Module 2

A patient requires only minimal assistance with ambulation. Which assistive device would be most appropriate? A. A cane B. A walker without wheels C. A wheeled walker D. Crutches

A A standard cane, also called a straight cane, is used with patients who need only minimal assistance with ambulation. A walker has four wide-placed legs and is the assistive device that provides the greatest support for ambulation. Crutches are used to remove weight from a lower extremity by transferring the weight to the upper extremities. Generally, axillary crutches are used temporarily by patients with weight-bearing restrictions to the lower extremities, while forearm crutches are used long term by patients with conditions such as general weakness or paraplegia.

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 Although the 72-year-old woman'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. Poor nutritional status is a risk factor for mobility impairment; however, the 55-year-old female patient has no other known risk factors. Her mental illness is irrelevant to her risk of mobility impairment, except as it affects her ability to follow her provider's dietary instructions and comply with her medication schedule after discharge. The 11-year-old boy may experience adverse consequences of impaired mobility, such as altered self-concept, diminished self-esteem, and depression. He may become restless or even show signs of aggression. It is unlikely, however, that his mobility will be permanently compromised after he recovers from his traumatic injury. The 79-year-old male patient's age puts him at risk of mobility impairment; however, he has no other known risk factors.

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 Assessing the patient for weakness, dizziness, or postural hypotension will help ensure the patient's safety. Two nurses or NAP can safely transfer a patient with a hydraulic lift. The assistance of three healthcare personnel is not necessary. Securing the patient's agreement does not help the nurse prepare for a safe transfer. It is not necessary to wear gloves while transferring a patient with a hydraulic lift.

Which nursing action is most therapeutic in response to a cognitively impaired patient who demands to know when his daughter is coming to visit? A. Marking the date of the visit on the patient's wall calendar B. Evaluating the patient's understanding of the concept of time and date C. Telling the patient when his daughter will be visiting and ensuring that he verbalizes his understanding D. Calling the daughter to suggest that she visit sooner than she had planned

A Marking the date of the visit on the patient's wall calendar is the most therapeutic option, because it will serve as a permanent visual cue to remind the patient of the date each time he becomes anxious about his daughter's visit. Evaluating the patient's understanding of the concept of time and date is not the correct option, because the patient's deficiencies have already been determined. Discussing the date of the visit with the patient is not the correct option because, even if the patient momentarily understands and can be reassured, it is likely that his anxiety or disorientation will return. Persuading the patient's daughter to hasten her visit is not the correct option, because it does not address the patient's anxiety regarding the date of her visit.

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 Returning the patient to the bed or chair allows patient to rest, and the nausea may subside. Encouraging the patient to complete the distance of ambulation does not focus on the patient's need to relieve nausea. The patient may become more nauseated, become weak or dizzy, and begin to fall. Helping the patient to the restroom does not focus on immediate need; it may require more exertion to reach the restroom, resulting in increased nausea. The patient's nausea indicates that the ambulation is not being well tolerated. Ease the patient to the floor only if the nausea is accompanied by dizziness or lightheadedness causing the patient to begin to fall.

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 Setting mutual goals increases the likelihood of success in achieving the goal of ambulation. The health care provider's order will only state "ambulate"; it will not specify how far to ambulate the patient. The patient's circumstances or condition may not be similar to those he or she undertook during the past several ambulations. Patient care should be individualized. The status of other patients in stroke rehabilitation is not relevant to this patient.

When preparing to apply compression 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 The nurse assesses for skin discoloration because it is one possible indicator of deep vein thrombosis (DVT). Improper patient positioning is not a rationale for why the nurse assesses for skin discoloration. The selection of proper stocking size would be done after the nurse assesses for skin discoloration. Determining whether the use of a sequential compression device is needed is not why the nurse assesses for skin discoloration.

Before applying a brace to a patient's back, what will the nurse do first? A. Check the patient's medical record and orders for positioning restrictions B. Measuring the patient's temperature to determine whether it is elevated C. Place a fresh cotton shirt or gown on the patient D. Smooth any wrinkles in the fabric that will be underneath the brace

A The nurse will check the patient's medical record and orders to verify if the patient can sit up or needs to remain lying down while putting on the back brace. The nurse does not need to measure the patient's temperature before the procedure. The nurse will place a fresh cotton shirt or gown on the patient after checking the patient's medical record. The nurse will smooth any wrinkles in the fabric that will be under the brace after checking the patient's medical record.

