Exam 2 - Skills

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group? a. "Are you able to hear the tornado sirens in our area?" b. "Are you able to read your favorite book?" c. "Are you able to taste spices like before?" d. "Are you able to open a jar of pickles?"

a. "Are you able to hear the tornado sirens in our area?" The ability to hear safety alerts and seek shelter is imperative to life safety. Decreased hearing acuity alters the ability to hear emergency vehicle sirens. Natural disasters such as floods, tsunamis, hurricanes, tornadoes, and wildfires are major causes of death and injury. Although age-related changes may cause a decrease in sight that affects reading, and although tasting is impaired and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the most important.

The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic? a. "Smoking even at parties is not good for my body." b. Our campus is safe; we leae our dorms unlocked all the time." c. As long as I have only two drinks, I can sill be he designated driver." d. I am young, so I can work nights and go to school with 2 hours sleep."

a. "Smoking even at parties is not good for my body." Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning.

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one? 1. Pull the alarm. 2. Remove the patient. 3. Use the fire extinguisher. 4. Close doors and windows. a. 2, 1, 4, 3 b. 1, 2, 4, 3 c. 1, 2, 3, 4 d. 2, 1, 3, 4

a. 2, 1, 4, 3 Nurses use the mnemonic RACE to set priorities in case of fire. The steps are as follows: Rescue and remove all patients in immediate danger; Activate the alarm; Confine the fire by closing doors and windows; and Extinguish the fire using an appropriate extinguisher.

The nurse is starting an exercise program in a local community as a health promotion project. Which information will the nurse include in the teaching session? a. A cool-down period lasts about 5 to 10 minutes. b. The purpose of weight training is to bulk up muscles. c. Resistance training is appropriate for warm-up and cool-down periods. d. Aerobic exercise should be done 3 to 5 times per week for about 20 minutes.

a. A cool-down period lasts about 5 to 10 minutes. The cool-down period follows the exercise routine and usually lasts about 5 to 10 minutes. The purposes of weight training from a health perspective are to develop tone and strength and to simulate and maintain healthy bone. Stretching and flexibility exercises are ideal for warm-up and cool-down periods. The recommended frequency of aerobic exercise is 3 to 5 times per week or every other day for approximately 30 minutes.

The patient weighs 450 lbs (204.5 kg) and reports shortness of breath with any exertion. The health care provider has recommended beginning an exercise program. The patient states that she can hardly get out of bed and just cannot do anything around the house. Which nursing diagnosis will the nurse add to the care plan? a. Activity intolerance related to excessive weight b. Impaired physical mobility related to bed rest c. Imbalanced nutrition: less than body requirements d. Impaired gas exchange related to shortness of breath

a. Activity intolerance related to excessive weight In hi cae, acii inolerance i relaed o he paien eceie eigh. The paien i no on bed rest although claims that it is difficult to get out of bed, making this diagnosis inappropriate. Shortness of breath is a symptom, not a cause, of Impaired gas exchange, making this nursing diagnosis ineffective. The patient certainly has an imbalance of nutrition, but it is more than body requirements (obesity).

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take? a. Assess the patient. b. Gather restraint supplies. c. Try alternatives to restraint. d. Call the health care provider for a restraint order.

a. Assess the patient. When a patient becomes suddenly confused, the priority is to assess the patient, to identify the reason for change in behavior, and to try to eliminate the cause. If interventions and alternatives are exhausted, the nurse working with the health care provider may determine the need for restraints.

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? (Select all that apply.) a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Move bedridden patients in their bed. e. Wait until the fire department arrives to act. f. Use type B fire extinguishers for electrical fires.

a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Move bedridden patients in their bed. Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case evacuation is needed. You will move bedridden patients from the scene of a fire by a stretcher, bed, or wheelchair. The nurse cannot wait until the fire department arrives to act. Type C fire extinguishers are used for electrical fires; type B is used for flammable liquids.

A nurse observes a patient rising from a chair slowly by pushing on the chair arms. Which type of tension and contraction did the nurse observe? a. Eccentric tension and isotonic contraction b. Eccentric tension and isometric contraction c. Concentric tension and isotonic contraction d. Concentric tension and isometric contraction

a. Eccentric tension and isotonic contraction This movement causes eccentric tension and isotonic contraction. Eccentric tension helps control the speed and direction of movement. For example, when using an overhead trapeze, the patient slowly lowers himself to the bed. The lowering is controlled when the antagonistic muscles lengthen. By pushing on the chair arms and rising eccentric tension and isotonic contraction occurred. In concentric tension, increased muscle contraction causes muscle shortening, resulting in movement such as when a patient uses an overhead trapeze to pull up in bed. Concentric and eccentric muscle actions are necessary for active movement and therefore are referred to as dynamic or isotonic contraction. Isometric contraction (static contraction) causes an increase in muscle tension or muscle work but no shortening or active movement of the muscle (e.g., instructing the patient to tighten and relax a muscle group, as in quadriceps set exercises or pelvic floor exercises).

The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which intervention will the nurse add to the care plan? a. Encourage the patient to perform as many self-care activities as possible. b. Provide a complete bed bath to promote patient comfort. c. Coordinate with occupational therapy for gait training. d. Place the patient on bed rest to prevent fatigue.

a. Encourage the patient to perform as many self-care activities as possible. Nurses should encourage the older-adult patient to perform as many self-care activities as possible, thereby maintaining the highest level of mobility. Sometimes nurses inadvertently contribute to a patient's immobility by providing unnecessary help with activities such as bathing and transferring. Placing the patient on bed rest without sufficient ambulation leads to loss of mobility and functional decline, resulting in weakness, fatigue, and increased risk for falls. After a stroke or brain attack, a patient likely receives gait training from a physical therapist; speech rehabilitation from a speech therapist; and help from an occupational therapist for ADLs such as dressing, bathing and toileting, or household chores.

A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess? a. Imbalance b. Hemiplegia c. Muscle sprain d. Lower extremity paralysis

a. Imbalance Damage to the cerebellum causes problems with balance, and motor impairment is directly related to the amount of destruction of the motor strip. A stroke can lead to hemiplegia. Direct trauma to the musculoskeletal system results in bruises, contusions, sprains, and fractures. A complete transection of the spinal cord can lead to lower extremity paralysis.

The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session? a. Increased aggressiveness and blood spots on clothing may indicate substance abuse. b. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing. c. Adolescents need information about the effects of uncoordination on accidents. d. Adolescents need to be reminded to use seat belts primarily on long trips.

a. Increased aggressiveness and blood spots on clothing may indicate substance abuse. Increased aggressiveness (psychosocial clue) and blood spots on clothing (environmental clue) may indicate substance abuse. School-age children are often uncoordinated. Seat belts should be used all the time. In fact, teens have the lowest rate of seat belt use.

The nurse is caring for a patient with inner ear problems. Which goal is the priority? a. Maintain balance. b. Maintain proprioception. c. Maintain muscle strength. d. Maintain body alignment.

a. Maintain balance. Within the inner ear are the semicircular canals, three fluid-filled structures that help maintain balance. Proprioception is the awareness of the position of the body and its parts, and proprioceptors are located on nerve endings, not the inner ear. Muscle strength is maintained with activity and exercise. Although body alignment is important, it is not maintained by the inner ear.

