Nursing Exam 4-Chapter 33 Questions
A nurse caring for patients in a pediatrician's office assesses infants and toddlers for physical developmental milestones. Which patient would the nurse refer to a specialist based on failure to achieve these milestones? a. A 4-month-old infant who is unable to roll over b. A 6-month-old infant who is unable to hold his head up himself c. An 11-month-old infant who cannot walk unassisted d. An 18-month-old toddler who cannot jump
b
An 85-year-old white woman walks 1 mile (1.6 km) every morning and every evening. She continues to smoke but has cut back to half a pack per day. She had a total oophorectomy at age 45 secondary to stage I ovarian cancer. This client is currently not on any medications. Which is not a primary risk factor for osteoporosis for this client? a. Caucasian race b. oophorectomy at age 45 c. sedentary lifestyle d. smoking
c
A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction? a. Hold the cane 6 in (15 cm) in front of you. b. You may switch hands with your cane if you become tired. c. Lean into the cane as it supports you. d. Hold your cane on the right side.
d
The nurse is assessing the client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement. How does the nurse document this finding? a. hypertrophy. b. atrophy. c. flaccidity. d. spasticity.
d
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason? a. Acts as a safeguard against legal action by the client b. Primarily protects the client from injury c .Primarily protects the nurse from injury d. Acts to prevent injury to the client and/or nurse
d
The pediatric nurse is caring for a 3-week-old infant. In which position will the nurse place the infant to sleep? a. prone b. Sims' c. lateral d. supine
d
Which type of mobility aid would be most appropriate for a client who has poor balance? a. a single-ended cane with a straight handle b. a single-ended cane with a half-circle handle c. axillary crutches d. a cane with four prongs on the end (quad cane)
d
A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? a. Fowler's b. prone c. Sims' d. supine
a
A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from: a. foot drop. b. pooling of blood. c. blood pressure changes. d. decubitus ulcers.
a
A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient? a. Support weight on stronger leg and cane and advance weaker foot forward. b. Hold the cane in the same hand of the leg with the most severe deficit. c. Stand with as much weight distributed on the cane as possible. d. Do not use the cane to rise from a sitting position, as this is unsafe.
a
A nurse is providing care to a client confined to bed. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate? a. bed trapeze b. foot board c. bed cradle d. trochanter roll
a
A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures? a. Carefully assessing the patient care environment b. Using two nurses to lift a patient who cannot assist c. Wearing a back belt to perform routine duties d. Properly documenting the patient lift
a
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? a. near the client's hip, with legs shoulder width apart and one foot near the head of the bed b. to the nondominant side of the client, with legs together and one foot near the head of the bed. c. to the dominant side of the client, with legs together and one foot near the head of the bed d. near the client's hip, with legs together
a
The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? a. "To preserve the client's functional ability to grasp and pick up objects." b. "To prevent the legs from rotating outward." c. "To prevent foot drop." d. "To help client to turn independently."
a
The nurse has been educating a client about health promotion and exercise. What statement made by the client demonstrates that the education has been successful? a. "I will invite a friend to exercise with me." b. "Ideally, I should exercise for an hour 2 times a week." c. "I will do the same kind of activity or exercise every day." d. "I will start a walking program, walking as fast as I can."
a
The nurse is assessing a client who has presented at the ambulatory care unit. The nurse notes the client has impaired muscle coordination. The nurse correctly documents the presence of: a. ataxia. b. tremors. c. chorea. d. athetosis.
a
The nurse is assessing a client's ability to use a walker. The nurse would provide additional information if which behavior were observed? a. The client pushes the walker ahead, following behind it. b. The client uses the arms of the chair as support when standing up to use the walker. c. When arising from a chair, the client puts one hand at a time on the walker. d. The client steps into the walker before moving the walker forward.
a
The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client? a. "Put your arm in this sleeve." b. "Put your pants on and zip the zipper." c. "Don't put on your shoes yet." d. "Put on your shirt."