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. B. Pull the draw sheet. C. Hold the patient's head stationary. D. Lock the brakes on the stretcher.

A The nurse, standing alone, will hold the slide board in place as the two assistants pull the draw sheet. The nurse will not hold the patient's head during the move; this action may be performed by an optional assistant. The nurse cannot lock the brakes on the stretcher while standing on the opposite side of the bed. The brakes should be locked prior to the transfer of the patient.

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 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. Attempting to sit the patient down on a chair or trying to hold up a patient to keep him or her from falling is never a safe action for either the nurse or the patient. Calling for assistance is not an appropriate initial response and does not provide immediate safety for the patient.

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 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. Positioning assistants on the side of the bed from which the patient will be turned is not helpful. Positioning assistants at the head or foot of the bed is not helpful. Positioning assistants at the foot of the bed is not helpful.

The nurse wants to offer some diversional activity to a patient with dementia. The patient's family has told the nurse that he is a bit of a loner who enjoyed a 40-year career as an aircraft mechanic. The patient seems frustrated and bored. What is the best activity for the nurse to offer him? A. Weekly pet therapy with a golden retriever B. A jigsaw puzzle of an appropriate level of difficulty C. A crossword puzzle book of an appropriate level of difficulty D. Frequent card games with other patients

B A jigsaw puzzle is a good choice, because it is a solitary activity that offers tactile stimulation and engages the patient's mental faculties, attributes that are likely to be familiar and pleasurable to him. Pet therapy would offer this patient tactile stimulation, but the activity would not be frequent enough to relieve his boredom. Doing crossword puzzles is an appropriately solitary activity for this patient, but it offers little tactile stimulation; in addition, a word puzzle is unlikely to appeal to this mechanically inclined patient. The family has told the nurse that the patient prefers to keep to himself, so social interaction is unlikely to provide meaningful, welcome stimulation that will relieve his boredom and frustration.

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 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. The patient should not be supine with the head of the bed at a 30-degree angle, sitting, or prone when being moved up in bed.

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 A trochanter roll is placed alongside the patient's legs to prevent external rotation of the hips, which contributes to contracture. The placement of a trochanter roll alongside the patient's legs will not reduce the risk of a fall while the side rails are down. The side rails must be raised to prevent the patient from falling. Although a trochanter roll placed alongside the patient's legs may assist to control pain and provide cushion to the legs, it is not the primary reason a trochanter roll is placed alongside of patient's legs.

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 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. The patient's weight is important to know, but it is not the first action the nurse must take. The most effective means of moving the patient will be determined in part by whether the patient is able to help.

When preparing to delegate the application of the SCD to NAP, the nurse must do what first? A. Ask the NAP to demonstrate the proper application of the SCD. B. Assess the patient's lower extremities for signs and symptoms of impaired circulation. C. Assess the patient's need for a SCD. D. Explain that the device is not to be removed.

B Before delegating the application of the SCD, the nurse must assess the patient's lower extremities for impaired circulation. The NAP need not demonstrate application of the device unless the NAP's ability to do so correctly is in question. The patient's need for a SCD has already been established, as evidenced by the physician's order; determining the patient's need for the device is a medical responsibility. The SCD can be removed to assess for skin breakdown or irritation and to permit the patient to ambulate to the bathroom.

The nurse has applied the SCD to a postoperative patient. The most appropriate way for the nurse to confirm proper fit is to do what? A. Ask the patient if the device is causing any pain. B. Ensure that two fingers will fit between the patient's leg and the device. C. Follow the manufacturer's instructions for the application of the device. D. Ask another nurse to check the patient for proper application of the device.

B Ensuring that two fingers can be inserted between the patient's skin and the device is the standard method for determining proper fit. The patient's complaint of pain may indicate that the device is too tight but does not indicate whether it is too loose. Although the manufacturer's instructions should be followed, such instructions do not pertain to determination of fit for a specific patient. Asking another nurse to check the fit is not necessary unless the nurse is unsure of his or her ability to determine proper fit.

When repositioning 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 Placing sandbags along the legs will prevent the hips from rolling outward. Therapeutic boots, a small pillow at the lumbar region of the back or a pillow under the calves will not prevent the hips from rolling outward.