A nurse is working in a facility that follows a comprehensive safe patient-handling program. Which finding will alert the nurse to intervene? a. Mechanical lifts are in a locked closet. b. Algorithms for patient handling are available. c. Ergonomic assessment protocols are being followed. d. A no-lift policy is in place with adherence by all staff.

a. Mechanical lifts are in a locked closet. The nurse will follow up when lifts are not kept in convenient locations. Comprehensive safe patient- handling programs include the following elements: an ergonomics assessment protocol for health care environments, patient assessment criteria, algorithms for patient handling and movement, special equipment kept in convenient locations to help transfer patients, back injury resource nurses, an "after-action review" that allows the health care team to apply knowledge about moving patients safely in different settings, and a no-lift policy.

The nurse is preparing to move a patient to a wheelchair. Which action indicates the nurse is following recommendations for safe patient handling? a. Mentally reviews the transfer steps before beginning b. Uses own strength to transfer the patient c. Focuses solely on body mechanics d. Bases decisions on intuition

a. Mentally reviews the transfer steps before beginning Safe patient handling includes mentally reviewing the transfer steps before beginning the procedure o enre boh he paien and or afe. Ue he paien rengh hen lifing, ranferring, or moving when possible. Body mechanics alone do not protect the nurse from injury to the musculoskeletal system when moving, lifting, or transferring patients. After completing the assessment, nurses use an algorithm to guide decisions about safe patient handling.

A home health nurse is assessing a family home after the birthdayh of an infant. A toddler also livas in the home. Which finding will cause the nurse to follow up? a. Plastic grocery bags are neatly stored under the counter. b. Electric outlets are covered in all rooms. c. No bumper pads are in the crib. d. Crib slats are 5 cm apart.

a. Plastic grocery bags are neatly stored under the counter. Plastic grocery bags increase the risk for suffocation. The nurse will follow up with instructions to remove or keep locked or out of reach. All the rest are correct and do not require follow-up. Electrical outlets should be covered to reduce electrical shock. Bumper pads are not used in the crib to prevent suffocation, strangulation, or entrapment. Crib slats should be less than 6 cm apart.

A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session? a. Proper fit of a bicycle helmet b. Proper fit of soccer shin guards c. Proper fit of swimming goggles d. Proper fit of baseball sliding shorts

a. Proper fit of a bicycle helmet Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries. Proper fit of the helmet helps to decrease head injuries resulting from these bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.

A nurse is working in a facility that uses no-lift policies. Which benefits will the nurse observe in the facility? (Select all that apply.) a. Reduced number of work-related injuries b. Increased musculoskeletal accidents c. Reduced safety of patients d. Improved health of nurses e. Increased indirect costs

a. Reduced number of work-related injuries d. Improved health of nurses Implementing evidence-based interventions and programs (e.g., lift teams) reduces the number of work-related injuries, which improves the health of the nurse and reduces indirect costs to the health care facility (e.g., workers' compensation and replacing injured workers). Knowing the movements and functions of muscles in maintaining posture and movement and implementing evidence-based knowledge about safe patient handling are essential to protecting the safety of both the patient and the nurse.

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next? a. Remove the restraint. b. Place a blanket over the feet. c. Immediately do a complete head-to-toe neurologic assessment. d. Take the patient's blood pressure, pulse, temperature, and respiratory rate.

a. Remove the restraint. If the patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness, remove the restraint immediately and notify the health care provider. Light blue is cyanosis, indicating the restraints are too tight, not that the patient is cold and needs a blanket. A complete head-to-toe neurological assessment is not needed at this time. The nurse can take vital signs after the restraint is removed.

A nurse writes the following outcomes for a patient who has chronic obstructive pulmonary disease to improve activity level: Diastolic blood pressure will remain below 70 mm Hg with systolic below 130 mm Hg. Resting heart rate will range between 65 and 75. The last goal is that the patient will exercise 3 times a week. Which evaluative findings indicate successful goal achievement? (Select all that apply.) a. Resting heart rate 70 b. Blood pressure 126/64 c. Blood pressure 140/90 d. Reports doing stretching and flexibility exercises 2 times this week e. Reports doing resistive training 1 time and aerobics 2 times this week

a. Resting heart rate 70 b. Blood pressure 126/64 e. Reports doing resistive training 1 time and aerobics 2 times this week Compare actual outcomes with epeced ocome o deermine he paien healh a and progression. Heart rate of 70 is between 65 and 75. Blood pressure 126/64 meets the goal. Did resistive training 1 time and aerobics 2 times equals exercising 3 times a week. Did stretching and flexibility exercises 2 times is below the 3 times a week. Blood pressure 140/90 is too high and does not meet the goal.

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Check on patient every 15 minutes. b. Risk for suffocation: Place "Oxygen in Use" sign on door. c. Disturbed body image: Encourage patient to express concerns about body. d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.

a. Risk for injury: Check on patient every 15 minutes. The priority nursing diagnosis is Risk for injury. This patient could cause harm to self by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include more frequent observations. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints. However, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient is at risk for suffocation.

A nurse notices that a patient has a structural curvature of the spine associated with vertebral rotation. Which condition will the nurse most likel find docmened in he paien medical record? a. Scoliosis b. Arthritis c. Osteomalacia d. Osteogenesis

a. Scoliosis Scoliosis is a structural curvature of the spine associated with vertebral rotation. Osteogenesis imperfecta is an inherited disorder that makes bones porous, short, bowed, and deformed. Osteomalacia is an uncommon metabolic disease characterized by inadequate and delayed mineralization, resulting in compact and spongy bone. Arthritis is an inflammatory joint disease characterized by inflammation or destruction of the synovial membrane and articular cartilage and by systemic signs of inflammation.

A nurse is assessing activity tolerance of a patient. Which areas will the nurse assess? (Select all that apply.) a. Skeletal abnormalities b. Emotional factors c. Pregnancy status d. Race e. Age

a. Skeletal abnormalities b. Emotional factors c. Pregnancy status e. Age Phiological, emoional, and deelopmenal facor (age) inflence he paien acii olerance. Factors influencing activity tolerance include physiological factors such as skeletal abnormalities, emotional factors such as anxiety/depression, developmental factors such as age and gender, and pregnancy status. Race is not a factor because people of all races are faced with similar factors that affect their activity tolerance.

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.) a. Smoking in bed helps me relax and fall asleep. b. We never leave candles burning when we are gone. c. We use the same space heater my grandparents used. d. We use the RACE method when using the fire extinguisher. e. There is a fire extinguisher in the kitchen and garage workshop.

a. Smoking in bed helps me relax and fall asleep. c. We use the same space heater my grandparents used. d. We use the RACE method when using the fire extinguisher. Incorrect information will cause the nurse to intervene. Accidental home fires typically result from smoking in bed. Advise families to only purchase newer model space heaters that have all of the current safety features. The PASS method is used for fire extinguishers. All the rest are correct and do not require follow-up. Candles should not be left burning when no one is home. Keep a fire extinguisher in the kitchen, near the furnace, and in the garage.