a
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client? a. Sims' b. prone c. supine d. Fowler's
a
The nurse is developing a plan of care for a client who has been in the (protective) prone position. What should the nurse be sure to monitor the client for, related to the positioning? a. plantar flexion of the feet b. flexion contracture of the neck c. skin breakdown of the sacrum d. hyperextension of the hips
a
The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary? a. "The hand rolls help me develop strength in my grip." b. "The hand rolls help keep my thumb positioned away from my hand." c. "I can use a rolled-up washcloth if I don't have a hand roll." d. "I need to remove the hand roll often to exercise my hand muscles."
a
The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement? a. Adduction b. Abduction c. Extension d. Circumduction
a
The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated? a. Active range of motion b. Passive range of motion c. Limited range of motion d. Active assistive range of motion
a
The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education? a. When I lift and carry a heavy box of supplies I will keep it at arm's length from my body. b. When lifting an object, I will keep my feet shoulder width apart. c. When lifting an object, I will bend at the knees instead of the waist. d. When I lift an object, I will get close to the object being lifted.
a
The nurse would like to assist a client out of bed and into a chair. The client is uncooperative, has a leg cast, and can bear weight on the unaffected leg. Which equipment or assistive device should the nurse use? a. powered full-body lift b. powered stand-assist device c. lateral assist device d. friction-reducing device
a
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? a. Shift their weight back and forth, from back leg to front leg. b. Rock the client back and forth to raise the client up in bed. c. Turn the client from side to side while pushing upward. d. Shift their weight back and forth from the legs to the back muscles.
a
When logrolling a client, the nurse should use supportive devices in turning the client in order to: a. maintain the natural alignment of the client's body. b. maximize the client's participation. c. prevent the blood stasis that can lead to skin breakdown. d. allow the client's leg to rest on the bed.
a
When moving a client up in bed with the assistance of another caregiver, the nurse should: a. have the client fold the arms across the chest. b. ask another nurse about the plan of care. c. maintain a pillow under the client's head. d. elevate the head of the bed.
a
When turning a client in bed, what muscle groups would the nurse use to pull the client to the opposite side of the bed? a. leg b. arm c. chest d. back
a
Which strategy(ies) does the nurse use to maintain proper body mechanics and prevent self-injury? Select all that apply. a. Place feet shoulder width apart when lifting an object b. Plant feet firmly on the floor when supporting the client during dangling c. Bend at the waist when lifting an object d. Lock elbows when grasping onto objects e. Hold objects an arm's length away when lifting and carrying them
a, b
A 90-year-old widower lives alone in her home. The nurse knows that older clients are at increased risk for falls. What other factors contribute to increased risk for falls in clients? Select all that apply. a. diuretics b. history of a fall 5 years ago c. ataxic gait d. installed carpeting
a, b, c
A client's job requires moving heavy objects from one surface to another. The nurse will provide which anticipatory guidance to help this client avoid a back injury? Select all that apply. a. Face in the direction in which you are moving the load. b. Work as closely to the objects you are moving as possible. c. Flex the knees to improve balance and strength. d. Standing with your feet close together will improve your balance. e. Pull objects toward you rather than pushing them away.