When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient's gown bunched around the patient's chest and the patient asking for help. What would the NAP do? A. Check the patient's blood pressure and pulse before smoothing the gown B. Untie the restraint and smooth the patient's gown C. Put on the call light for help D. Ask the patient what specific help she would like

B The NAP would untie the restraint, smooth the patient's gown, and replace the restraint. Checking the patient's blood pressure and pulse is not appropriate at this time. Putting on the call light is not appropriate, since the call light is intended to summon the NAP. Asking the patient what help is needed is not appropriate. The difficulty is obvious, and the patient may have a cognitive impairment that makes clear expression of his or her needs impossible.

To which patient might the nurse apply a physical restraint? A. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling. B. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. C. A 74-year-old patient confined to bed who is at risk of pressure ulcers. D. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.

B The critical care nurse might apply a physical restraint to keep this 42-year-old patient from injuring herself by dislodging her shunt. Disruption of therapy causes patient injury, pain, or discomfort and increases the risk of infection. There is no evidence that the use of restraints prevents falls or reduces wandering. Research has shown that patients suffer fewer injuries if left unrestrained. Use of physical restraints does not prevent pressure injuries; to the contrary, pressure injury formation is a possible complication associated with the use of physical restraints. Any patient with a physical restraint must be monitored frequently for skin integrity, pulse, temperature, and color, as well as sensation and range of motion of the restrained body part. The nurse would not apply a physical restraint to a patient who had exhibited increased confusion, disorientation, or agitation during the previous application of a restraint. Instead, the nurse would evaluate the cause of the behavior and try to eliminate it, provide appropriate sensory stimulation, reorient the patient, use restraint alternatives, and enlist the family's support if possible.

When applying a commercially-prepared immobilization device the nurse ensures that wraps are applied: A. Anterior to posterior B. Distal to proximal C. Posterior to anterior D. Proximal to distal

B The nurse applies any wraps from distal to proximal. The nurse does not apply wraps from proximal to distal. The nurse does not apply wraps from posterior to anterior. The nurse does not apply wraps from anterior to posterior.

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

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

What will the nurse do first before applying an immobilization device over a dressing? A. Alter the immobilization device so it will not cover the dressing B. Change the dressing C. Cover the dressing in a protective wrap D. The nurse would never apply an immobilization device over a dressing because it restricts access to the area

B The nurse will change the dressing before applying an immobilization device over a dressing. The nurse will not alter the immobilization device so it will not cover the dressing. There is no need to cover the dressing with a protective wrap. It is not necessary to forgo the immobilization device because of a dressing.

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 The nurse will need two additional people to help move this patient. Three nurses are recommended for a slide board transfer. The nurse does not need four additional people to help transfer this patient. The nurse needs more than one additional person to help move this patient. The nurse cannot perform this move without assistance.

What will the nurse do next after applying an immobilization device to a patient? A. Change the bandages that are underneath the immobilization device B. Provide an opportunity for a return demonstration C. Raise the bed side rails as appropriate and place the bed in the lowest position D. Return the patient to a position of comfort

B The nurse will provide an opportunity for the patient or family to provide a return demonstration. Bandages underneath an immobilization device are changed before the brace is applied. Raising the side rails and returning the bed to the lowest position is done after the nurse provides an opportunity for a return demonstration. Returning the patient to a position of comfort is done after the nurse provides an opportunity for a return demonstration.

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 The nurse would raise the head of the bed 30 degrees right before moving the patient to the side of the bed. Footwear and the transfer belt would not be applied at this point in the process. The wheelchair would already be in position at this point in the process.

The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action? A. Move the joint through the full range of motion exercises. B. Perform range of motion to the left elbow until resistance is met. C. Omit all the 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 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. The nurse would not move the left elbow joint through the full range of motion because resistance is met. Range of motion exercises should not be omitted. When you note resistance within a joint, do not force the joint motion. Consult with the health care provider or a physical therapist. The nurse would not notify the health care provider without information to support the patient is uncooperative with exercising.

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 The patient's weak side would need support if the patient begins to fall. Stand on the patient's weak side. The strong side has no need of support from the nurse. Standing behind the patient or in front of the patient would provide no support to the patient if the patient begins to fall.