A nurse is teaching a health promotion class about isotonic exercises. Which types of exercises will the nurse give as examples? a. Swimming, jogging, and bicycling b. Tightening or tensing of muscles without moving body parts c. Quadriceps set exercises and contraction of the gluteal muscles d. Push-ups, hip lifting, pushing feet against a footboard on the bed

a. Swimming, jogging, and bicycling Examples of isotonic exercises are walking, swimming, dance aerobics, jogging, bicycling, and moving arms and legs with light resistance. Isometric exercises involve tightening or tensing of muscles without moving body parts. Examples include quadriceps set exercises and contraction of the gluteal muscles. Examples of resistive isometric exercises are push-ups and hip lifting, as well as placing a footboard on the foot of the bed for patients to push against with their feet.

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboraion ih ocial erice o addre he paien healh care need? a. The electricity was turned off 3 days ago. b. The water comes from the county water supply. c. A son and family recently moved into the home. d. This home is not furnished with a microwave oven.

a. The electricity was turned off 3 days ago. Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the naea, omiing, and diarrhea de o food poioning. Thi dicion abo he paien elecrical needs can be referred to social services. Foods that are inadequately prepared or stored or subject o naniar condiion increae he paien rik for infecion and food poioning, and an assessment should include storage practices. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.

A nurse is assessing body alignment. What is the nurse monitoring? a. The relationship of one body part to another while in different positions b. The coordinated efforts of the musculoskeletal and nervous systems c. The force that occurs in a direction to oppose movement d. The inability to move about freely

a. The relationship of one body part to another while in different positions The terms body alignment and posture are similar and refer to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Body alignment means that the individual center of gravity is stable. Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems. Friction is a force that occurs in a direction to oppose movement. Immobility is the inability to move about freely.

Which activity will cause the nurse to monitor for equipment-related accidents? a. Uses a patient-controlled analgesic pump b. Uses a computer-based documentation record c. Uses a measuring device that measures urine d. Uses a manual medication-dispensing device

a. Uses a patient-controlled analgesic pump Accidents that are equipment related result from the malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient- controlled analgesic pumps need to have free-flow protection devices. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient and are considered procedure-related accidents.

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens? a. Wash hands b. Wash wound c. Wear gloves d. Wear eye protection

a. Wash hands One of the most effective methods for limiting the transmission of pathogens is the medically aseptic practice of hand hygiene. The most common means of transmission of pathogens is by the hands. While washing the wound is needed, the best method to prevent transmission is hand hygiene. Wearing gloves and possibly eye protection help protect the nurse, but handwashing is best for limiting the transmission of pathogens.

A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal? a. When observed laterally, the spinal curves align in a reversed S pattern. b. When observed posteriorly, the hips and shoulders form an S pattern. c. The arms should be crossed over the chest or in the lap. d. The feet should be close together with toes pointed out.

a. When observed laterally, the spinal curves align in a reversed S pattern. When the patient is observed laterally, the head is erect and the spinal curves are aligned in a reered S paern. When obered poeriorl, he holder and hip are raigh and parallel. The arms hang comfortably at the sides. The feet are slightly apart to achieve a base of support, and the toes are pointed forward.

The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? (Select all that apply.) a. Where did you fall? b. What time did the fall occur? c. What were you doing when you fell? d. What types of injuries occurred after the fall? e. Did you obtain an electronic safety alert device after the fall? f. What are your medical problems that may have caused the fall?

a. Where did you fall? b. What time did the fall occur? c. What were you doing when you fell? d. What types of injuries occurred after the fall? Assess previous falls; using the acronym SPLATT: Symptoms at time of fall, Previous fall, Location of fall, Activity at time of fall, Time of fall, Trauma after fall. Medical diagnoses and an alert device are not components of SPLATT.

The nurse is teaching a patient how to sit with crutches. In which order will the nurse present the instructions starting with the first step? 1. Place both crutches in one hand. 2. Grasp arm of chair with free hand. 3. Completely lower self into chair. 4. Transfer weight to crutches and unaffected leg. a. 4, 1, 2, 3 b. 1, 4, 2, 3 c. 1, 2, 4, 3 d. 4, 2, 1, 3

b. 1, 4, 2, 3 A patient is sitting in a chair with crutches. Both crutches are held in one hand. The patient then transfers weight to the crutches and the unaffected leg. Next, the patient grasps the arm of the chair with the free hand and begins to lower self into chair. Finally, the patient completely lowers self into chair.

The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat? a. 60° to 64° F b. 65° to 75° F c. 15° to 17° C d. 25° to 28° C

b. 65° to 75° F A peron comfor one i all beeen 18.3 and 23.9 C (65 and 75 F). The oher range are too low or too high and do no reflec he aerage peron comfor one.

Which patient will the nurse see first? a. A 56-year-old patient with oxygen with a lighter on the bedside table b. A 56-year-old patient with oxygen using an electric razor for grooming c. A 1-month-old infant looking at a shiny, round battery just out of arms reach d. A 1-month-old infant with a pacifier that has no string around the baby's neck

b. A 56-year-old patient with oxygen using an electric razor for grooming The nurse will see the patient shaving with an electric razor first as this is an actual problem. Do not use oxygen around electrical equipment or flammable products. A lighter on the bedside table and a shiny, round battery are potential problems, not actual. Plus, it would be hard, almost impossible, for a 1 month old to actually grab the battery when it is out of arm's reach. A baby should use a pacifier without strings.

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan? a. A patient who is completely immobile b. A patient who is not completely immobile c. A patient at risk for single-system involvement d. A patient who is at risk for multisystem problems

b. A patient who is not completely immobile The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems.

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? a. No blood incompatibility occurs with a blood transfusion. b. A surgical sponge is left in he patients incision. c. Pulmonary embolism after lung surgery d. Stage II pressure ulcer

b. A surgical sponge is left in he patients incision. The Centers for Medicare and Medicaid Services names select serious reportable events as Never Events (i.e., adverse events that should never occur in a health care setting). A surgical sponge left in a patient's incision is a Never Event. No blood incompatibility reaction Is safe practice. Pulmonary embolism after certain orthopedic procedures is like a total knee and hip replacement. Stage III and IV pressure ulcers are Never Events.

The nurse is preparing to lift a patient. Which action will the nurse take first? a. Position a drawsheet under the patient. b. Assess weight and determine assistance needs. c. Delegate the task to a nursing assistive personnel. d. Attempt to manually lift the patient alone before asking for assistance.

b. Assess weight and determine assistance needs. When lifting, assess the weight you will lift, and determine the assistance you will need. The nurse has to assess before positioning a drawsheet or delegating the task. Manual lifting is the last resort, and it is used when the task at hand does not involve lifting most or all of the patient's weight; most facilities have a no-lift policy.

The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take when assessing the respiratory system? a. Inspect chest wall movements primarily during the expiratory cycle. b. Auscultate the entire lung region to assess lung sounds. c. Focus auscultation on the upper lung fields. d. Assess the patient at least every 4 hours.

b. Auscultate the entire lung region to assess lung sounds. Auscultate the entire lung region to identify diminished breath sounds, crackles, or wheezes. Perform a respiratory assessment at least every 2 hours for patients with restricted activity. Inspect chest wall movements during the full inspiratory-expiratory cycle. Focus auscultation on the dependent lung fields because pulmonary secretions tend to collect in these lower regions.

