse supports the distal portion of the extremity in order to ensure joint stability.

The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to ________________________.

Promote venous return to the heart