Why might a sequential compression device (SCD) be applied to the legs of an immobile patient? A. To stimulate circulation in the deep arterial vascular system B. To help prevent deep vein thrombosis (DVT) C. To aid peripheral circulation to reduce the risk of skin breakdown D. To assist in passive range-of-motion exercise of the patient's lower extremities

B The prevention of DVT by promoting venous circulation is a stated SCD application. Compression devices affect venous, not arterial, blood flow. SCDs are not intended to minimize skin breakdown. SCDs have no role in passive range-of-motion exercise.

After determining the proper size stocking and assessing the patient's circulatory status, a nurse delegates the application of compression 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 he or she is allergic to the moisturizer. D. Inspect the patient's skin for color variations.

B Using a small amount of cornstarch or powder will decrease friction and make the stockings easier to apply. A moisturizer applied to the legs may not cause skin breakdown, but putting it on the patient's skin just before applying compression stockings will make them harder to apply. Sensitivity to moisturizer may cause skin breakdown. An allergy to the moisturizer should have been identified before the moisturizer was applied to the legs. Skin color variations are not related to the use of moisturizers before applying compression stockings. Skin color variations are associated with changes in peripheral circulation, or pathologic conditions. The nurse should have inspected the skin for color variations prior to delegating the application of compression stockings.

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 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. Joints should never be exercised to the point of fatigue or pain. Exercises should be done twice a day to improve joint mobility and increase circulation. Pain will not be lessened with exercising. Pain should not be felt by the patient. Use a variety of support measures, cupping with your hand under joint or cradling the distal portion with arm. Support measures prevent muscle strain or injury to the patient.

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 Using the under-axillae technique is not a safe lifting technique, so this statement requires the nurse to follow up. Applying nonskid socks or slippers will help minimize the risk of falling, so this statement does not require the nurse to follow up. The rocking technique gives the patient's body momentum and helps facilitate standing, so this statement does not require the nurse to follow up. If the patient begins to fall, the grasping of the gait belt provides support at the patient's waist (so the center of gravity remains midline) and allows the nurse to move him or her to the stronger side and reduce injury.

What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint? A. "Tell me if the patient's pulse changes." B. "Tell me if the skin under the restraint becomes abraded or raw." C. "Let me know if you think she's ready for them to come off." D. "Let me know if the patient needs anything for pain."

B When caring for a patient in a wrist restraint, the nurse would instruct NAP to report the condition of the skin beneath the restraint. When caring for a patient in a wrist restraint, the nurse would assess the patient for pulse changes in the extremity to which the restraint has been applied. This skill would not be delegated to NAP. Patient assessment is a nursing responsibility, and the nurse would make the determination of when a patient's restraints can be removed, in accordance with agency policy and all applicable laws and regulations. Assessment of pain is a nursing responsibility and cannot be delegated to NAP.

The nurse has one bed alarm available and can use it for any of the following patients, all of whom have dementia. Having an alarm is most important for which patient? A. A patient who has refused most meals for the past week and whose weight has dropped by 10% in the past month. B. A patient who has become verbally combative with health care team members in recent weeks. C. A patient who was returned to the unit last week by staff in an adjacent assisted living facility. D. A patient whose abdominal feeding tube is covered with an abdominal binder.

C A patient who was returned to the unit last week by health care team members in an adjacent assisted living facility is the correct answer, because the nurse will use the alarm for the patient who has recently been found wandering. Refusal of meals and associated weight loss are not addressed by placement of a bed alarm. This patient's combativeness is not necessarily associated with attempts to get out of bed without assistance, neither does it necessarily correlate with a higher risk of falling. The presence of a feeding tube, disguised or not, does not increase the likelihood that the patient will try to get out of bed without assistance.

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 Administering a prescribed analgesic 30 to 60 minutes before the transfer helps prevent unnecessary pain during the transfer by allowing time for the medication to take effect before the patient is moved. The remaining actions do not pertain to pain prevention.

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 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. The nurse must determine whether extra help is needed before arranging for such assistance. Assessing vital signs is not the first action the nurse would take. Determining whether to transfer the patient to a wheelchair or chair is not the first action the nurse would take.

Why might the nurse choose not to apply a pair of prescribed compression 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 Compression stockings should not be applied if the skin of the legs is irritated. A scheduled bath would not be a reason to postpone application of the stockings. The patient is likely to find them uncomfortable, but careful measurement of the legs ensures that he or she is given the proper size. Incompetent venous values or decreased venous circulation may necessitate the need for compression stockings even though the patient is fully ambulatory.