An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient? a. Positions patients buttocks close to the front of wheelchair seat b. Backs wheelchair into elevator, leading with large rear wheels first c. Places locked wheelchair on same side of bed as patient's weaker side d. Unlocks wheelchair for easy maneuverability when patient is transferring

b. Backs wheelchair into elevator, leading with large rear wheels first A correct action when using a wheelchair is to back wheelchair into an elevator, leading with large rear wheels first. A patient buttocks should be well back into the seat. A locked wheelchair should be placed on a patient's strong or unaffected side. Brakes should be securely locked when a patient is transferring.

The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding? a. The edge of the seat is in contact with the popliteal space. b. Both feet are supported on the floor with ankles flexed. c. The body weight is directly on the buttocks only. d. The arms hang comfortably at the sides.

b. Both feet are supported on the floor with ankles flexed. Both feet are supported on the floor, and the ankles are comfortably flexed. Body weight is evenly distributed on the buttocks and thighs. A 1- to 2-inch space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee to ensure that no pressure is placed on he poplieal arer or nere. The paien forearm are ppored on he armre, in he lap, or on a table in front of the chair.

A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel? a. Determining the level of comfort b. Changing the patient's position c. Identifying immobility hazards d. Assessing circulation

b. Changing the patient's position The skill of moving and positioning patients in bed can be delegated to nursing assistive personnel (NAP). The nre i reponible for aeing he paien leel of comfort and for any hazards of immobility and assessing circulation.

The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first? a. Maintain a narrow base of support. b. Dangle the patient at the bedside. c. Encourage isometric exercises. d. Suggest a high-calcium diet.

b. Dangle the patient at the bedside. To prevent injury, nurses implement interventions that reduce or eliminate the effects of orthostatic hypotension. Mobilize the patient as soon as the physical condition allows, even if this only involves dangling at the bedside or moving to a chair. A wide base of support increases balance. Isometric exercises (i.e., activities that involve muscle tension without muscle shortening) have no beneficial effect on preventing orthostatic hypotension, but they improve activity tolerance. A high-calcium diet can help with osteoporosis but can be detrimental in an immobile patient.

The patient applies sequential compression devices after going to the bathroom. The nurse check the patient's application of the device and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient plan of care? a. Risk for falls b. Deficient knowledge c. Risk for suffocation d. Impaired physical mobility

b. Deficient knowledge The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for falls, impaired physical mobility, or suffocation.

A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session? a. Run wires under the carpet. b. Disconnect items before cleaning. c. Grasp the cord when unplugging items. d. Use masking tape to secure cords to the floor.

b. Disconnect items before cleaning. A guideline to prevent electrical shock is to disconnect items before cleaning. Do not run wires under carpeting. Grasp the plug, not the cord, when unplugging items. Use electrical tape to secure the cord to the floor, preferably against baseboards.

A nurse is preparing to move a patient who is able to assist. Which principles will the nurse consider when planning for safe patient handling? (Select all that apply.) a. Keep the body's center of gravity high. b. Face the direction of the movement. c. Keep the base of support narrow. d. Use the under-axilla technique. e. Use proper body mechanics. f. Use arms and legs.

b. Face the direction of the movement. e. Use proper body mechanics. f. Use arms and legs. When a patient is able to assist, remember the following principles: The wider the base of support, the greater the stability of the nurse; the lower the center of gravity, the greater the stability of the nurse; facing the direction of movement prevents abnormal twisting of the spine. The use of assistive equipment and continued use of proper body mechanics significantly reduces the risk of musculoskeletal injuries. Use arms and legs (not back) because the leg muscles are stronger, larger muscles capable of greater work without injury. The under-axilla technique is physically stressful for nurses and uncomfortable for patients.

The nurse is preparing to transfer an uncooperative patient who does not have upper body strength. Which piece of equipment will be best for the nurses to obtain? a. Drawsheet b. Full body sling c. Overhead trapeze d. Friction-reducing slide sheet

b. Full body sling Using a mechanical lift and full body sling to transfer an uncooperative patient who can bear partial weight or a patient who cannot bear weight and is either uncooperative or does not have upper body strength to move from bed to chair prevents musculoskeletal injuries to health care workers. The nurse should not attempt to move the patient with a drawsheet. The patient does not have upper body strength so an overhead trapeze is not appropriate. A friction-reducing slide sheet that minimizes shearing forces is not as effective as a full body sling.

A patient requires restraints after alternatives are not successful. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care? (Select all that apply.) a. Health care provider orders restraints prn (as needed). b. Health care provider writes the type and location of the restraint. c. Health care provider renews orders for restraints every 24 hours. d. Health care provider performs a face-to-face assessment prior to the order. e. Health care provider specifies the duration and circumstances under which the restraint will be used.

b. Health care provider writes the type and location of the restraint. d. Health care provider performs a face-to-face assessment prior to the order. e. Health care provider specifies the duration and circumstances under which the restraint will be used. A phician/healh care proider order i reqired, baed on a face-to-face assessment of the patient. The order must be current, state the type and location of restraint, and specify the duration and circumstances under which it will be used. These orders need to be renewed within a specific time frame according to the policy of the agency. In hospital settings each original restraint order and renewal is limited to 8 hours for adults, 2 hours for ages 9 through 17, and 1 hour for children under age 9. Restraints are not to be ordered prn (as needed).

The nurse is developing a plan of care for a patient diagnosed with activity intolerance. Which strategy will the nurse use to provide the best chance of maintaining patient compliance? a. Performing 20 minutes of aerobic exercise 7 days a week with 10-minute warm-up and cool-down periods b. Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity c. Stressing the harm of not exercising by getting the patient to take responsibility for current health status d. Arranging for the patient to join a gym that takes self-pay rather than insurance

b. Instructing the patient to use an exercise log to record day, time, duration, and responses to exercise activity Keeping a log may increase adherence to an exercise prescription. Recommended frequency of aerobic exercise is 3 to 5 times per week or every other day for approximately 30 minutes. Focusing on the harm of not exercising is usually counterproductive. Instead, the nurse should instruct the patient about the physiological benefits of a regular exercise program. Developing a plan of exercise that the patient may perform at home may improve compliance.

The nurse is assessing body alignment for a patient who is immobilized. Which patient position will the nurse use? a. Supine position b. Lateral position c. Lateral position with positioning supports d. Supine position with no pillow under the patient's head

b. Lateral position Assess body alignment for a patient who is immobilized or bedridden with the patient in the lateral position, not supine. Remove all positioning supports from the bed except for the pillow under the head, and support the body with an adequate mattress.

An adolescent tells the nurse that a health professional said the fibrous tissue that connects bone and cartilage was strained in a sporting accident. On which structure will the nurse focus an assessment? a. Tendon b. Ligament c. Synergistic muscle d. Antagonistic muscle

b. Ligament Ligaments are white, shiny, and flexible bands of fibrous tissue that bind joints and connect bones and cartilage. Tendons are strong, flexible, and inelastic as they serve to connect muscle to bone. Muscles attach bone to bone. Synergistic muscles contract to accomplish the same movement. Antagonistic muscles cause movement at the joint.

A patient with diabetes mellitus is starting an exercise program. Which types of exercises will the nurse suggest? a. Low intensity b. Low to moderate intensity c. Moderate to high intensity d. High intensity

b. Low to moderate intensity Instruct patients diagnosed with diabetes mellitus to perform low- to moderate-intensity exercises, carry a concentrated form of carbohydrates (sugar packets or hard candy), and wear a medical alert bracelet. Low intensity is not beneficial. Moderate to high and high intensity are not recommended for a beginner exercise program.