a, b, c
The client is a clerical assistant for an inpatient hospital unit. He spends most of his day at a desk. What would the nurse advise the clerical assistant to do to minimize damage to his musculoskeletal system? Select all that apply. a. face in the direction of the activity he is performing b. adjust the height of the work area c. use a wide stance and lift with the large leg muscles d. hold his breath only when lifting heavy objects
a, b, c
The nurse assists a client who has had a stroke affecting the left side causing difficulty moving the hand and fingers. Which range-of-motion exercise(s) will the nurse use? Select all that apply. a. Flexion of fingers b. Extension of fingers c. Adduction of fingers d. Abduction of fingers e. Hyperextension of fingers
a, b, c, d
The nurse directs the unlicensed assistive personnel (UAP) to help a partially blind older adult client with meals. Which information is appropriate for the nurse to provide the UAP to facilitate the client's comfort and safety during mealtime? Select all that apply. a. Ensure that the temperature of food is safe b. Provide verbal cues regarding location of food on plate c. Place a pillow behind the neck for support d. Cut food into small pieces e. Place client in upright position at a 45- to 90-degree angle in the bed or chair
a, b, d, e
The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply. a. Upright b. Supine c. Semi-Fowler d. Modified supine e. Fowler
a, c, e
A nurse is assessing a client's mobility status. What data would the nurse document as normal findings? Select all that apply. a. independent maintenance of correct alignment b. increased joint mobility c. full range of motion d. Fasciculations e. scissors gait f. head, shoulders, and hips aligned in bed
a, c, f
A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply. a. Stop performing the exercises. b. Decrease the number of repetitions performed. c. Reevaluate the nursing care plan. d. Move to the patient's other side to perform exercises. e. Encourage the patient to finish the exercises and then rest. f. Assess the patient for other symptoms.
a, c, f
A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient? a. Use the axillae to bear body weight. b. Keep elbows close to the sides of the body. c. When rising, extend the uninjured leg to prevent weight bearing. d. To climb stairs, place weight on affected leg first.
b
A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply. a. Instruct the patient to avoid sudden position changes that may cause dizziness. b. Recommend that the patient restrict fluid until after exercising is finished. c. Instruct the patient to push a little further beyond fatigue each session. d. Instruct the patient to avoid exercising in very cold or very hot temperatures. e. Encourage the patient to modify exercise if weak or ill. Recommend that the patient consume a high-carb, low-protein diet.
a, d
A nurse is assisting in the transfer of a client with a diagnosis of Alzheimer's disease to a stretcher. The client experiences frequent periods of agitation and is unable to follow cues or directions. Which device would be the best choice for transferring this client? a. Gait belt b. Transfer chair c. Repositioning lift d. Powered stand-assist
b
A nurse is caring for a client who is wearing antiembolism stockings per the health care provider's prescription. The client reports that the stockings are too uncomfortable and asks whether he can take them off. Which action should the nurse take? a. Explain that the stockings must be worn 48 hours straight before they may be removed temporarily. b. Tell the client he can remove them for 20 or 30 minutes during this shift. c. Permit the client to remove the stockings indefinitely and speak to the physician about the necessity of having the client wear them. d. Instruct the client to not remove them until the primary care provider writes a prescription to discontinue them.
b
A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient? a. Improved renal blood supply to the kidneys b. Urinary stasis c. Decreased urinary calcium d. Acidic urine formation
b
A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop? a. Supination b. Dorsiflexion c. Hyperextension d. Abduction
b
A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: "Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self." Based on this data, which score would the patient receive on the Katz index? a. 2 b. 4 c. 5 d. 6
b
A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program? a. understand that the activity will have positive benefits. b. obtain a pre-exercise medical examination for clearance c. pick an activity the client enjoys to promote adherence d. choose a specific single-exercise activity
b
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? a. Avoid the use of powders on the legs before applying stockings. b. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. c. Apply the stockings at night when the client is going to bed. d. Apply the stockings after the client has been sitting up for an hour.
b
The client is ambulating in the room and walks around a bedside table. What is the bestexplanation for why the client does not bump into the table? a. The cerebellum is responding to impulses from the inner ear. b. The client is aware of spatial relationships to avoid the table. c. The client's muscles are being stretched to walk around the table. d. The brain is sending impulses to the muscles to avoid the table.
b
The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client: a. places the walker far in front when walking. b. steps into the walker when walking. c. leans over the walker when walking. d. uses the sides of the walker to rise from a chair.