Where do the patient's feet stop when performing the swing-through crutch gait? A. Before reaching the crutch tips B. Level with the crutch tips C. Past the crutch tips D. The patient does not put his feet down

C During the swing-through gait, the patient advances both crutches, then lifts and swings both legs past the crutch tips. During the swing-to gait, the patient advances both crutches, then lift and swing both legs to the crutch tips. The patient does not stop before reaching the crutch tips. The patient does place his feet on the ground at the end of the movement.

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 front leg to the back leg.

C Flexing the hips and knees is the safest posture for both caregivers to assume when moving a patient in bed. Standing with the knees locked could injure the legs or the back. Standing with the feet together could injure the legs or the back. The body weight should be shifted from the back leg to the front leg.

In the United States, forearm crutches are generally used by patients with which types of conditions? A. Fractures of the lower extremities B. Fractures of the upper extremities C. General weakness or paraplegia D. Weight-bearing restrictions to the lower extremities

C Generally, axillary crutches are used temporarily by patients with weight-bearing restrictions to the lower extremities, such as a leg fracture, while forearm crutches are used long term by patients with conditions such as general weakness or paraplegia. Crutches are used to remove weight from a lower extremity by transferring the weight to the upper extremities, therefore crutches are not appropriate for patients with upper extremity fractures.

The nurse is teaching a patient who has crutches how to sit down in a chair. In which hand should the patient hold both crutches? A. The patient's dominant hand B. The patient's nondominant hand C. The hand on the injured side D. The hand on the uninjured side

C Hold the patient's gait belt and had the patient back up until the patient feels the seat of the chair against the back of his or her legs, then move the weak leg forward and balance on the strong leg. Have the patient transfer both crutches to one hand on the injured side. Instruct the patient to grasp the arm of the chair with his or her free hand and lower body onto the seat.

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

C 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. A left lateral recumbent position would not facilitate maximal breathing space and respirations would be difficult for the patient. The 30-degree lateral or side-lying position requires the head of bed to be lowered completely or as low as the patient can tolerate. The patient is positioned on the side. Lying on the side will not promote maximal breathing space and respirations would be difficult for the patient. In the prone position, the patient is positioned flat and on the abdomen. Lying flat on the abdomen would not facilitate respirations and is a difficult position for the patient to maintain.

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 Since a friction-reducing device will be used and the client weighs 200 lbs., a minimum of three to four people are needed to move this patient safely. The device does not function independently, and the nurse cannot use it without the help of other caregivers. The nurse cannot carry out this move by himself or herself.

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 Specialized expertise is usually required to perform passive ROM exercises for a patient with orthopedic trauma or spinal cord injury. The patient's age or the existence of a chronic medical condition generally does not necessitate additional expertise. If a patient is concerned about injury, the nurse can address the patient's anxiety by explaining the procedure, easing into the exercises, and offering continual reassurance. If the provider is aware that the patient's pain is worse with exercise and the provider nevertheless orders the exercise, the nurse can offer pain medication before the intervention, as prescribed, and exercise the patient as tolerated.

When applying an immobilization device, the nurse will place the bed in which position? A. A height that allows the patient full range of motion B. All side rails are always raised for the patient's safety C. An appropriate height for the patient's position during immobilization device application. D. The bed is always positioned locked and low

C The bed is set to an appropriate height for the patient's position during immobilization device application so that the nurse can reach the patient safely and easily. For instance, if the brace will be applied while the patient is supine, the bed is raised to a comfortable working height for the nurse. If the brace will be applied while the patient is sitting at the side of the bed, the bed will be adjusted accordingly. The bed's height has little effect on the patient's range of motion. Having all side rails raised is considered a restraint and would make it difficult for the nurse to access the patient. Locked and low is not necessarily the best position in which to place the bed for the nurse's comfort and the patient's safety.

An otherwise strong, healthy patient with a lower leg cast is learning to ambulate with axillary crutches. Which gait is most appropriate? A. Any gait is appropriate B. Four point gait C. Three point gait D. Two point gait

C The four-point gait approximates a normal step pattern, is stable, and requires low energy expenditure. The patient must be able to bear weight on both feet. The three-point gait is the least stable pattern and requires balance, coordination, and strength. This pattern is tiring but allows for rapid ambulation. The two-point pattern is used when additional gait stability is needed; the patient must be able to bear full weight on both legs. Because the patient cannot bear weight on one leg, the three point gait is the most appropriate, as the two point and four point gaits require weight bearing on both legs.

Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours? A. To try a less restrictive type of restraint if a more confining restraint has proved effective B. To double-check the size by inserting one finger between the wrist and the restraint C. To check the skin integrity and range of motion of the wrist D. To comply with Joint Commission standards

C The nurse instructs the NAP to remove the wrist restraint of a confused patient every 2 hours to ensure that the wrist is checked for skin integrity, pulse, temperature, color, sensation, and range of motion. In acute care settings, the health care provider must order the least restrictive type of restraint first, not after a more confining restraint has proved effective. The nurse would select the appropriate size restraint for the patient, according to the manufacturer's instructions, when the restraint is initially applied, and he or she would double-check the fit when the restraint is applied, not 2 hours later. The fit need not be checked at 2-hour intervals thereafter. The Joint Commission policy states that, in most circumstances, a physical restraint may be maintained up to 4 hours in an adult.

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 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. Removing the leg rests will not help position the patient safely in the wheelchair. Asking about the patient's pain is not relevant to safe positioning, since a patient may be comfortable even when positioned unsafely. Removing the transfer belt will not help position the patient safely in the wheelchair.

After moving a patient from the bed to a stretcher, what will the nurse do next? A. Lock the wheels on the stretcher. B. Cover the patient with a blanket. C. Raise the head of the stretcher if doing so is not contraindicated. D. Unlock the wheels of the bed.

C The nurse raises the head of the stretcher if doing so is not contraindicated. The wheels of the stretcher will have been locked before moving the patient from the bed to the stretcher. Covering the patient with a blanket will occur after the side rails are raised on the stretcher. Unlocking the wheels of the bed is not an action the nurse will take after transferring a patient from the bed to the stretcher.

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 The nurse turns off the check valve as soon as the patient has been placed in the chair. After the patient crosses the arms over the chest and the eyeglasses are removed, the patient has not yet been moved to the chair, so the nurse does not turn off the check valve at these steps. By the time the nurse removes the straps, the check valve already will have been turned off.

The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first? 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 The nurse's first action would be to verify that the bed brakes are locked prior to moving the patient. Crossing the patient's arms over the chest is done after the head of the bed is lowered. Lowering the side rails of the bed occurs after the bed brakes are locked. The draw sheet would be fanfolded after the bed brakes are locked.

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 The patient is placed in the supine position before he or she is transferred from the bed to a chair with a hydraulic lift. Prone, side-lying, and Sims are not positions used to transfer a patient with a hydraulic lift.

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 drawsheet, and replace it with the device. C. Roll the patient from side to side, and place the device under the drawsheet. D. Sit the patient up in the bed, and place the device behind the shoulders.

C The patient will be rolled from side to side and the device placed under the drawsheet. The patient is not lifted in order to place the device under him or her. The device must be placed under the drawsheet. The device must be behind the entire length of the patient, and not just placed at the level of the shoulders.

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.

C The patient's arms are crossed over the chest after attaching the hooks to the holes in the sling. The head of the bed is elevated immediately before the hooks are attached to the sling. The head of the bed is lowered before the sling is placed under the patient. If the patient wears eyeglasses, they are removed before the hooks are attached to the sling.

While preparing to apply a SCD for a postoperative patient, the nurse realizes that which assessment observation contraindicates the application of the device? A. Having a low-grade fever B. Taking a prescribed anticoagulant C. Having dermatitis on the legs D. Wearing compression stockings

C The presence of dermatitis or skin ulcers on the leg, or having had a recent skin graft to the leg, contraindicates the application of a SCD, since use of the device is likely to further alter skin integrity. Having a low-grade fever is not a contraindication to the use of a SCD. It may, however, be an indication of DVT. Since anticoagulant medications are used to control thrombus formation, the patient's prescribed drug does not contraindicate the use of it. The use of compression stockings does not contraindicate the application of a SCD.

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 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. The pillows are positioned by the nurse who is standing on the side from which the patient was turned. Two assistants are not needed to keep the patient's spine straight while logrolling a patient. Two assistants are not needed to ease the patient back onto the support pillows.