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority? a. Monitor for specific symptoms. b. Manage all patients using standard precautions. c. Transport patients quickly and efficiently through the elevators. d. Prepare for post-traumatic stress associated with this bioterrorism attack.

b. Manage all patients using standard precautions. Manage all patients with suspected or confirmed bioterrorism-related illnesses using standard precautions. For certain diseases, additional precautions may be necessary. The early signs of a bioterrorism-related illness often include nonspecific symptoms (e.g., nausea, vomiting, diarrhea, skin rash, fever, confusion) that may persist for several days before the onset of more severe disease. Limit the transport and movement of patients to movement that is essential for treatment and care. Psychosocial concerns (post-traumatic stress) are important but are not the first priority at this moment.

The nurse is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the nurse take? a. Remove elastic stockings every 4 hours. b. Measure the calf circumference of both legs. c. Lightly rub the lower leg for redness and tenderness. d. Dorsiflex the foot while assessing for patient discomfort.

b. Measure the calf circumference of both legs. Measure bilateral calf circumference and record it daily as an assessment for DVT. Unilateral increase in calf circumference are an early indication of thrombosis. Homan's sign, or calf pain on dorsiflexion of the foot, is no longer a reliable indicator in assessing for DVT, and it is present in other condition. Remove the patient's elastic stocking and/or sequential compression device (SCDs) every 8 hours, and observe the calves for redness, warmth, and tenderness. Instruct the family, patient, and all health care personnel not to massage the area because of the danger of dislodging the thrombus.

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next? a. Do nothing, no harm has occurred. b. Notify the healthcare provider. c. Complete an incident report. d. Assess the patient.

b. Notify the healthcare provider. Report immediately to physician or health care provider if the patient sustains a fall or an injury. The nurse must provide safe care, and doing nothing is not safe care. The scenario indicates the nurse has already assessed the patient. After the patient has stabilized, completing an incident report would be the last step in the process.

The nurse is caring for a patient in restraints. Which essential information will the nurse document in he paien medical record o proide afe care? (Select all that apply.) a. One family member has gone to lunch. b. Patient is placed in bilateral wrist restraints at 0815. c. Bilateral radial pulses present, 2+, hands warm to touch d. Straps with quick-release buckle attached to bed side rails e. Attempts to distract the patient with television are unsuccessful. f. Released from restraints, active range-of-motion exercises completed

b. Patient is placed in bilateral wrist restraints at 0815. c. Bilateral radial pulses present, 2+, hands warm to touch e. Attempts to distract the patient with television are unsuccessful. f. Released from restraints, active range-of-motion exercises completed Proper documentation, including the behaviors that necessitated the application of restraints, the procedure used in restraining, the condition of the body part restrained (e.g., circulation to hand), and the evaluation of the patient response, is essential. Record nursing interventions, including rerain alernaie ried, in nre noe. Record prpoe for rerain, pe and locaion of restraint used, time applied and discontinued, times restraint was released, and routine observations(e.g., kin color, ple, enaion, ial ign, and behaior) in nre noe and flo hee. Straps are not attached to side rails. Comments about the activities of one family member are not necessarily required in nursing documentation of restraints.

The nurse is teaching a patient how to use a cane. Which information will the nurse include in the teaching session? a. Place the cane at the top of the hip bone. b. Place the cane on the stronger side of the body. c. Place the cane in front of the body and then move the good leg. d. Place the cane 10 to 15 inches in front of the body when walking.

b. Place the cane on the stronger side of the body. Have the patient keep he cane on he ronger ide of he bod. A peron cane lengh i eqal o the distance between the greater trochanter and the floor. The cane should be moved first and then the weaker leg. For maximum support when walking, the patient places the cane forward 15 to 25 cm (6 to 10 inches), keeping body weight on both legs. The weaker leg is then moved forward to the cane, so body weight is divided between the cane and the stronger leg.

A nurse reviews an immobilized patient laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient? a. Hypostatic pneumonia b. Renal calculi c. Pressure ulcers d. Thrombus formation

b. Renal calculi Renal calculi are calcium stones that lodge in the renal pelvis or pass through the ureters. Immobilized patients are at risk for calculi because they frequently have hypercalcemia. Hypercalcemia does not lead to hypostatic pneumonia, pressure ulcers, or thrombus formation. Immobility is one cause of hypostatic pneumonia, which is inflammation of the lung from stasis or pooling of secretions. A pressure ulcer is an impairment of the skin that results from prolonged ischemia (decreased blood supply) within tissues. A thrombus is an accumulation of platelets, fibrin, clotting factors, and cellular elements of the blood attached to the interior wall of a vein or artery, which sometimes occludes the lumen of the vessel.

The nurse is caring for a patient in the emergency department with an injured shoulder. Which type of joint will the nurse assess? a. Fibrous b. Synovial c. Synergistic d. Cartilaginous

b. Synovial Synovial joints, or true joints, such as the hinge type at the elbow, are freely movable and the most mobile, numerous, and anatomically complex body joints. Fibrous joints fit closely together and are fixed, permitting little, if any, movement such as the syndesmosis between the tibia and the fibula. Synergistic is a type of muscle, not joint. Cartilaginous joints have little movement but are elastic and use cartilage to unite separate bony surfaces such as the synchondrosis that attaches the ribs to the costal cartilage.

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately? a. Respiratory rate b. Temperature c. Apical pulse d. Blood pressure

b. Temperature The temperature indicates the patient is experiencing hypothermia. Homeless individuals are more at risk for hypothermia. While all the vital signs are low, the most critical vital sign at this time is the temperature.

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint? a. The patient refuses to call for help to go to the bathroom. b. The patient continues to remove the nasogastric tube. c. The patient gets confused regarding the time at night. d. The patient does not sleep and continues to ask for items.

b. The patient continues to remove the nasogastric tube. Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feeding, or Foley catheterization. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

When making rond he nre obere a prple riband on a paien ri. Ho ill he nurse interpret this finding? a. The patient is allergic to certain medications or foods. b. The patient has do not resuscitate preferences. c. The patient has a high risk for falls. d. The patient is at risk for seizures.

b. The patient has do not resuscitate preferences. In 2008 the American Hospital Association issued an advisory recommending that hospitals standardize wristband colors: red for patient allergies, yellow for fall risk, and purple for do not resuscitate preferences. Purple does not indicate seizures.

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls? a. The patient is oriented. b. The patient takes a hypnotic. c. The patient walks 2 miles a day. d. The patient recently became widowed.

b. The patient takes a hypnotic. Numerous factors increase the risk of falls, including a history of falling and the effects of various medications such as anticonvulsants, hypnotics, sedatives, and certain analgesics. Being oriented will decrease risk for falls while disorientation will increase the risk of falling. Walking has many benefits, including increasing strength, which would be beneficial in decreasing risk. Becoming widowed would increase stress and may affect concentration but is not a great risk.

The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action? a. The patient removes the armband to bathe. b. The patient wears the red nonslip footwear. c. The patient insists on taking a "water" pill in he evening. d. The patient who is allergic to penicillin asks the name of a new medicine.

b. The patient wears the red nonslip footwear. A yellow armband is an alert for high risk of falls. Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for fall. A red armband indicates an allergen. Give diuretics ("water" pill) in the morning to decrease risk of falls during the night - when most falls occur.

The patient is brought to the emergency department with possible injury to the left shoulder. Which area will the nurse assess to best determine joint mobility? a. The patients gait b. The patient's range of motion c. The patient's ethnic influences d. The patient's fine-motor coordination

b. The patient's range of motion Assessing range of motion is one assessment technique used to determine the degree of joint mobility and injury to a joint. Gait is the manner or style of walking. It has little bearing on the shoulder damage. Assessing fine-motor coordination would be beneficial in helping to assess the patient's ability to perform tasks such as feeding and dressing but would not help in evaluating the shoulder. Ethnic influences would not have a direct bearing on the amount of mobility in the joint.

The patient is eager to begin an exercise program with a 2-mile jog. The nurse instructs the patient to warm up. The patient does not want o ae ime ih a arm-p. Which informaion ill the nurse share with the patient? a. The warm-up in this case can be done after the 2-mile jog. b. The warm-up prepares the body and decreases the potential for injury. c. The warm-up allows the body to readjust gradually to baseline functioning. d. The warm-up should be performed with high intensity to prepare for the coming challenge.

b. The warm-up prepares the body and decreases the potential for injury. The warm-up activity prepares the body for activity and decreases the potential for injury and should not be omitted. It usually lasts about 5 to 10 minutes and may include stretching, calisthenics, and/or aerobic activity performed at a lower intensity. The warm-up is before the exercise, while the cool- down period is after the exercise. The cool-down, not the warm-up, allows the body to readjust gradually to baseline functioning and provides an opportunity to combine movement such as stretching with relaxation-enhancing mind-body awareness. The warm-up should not be a high- intensity workout.

The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing? a. Young infant b. Toddler c. Preschooler d. Adolescent

b. Toddler The incidence of lead poisoning is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouths. Young infant is too young. A preschooler and an adolescent are too old.

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which information will the nurse include in the teaching session? (Select all that apply.) a. Water outdoor plants with a nozzle and hose. b. Walk to the mailbox in the summer. c. Encourage yearly eye examinations. d. Use bathtubs without safety strips. e. Keep pathways clutter free.

b. Walk to the mailbox in the summer. c. Encourage yearly eye examinations. e. Keep pathways clutter free. Walking to the mailbox in summer provides exercise when pathways are not icy and slick. Encourage annual vision and hearing examinations. Pathways that are clutter free reduce fall risk. Using a hose to water plants and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home.

The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with chronic obstructive pulmonary disease doing stretching exercises b. A patient with diabetes mellitus carrying hard candy while doing exercises c. A patient with a heart attack doing isometric exercises d. A patient with hypertension doing Tai Chi exercises

c. A patient with a heart attack doing isometric exercises The nurse must see the myocardial infarction patient first to stop this type of exercise. It is important to understand the energy expenditure (increased respiratory rate and increased work on the heart) associated with isometric exercises because the exercises are sometimes contraindicated in certain patients' illnesses (e.g., myocardial infarction or chronic obstructive pulmonary disease). All the rest are appropriate. Stretching exercises are beneficial for patients with chronic obstructive pulmonary disease. Also instruct patients to perform low- to moderate-intensity exercises, carry a concentrated form of carbohydrates (sugar packets or hard candy), and wear a medical alert bracelet. The effect of a Tai Chi exercise program has demonstrated a significant reduction in systolic and diastolic blood pressures.

The patient reports being tired and weak and lacks energy. Upon assessment, the nurse finds that patient has gained weight, and blood pressure and pulse are elevated after climbing stairs. Which nursing diagnosis will the nurse add to the care plan? a. Fatigue b. Ineffective coping c. Activity intolerance d. Decreased cardiac output

c. Activity intolerance You consider nursing diagnoses of Activity intolerance or Fatigue in a patient who reports being tired and weak. Further review of assessed defining characteristics (e.g., abnormal heart rate and verbal report of weakness and the assessment findings occurring during the activity of climbing the stairs) leads to the definitive diagnosis (Activity intolerance). There is no data to support ineffective coping or decreased cardiac output.

A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition? a. Thermometer b. Elastic stockings c. Blood pressure cuff d. Sequential compression devices

c. Blood pressure cuff A blood pressure cuff is needed. Orthostatic hypotension is a drop of blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure and symptoms of dizziness, light- headedness, nausea, tachycardia, pallor, or fainting when the patient changes from the supine to standing position. A thermometer is used to assess for fever. Elastic stockings and sequential compression devices are used to prevent thrombus.

A nurse is assessing a patient with activity intolerance for possible orthostatic hypotension. Which finding will help confirm orthostatic hypotension? a. Blood pressure sitting 120/64; blood pressure 140/70 standing b. Blood pressure sitting 126/64; blood pressure 120/58 standing c. Blood pressure sitting 130/60; blood pressure 110/60 standing d. Blood pressure sitting 140/60; blood pressure 130/54 standing

c. Blood pressure sitting 130/60; blood pressure 110/60 standing Orthostatic hypotension results in a drop of 20 mm Hg systolic or more in blood pressure when rising from sitting position (110/60). 120 to 140 means the blood pressure increased rather than dropped. 126 to 120 is only a six point difference. 140 to 130 is only a 10 point difference.

The nurse is caring for a patient who cannot bear weight but needs to be transferred from the bed to a chair. The nurse decides to use a transportable hydraulic lift. What will the nurse do? a. Place a horseshoe-shaped base on the opposite side from the chair. b. Remove straps before lowering the patient to the chair. c. Hook longer straps to the bottom of the sling. d. Attach short straps to the bottom of the sling.

c. Hook longer straps to the bottom of the sling. The nurse should attach the hooks on the strap to the holes in the sling. Short straps hook to top holes of the sling; longer straps hook to the bottom of the sling. The horseshoe-shaped base goes under the side of the bed on the side with the chair. Position the patient and lower slowly into the chair in accordance with manufacturer guidelines to safely guide the patient into the back of the chair as the seat descends; then remove the straps and the mechanical/hydraulic lift.

The nurse is performing the "Timed Get Up and Go (TUG)" assessment. Which actions will the nurse take? (Select all that apply.) a. Ranks a patient as high risk for falls after patients take 18 seconds to complete b. Teaches patient to rise from straight back chair using arms for support c. Instructs the patient to walk 10 feet as quickly and safely as possible d. Observes for unsteadiness in patient's gait e. Begins counting after the instructions f. Allows the patient a practice trial

c. Instructs the patient to walk 10 feet as quickly and safely as possible d. Observes for unsteadiness in patient's gait f. Allows the patient a practice trial The nurse instructs the patient to walk 10 feet (3 m) as quickly and safely as possible and observes for neadine in he paien gai. For accrac, a paien hold hae one pracice rial ha i not included in the score. Patient taking less than 20 seconds to complete TUG is adequate for independent mobility. Score over 30 seconds is dependent and at risk for fall. Counting does not begin after instructions. The patient rises from a straight back chair without using arms for support.

A nurse is following the no-lift policy when working to prevent personal injury. Which type of personal back injury is the nurse most likely trying to prevent? a. Thoracic b. Cervical c. Lumbar d. Sacral

c. Lumbar The most common back injury for nurses is strain on the lumbar muscle group, which includes the muscles around the lumbar vertebrae. While cervical, thoracic, and sacral can occur, lumbar is the most common.