When caring for a patient with Alzheimer's disease, why does the nurse cover the external urinary collection catheter? A. To protect the bed from being soiled B. To avoid offending visitors who would otherwise see the device C. To reduce the patient's access to the device D. To keep the patient from trying to get out of bed alone

C When caring for a patient with Alzheimer's disease, the nurse may camouflage the external urinary collection catheter to reduce the patient's access to the device. Covering the device does not protect the bed from being soiled. Visitors' sensibilities are not relevant. Unassisted ambulation attempts are an unrelated problem.

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 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. Placing a small pillow under the shoulder will not help when rolling a patient with hemiplegia onto her side while moving into the prone position. The nurse should not use the affected arm as a guide when rolling a patient with hemiplegia onto her side while moving into the prone position. The nurse should not place rolled bath blankets along the dependent leg when rolling the hemiplegic patient onto her side while moving into the prone position.

The nurse is preparing to delegate the application of a SCD to nursing assistive personnel (NAP). Which statement by the NAP requires follow-up by the nurse? A. "I will check for a green light on the mechanical unit." B. "I will remove the SCD before ambulating the patient." C. "I will tell you if I see any signs of itching, redness, or irritation on the patient's legs." D. "I will measure the patient's legs to determine what size SCD sleeve to use."

D Measuring the patient's legs to determine the appropriate size SCD sleeve to apply is an intervention that cannot be delegated, so this statement does require the nurse to follow up. It is appropriate for NAP to check for the green light on the mechanical unit, to remove the device before ambulating the patient, and to report such observations immediately. These statements do not require the nurse to follow up.

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 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. The patient and nurse rock together for three counts. The patient would not be instructed to hold on to the nurse's waist. Doing so is not a safe action. Asking the patient to advise the nurse does not instruct the patient on moving from the bed to a wheelchair.

Why does the nurse remove the patient's compression 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 The nurse removes the patient's compression stockings at least once per shift to check the skin for irritation or breakdown. Although proper skin care is important, the nurse does not remove the compression stockings once per shift to permit the skin to breathe or to allow sweat to evaporate. The legs do not need to be washed once every shift.

The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse's best response when the patient's wife says, "I don't like him being tied down in the bed?" A. "I'm sure you don't want him to fall again." B. "Can you suggest an alternative?" C. "What did you do to prevent him from falling when he was at home?" D. "We will try all other alternatives before using physical restraints."

D The nurse stating they will try all other alternatives before using physical restraints is the correct answer because the response attempts to reassure the family that restraints will be used only as a last resort. The nurse stating that you don't want him to fall again is not the correct answer because it appears to use guilt to secure family consent. Asking the patient's wife for an alternative suggestion is not the correct answer because it indicates impatience with the family's concerns and places an inappropriate responsibility on the patient's wife. Asking the patient's wife what she did to prevent him from falling when he was at home is not the correct option, because it appears to place responsibility for the patient's safety on the family. In addition, the patient's condition and circumstances are different in the facility than they were at home, so using the same fall-prevention strategies is likely to be ineffective.

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 The nurse supports the distal portion of the extremity in order to ensure joint stability. It is not necessary to keep the arm above the level of the heart. Muscle tension is not assessed while performing passive ROM exercises. This patient is recovering from surgery to remove a soft-tissue tumor, which would not cause crepitus, a grating sound produced as the ends of long bones rub together in a patient with arthritis.

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 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. Placing both feet together on the floor will not help the patient stand safely. Placing the weaker foot forward places the stronger leg in the dependent position. The weaker leg, called upon to bear the bulk of the patient's weight, may not be able to do so. Extending both of the legs and feet will not help the patient stand safely.

Which statement made by nursing assistive personnel (NAP) assigned to care for a patient with dementia requires the nurse to follow up? A. "I encouraged his son and daughter-in-law to stay with him during visiting hours, if possible, even if they run out of things to talk about." B. "He can't see his Foley because it's covered by his boxer shorts." C. "I'll ask the patient every hour or so whether he needs to use the bathroom." D. "He doesn't understand much of what anyone says to him today, so I didn't put in his hearing aids."

D This statement requires the nurse to follow up, because the patient will become all the more disoriented if he cannot hear what is going on around him. This statement is appropriate, because having familiar visitors for extended periods helps orient the patient to his environment and decrease anxiety and restlessness. This statement is appropriate, because positioning catheters, tubes, and drains out of sight reduces the patient's access to them, allowing medical treatment to be administered without interruption. This statement is appropriate, because being offered an opportunity to void regularly reduces the likelihood that the patient will try to reach the bathroom alone.