The nurse is providing care to a patient who is bedridden. The nurse raises the height of the bed. Wha i he raionale for he nre acion? a. b. c. d. a. Narrows the nurse's base of support. b. Allows the nurse to bring feet closer together. c. Presents a shift in the nurse's base of support d. Shifts the nurse's center of gravity farther away from the base of support.

c. Presents a shift in the nurse's base of support Raising the height of the bed when performing a procedure prevents bending too far at the waist and shifting the base of support. Balance is maintained by proper body alignment and posture through two simple techniques. First, widen the base of support by separating the feet to a comfortable distance. Second, increase balance by bringing the center of gravity closer to the base of support.

The nurse gives instructions to a nursing assistive personnel (NAP) regarding exercise for a patient. Which action by the NAP indicates a correct understanding of the directions? a. Determines the patient's ability to exercise b. Teaches the patient how to do the exercises c. Reports the patient got dizzy after exercising d. Advises the patient to work through the pain

c. Reports the patient got dizzy after exercising The NAP notifies the nurse if a patient reports increased fatigue, dizziness, or light-headedness when obtaining preexercise and/or postexercise vital signs. The nurse first must assess the patient's ability and tolerance to exercise. The nurse also teaches patients and their families how to implement exercise programs. The NAP can prepare patients for exercise (e.g., putting on shoes and clothing, providing hygiene needs, and obtaining preexercise and postexercise vital signs). The NAP can help the patient exercise.

A nurse is assisting the patient to perform isometric exercises. Which action will the nurse take? a. Encourage wearing tight shoes. b. Set the pace for the exercise session. c. Stop the exercise if pain is experienced. d. Force muscles or joints to go just beyond resistance.

c. Stop the exercise if pain is experienced. Instruct the patient to stop the activity if pain, fatigue, or discomfort is experienced. Assess for pain, shortness of breath, or a change in vital signs; if present, stop the exercise. Let each patient move at his or her own pace. Assess for joint limitations, and do not force a muscle or a joint during exercise. Teach patient to wear comfortable shoes and clothing for exercise.

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident? a. Pathogenic asepsis b. Medical asepsis c. Surgical asepsis d. Clean asepsis

c. Surgical asepsis The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter. Pathogenic and clean asepsis are not types of asepsis. Medical asepsis is not sterile.

The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working? a. The patient continues to get up from the chair at the nurses' station. b. The patient gets restless when the sitter leaves for lunch. c. The patient folds three washcloths over and over. d. The patient apologizes for being "such a bother".

c. The patient folds three washcloths over and over. Restraint alternatives include more frequent observations, social interaction such as involvement of family during visitation, frequent reorientation, regular exercise, and the introduction of familiar and meaningful stimuli (e.g., involve in hobbies such as knitting or crocheting or looking at family photos) within the environment or folding washcloths. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Getting restless when the sitter leaves indicates the alternative is not working.

The nurse is evaluating care of a patient for crutches. Which finding indicates a successful outcome? a. The top of the crutch is three to four finger widths from the armpit. b. The elbows are slightly flexed at 30 to 35 degrees when the patient is standing. c. The tip of the crutch is 4 to 6 inches anterior to the front of the patient's shoes. d. The position of the handgrips allows the axilla to support the patient's body weight.

c. The tip of the crutch is 4 to 6 inches anterior to the front of the patient's shoes. When crutches are fitted, the tip of the crutch is 4 to 6 inches anterior to the front of the patien shoes, and the length of the crutch is two to three finger widths from the axilla. Position the handgrip o he aillae are no pporing he paien bod eigh. Prere on he aillae increases risk to underlying nerves, which sometimes results in partial paralysis of the arm. Determine correct position of the handgrips with the patient upright, supporting weight by the handgrips with the elbows slightly flexed at 20 to 25 degrees.

A nurse is assessing the skin of an immobilized patient. What will the nurse do? a. Assess the skin every 4 hours. b. Limit the amount of fluid intake. c. Use a standardized tool such as the Braden Scale. d. Have special times for inspection so as to not interrupt routine care.

c. Use a standardized tool such as the Braden Scale. Consistently use a standardized tool, such as the Braden Scale. This identifies patients with a high risk for impaired skin integrity. Skin assessment can be as often as every hour. Limiting fluids can lead to dehydration, increasing skin breakdown. Observe the skin often during routine care.

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals? a. Identifies patient with one identifier before transporting to x-ray department b. Initiates an intravenous (IV) catheter using clean technique on the first try c. Uses medication bar coding when administering medications d. Obtains vital signs to place on a surgical patient's chart

c. Uses medication bar coding when administering medications One of the National Patient Safety Goals is to use medicines safely. For example, proper preparaion and adminiraion of medicaion, e of paien and medicaion bar coding, and mar intravenous (IV) pumps reduce medication errors. Identifying patients correctly is a national patient safety goal, and two identifiers are needed, not one. Another goal is to prevent infection; starting an IV should be a sterile technique, not a clean technique. While obtaining vital signs is a component of safe care, it does not meet a national patient safety goal.

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene? a. b. c. d. a. "The number for poison control is 800-222-1222." b. "Never induce vomiting if my grandchild drinks bleach." c. "I should call 911 if my grandchild loses consciousness." d. "If my grandchild eats a plan, I should provide syrup of ipecac."

d. "If my grandchild eats a plan, I should provide syrup of ipecac." The administration of ipecac syrup or induction of vomiting is no longer recommended for routine home treatment of poisoning. The nurse must intervene to provide additional teaching. All the rest are correct and do not require follow up. The poison control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the substance is eliminated. Loss of consciousness associated with poisoning requires calling 911.

A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up? a. "Every December is the time to change batteries on the carbon monoxide detector." b. "I will schedule an appointment with a chimney inspector next week." c. "If I feel dizzy when using the heater, I need to have it inspected." d. "When it is cold outside in the winter, I will use a nonvoter furnace."

d. "When it is cold outside in the winter, I will use a nonvoter furnace." Using a nonvented heater introduces carbon monoxide into the environment and decreases the available oxygen for human consumption and the nurse should follow up to correct this behavior. Checking the chimney and heater, changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that are safe and appropriate and need no follow-up.

A nurse is developing an exercise plan for a middle-aged patient. In which order will the nurse instruct the patient to execute the plan, beginning with the first step? 1. Design the fitness program. 2. Assemble equipment. 3. Assess fitness level. 4. Monitor progress. 5. Get started. a. 5, 1, 3, 2, 4 b. 1, 2, 3, 5, 4 c. 2, 5, 3, 1, 4 d. 3, 1, 2, 5, 4

d. 3, 1, 2, 5, 4 Five steps to beginning an exercise program are Step 1: Assess fitness level; Step 2: Design the fitness program; Step 3: Assemble equipment; Step 4: Get started; and Step 5: Monitor progress.

A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient? a. Increased appetite b. Increased diarrhea c. Increased metabolic rate d. Altered nutrient metabolism

d. Altered nutrient metabolism 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, leading to constipation.

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel? a. Determining the need for restraints b. Assessing he patient's orientation c. Obtaining an order for a restraint d. Applying the restraint

d. Applying the restraint The application and routine checking of a restraint can be delegated to nursing assistive personnel. The skill of assessing a patient's behavior, orientation to the environment, need for restraints, and appropriate use cannot be delegated. A nurse must obtain an order from a health care provider.

The patient has the nursing diagnosis of Impaired physical mobility related to pain in the left shoulder. Which priority action will the nurse take? a. Encourage the patient to do self-care. b. Keep the patient as mobile as possible. c. Encourage the patient to perform ROM. d. Assist the patient with comfort measures.

d. Assist the patient with comfort measures. The diagnosis related to pain requires the nurse to assist the patient with comfort measures so that the patient is then willing and more able to move. Pain must be controlled so the patient will not be reluctant to initiate movement. The diagnosis related to reluctance to initiate movement requires interventions aimed at keeping the patient as mobile as possible and encouraging the patient to perform self-care and ROM.

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. Which interventions should the nurse utilize for this patient and family? (Select all that apply.) a. Demonstrate how to restrain the patient in the event of a seizure. b. Instruct the family to move the patient to a bed during a seizure. c. Teach the family how to insert a tongue depressor during the seizure. d. Discuss with the family steps to take if the seizure does not discontinue. e. Instruct the family to reorient and reassure the patient after consciousness is regained.

d. Discuss with the family steps to take if the seizure does not discontinue. e. Instruct the family to reorient and reassure the patient after consciousness is regained. Prolonged or repeated seizures indicate status epilepticus, a medical emergency that requires intensive monitoring and treatment. Family should know what to do. Family should reorient and reassure the patient after consciousness is regained. Never force apart a patient's clenched teeth. Do not place an object into patient's mouth such as fingers, medicine, tongue depressor, or airway when teeth are clenched. Do not lift patient from floor to bed while seizure is in progress. Do not restrain patient; hold limbs loosely if they are flailing. Loosen clothing.

A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement? a. b. c. d. a. Each movement is repeated 5 times by the patient. b. Each movement is performed until the patient experiences pain. c. Each movement is completed quickly and smoothly by the nurse. d. Each movement is moved just to the point of resistance by the nurse.

d. Each movement is moved just to the point of resistance by the nurse. Passive ROM exercises are performed by the nurse. Carry out movements slowly and smoothly, just to the point of resistance; ROM should not cause pain. Never force a joint beyond its capacity. Each movement needs to be repeated 5 times during the session. The patient moves all joints through ROM unassisted in active ROM.

The nurse is observing the way a patient walks. Which aspect is the nurse assessing? a. Activity tolerance b. Body alignment c. Range of motion d. Gait

d. Gait Gait describes a particular manner or style of walking. Activity tolerance is the type and amount of exercise or work that a person is able to perform. Body alignment refers to the position of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Range of motion is the maximum amount of movement available at a joint in one of the three planes of the body: sagittal, frontal, or transverse.

A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding indicates successful goal achievement? a. Heart rate decreased. b. Contractures developed. c. Muscle strength improved. d. Joint mobility maintained.

d. Joint mobility maintained. When patients cannot participate in active ROM, maintain joint mobility and prevent contractures by implementing passive ROM into the plan of care. Exercise and active ROM can improve muscle strength. ROM is not performed for the heart but for the joints.

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take? a. Check on the patient once a shift. b. Encourage visitors in the early evening. c. Place all for side rails in he p position. d. Keep the patient on fall risk until discharge.

d. Keep the patient on fall risk until discharge. A fall-reduction program includes a fall risk assessment of every patient, conducted on admission and routinely (see hospital policy) until a patient's discharge. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour.

A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider? a. Loss of bone mass b. Loss of strength c. Loss of weight d. Loss of hope

d. Loss of hope Loss of hope is a psychosocial aspect. Patients with restricted mobility may have some depression. Depression is an affective disorder characterized by exaggerated feelings of sadness, melancholy, dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. All the rest are physiological aspects: bone mass, strength, and weight.

A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take? a. b. c. d. a. Moves patient's arm in a full circle b. Moves patient's arm cross the body as far as possible c. Moves patient' s arm behind body, keeping elbow straight d. Moves patient's arm until thumb is upward and lateral to head with elbow flexed

d. Moves patient's arm until thumb is upward and lateral to head with elbow flexed External rotation: With elbow flexed, move arm until thumb is upward and lateral tohead. Circumduction: Move arm in full circle (Circumduction is combination of all movements of ball- and-socket joint.) Adduction: Lower arm sideways and across body as far aspossible. Hyperextension: Move arm behind body, keeping elbow straight.

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? a. 55 years old b. 20/20 vision c. Urinary continence d. Orthostatic hypotension

d. Orthostatic hypotension Numerous factors increase the risk of falls, including a history of falling, being age 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, hypnotics, sedatives, certain analgesics).

A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action? a. Prevention of atelectasis b. Prevention of renal calculi c. Prevention of pressure ulcers d. Prevention of joint contractures

d. Prevention of joint contractures Goal achievement for passive ROM is prevention of joint contractures. Contractures develop in joints not moved periodically through their full ROM. ROM exercises reduce the risk of contractures. Researchers noted that prompt use of splinting with prescribed ROM exercises reduced contractures and improved active range of joint motion in affected lower extremities. Deep breathing and coughing and using an incentive spirometer will help prevent atelectasis. Adequate hydration helps prevent renal calculi and urinary tract infections. Interventions aimed at prevention of pressure ulcers include positioning, skin care, and the use of therapeutic devices to relieve pressure.

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan? a. Impaired home maintenance b. Deficient knowledge c. Risk for poisoning d. Risk for injury

d. Risk for injury The paien behaviors support the nursing diagnosis of Risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lack knowledge or Is at risk for poisoning. Nohing in the scenario refers to the paient's home maintenance.

The nurse is caring for an older-adult patient with a diagnosis of urinary tract infection (UTI). Upon assessment the nurse finds the patient confused and agitated. How will the nurse interpret these assessment findings? a. These are normal signs of aging. b. These are early signs of dementia. c. These are purely psychological in origin. d. These are common manifestation with UTIs.

d. These are common manifestation with UTIs. The primary symptom of compromised older patients with an acute urinary tract infection or fever is confusion. Acute confusion in older adults is not normal; a thorough nursing assessment is the priority. With the diagnosis of urinary tract infection, these are not early signs of dementia and they are not purely psychological.

A nurse is caring for a patient who has some immobility from noninflammatory joint degeneration. The nurse is teaching the patient about this process. Which information will the nurse include in the teaching session? a. b. c. d. a. This will affect synovial fluid. b. This will affect the body systemically. c. This involves mostly nonweight-bearing joints. d. This involves overgrowth of bone at the articular ends.

d. This involves overgrowth of bone at the articular ends. Joint degeneration, which can occur with inflammatory and noninflammatory disease, is marked by changes in articular cartilage combined with overgrowth of bone at the articular ends. Degenerative changes commonly affect weight-bearing joints. Synovial fluid is normal in noninflammatory diseases. Inflammatory joint disease (e.g., arthritis) is characterized by inflammation or destruction of the synovial membrane and articular cartilage and by systemic signs of inflammation.

The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Dirty floors, hallways blocked, medication room locked, and alarms set c. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly Specific rik o a paien afe ihin he healh care enironmen inclde fall, paien-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient- inherent issues in the hospital setting but are more of patient satisfaction, infection control, or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are examples of following a procedure correctly.