b
The nurse is caring for a client with multiple areas of skin breakdown on the back. In which position will the nurse choose to place the client to improve arterial oxygenation? a. supine b. prone c. Sims' d. Fowler's
b
The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include? a. helping the client change positions every 4 hours b. placing the client in good alignment with joints slightly flexed c. providing skin care before repositioning d. using a sheet to drag and lift the client
b
The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group? a. shifted center of gravity b. scoliosis c. kyphosis d. increased need for calcium and vitamin D
b
The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change? a. reports of pain in the lower back b. decrease in flexibility c. stumbling gait d. unequal pupil size
b
The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? a. lying flat with feet raised slightly b. lying flat c. sitting up d. lying prone
b
The nurse is preparing the client for the administration of an enema. The nurse will place the client into which position? a. prone b. Sims' c. supine d. Fowler's
b
The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? a. oliguria b. thrombus formation c. skeletal contractures d. pooling of secretions
b
The nurse should intervene immediately when observing the nursing assistive personnel (NAP) performing which activity with a stable client? a. Applying graduated compression stockings b. Teaching a client range-of-motion exercises c. Transferring a client from the bed to a chair d. Transferring a client from the bed to a stretcher
b
The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client? a. Sims' b. slight Trendelenburg c. prone d. supine
b
The nurse would like to promote ventilation in a client with chronic obstructive pulmonary disease by elevating the client's arms. What intervention should the nurse implement? a. place a trochanter roll under the arms b. place a small pillow under each arm c. instruct the client to place arms on the side rails d. elevate the head of the bed
b
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. a. installing hardwood floors b. moving the bedroom to the ground floor c. removing clutter from the floor d. placing nightlights in the bathroom and hallways
b, c, d
A nurse is conducting an in-service education program for a group of staff nurses about ways to reduce the risk of client handling injuries. Which actions would the nurse include as contributing to this risk? Select all that apply. a. standing for long periods b. engaging in repetitive movements c. using uncoordinated lifts d. lifting when tired e. using assistive devices
b, c, d
The nurse is performing an assessment of a client's joint mobility. What documentation should the nurse provide related to this assessment if joint function is considered normal? Select all that apply. a. Walks 20 feet b. No swelling, heat, tenderness, pain, nodules, or crepitation c. No masses, deformities, or muscle atrophy d. Able to lift head from pillow e. Full range of motion with each joint
b, c, e
The occupational nurse is teaching employees about maintaining good posture. Which teaching will the nurse include? (Select all that apply.) a. Alternate placing weight on one foot versus the other. b. Bend the knees slightly to avoid straining joints. c. Maintain the hips at an even level. d. Push the buttocks out and hold the abdomen up to properly align the spine. e. Keep the shoulders even and centered above the hips.
b, c, e
A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply. a. Do full-body pushups in bed six to eight times daily. b. Breathe in and out smoothly during quadriceps drills. c. Place the bed in the lowest position or use a footstool for dangling. d. Dangle on the side of the bed for 30 to 60 minutes. e. Allow the nurse to bathe the patient completely to prevent fatigue. f. Perform quadriceps two to three times per hour, four to six times a day.
b, c, f
A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply. a. Exercise decreases appetite. b. Exercise increases efficiency of the metabolic system. c. Exercise increases resting heart rate and blood pressure. d. Exercise increases intestinal tone. e. Exercise increases blood flow to kidneys. f. Exercise decreases rate of carbon dioxide excretion.
b, d, e
A nurse is teaching a client how to use a walker. Which instructions should the nurse provide? Select all that apply. a. "Your elbows should be nearly straight when you grasp the walker." b. "Keep your arms relaxed at the side of the walker." c. "Move the walker forward 12 to 18 in (30 to 45 cm) with each step and set it down." d. "Stand centered between the back legs of the walker." e. "Line up the top of the walker with the crease on the inside of your wrist."
b, d, e
A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? a. administering a muscle relaxer b. positioning the client on the stomach c. placing a small towel under the neck d. contacting the primary care physician
c
A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care? a. foot splints b. foot boards c. trochanter rolls d. roller sheets
c
A nurse is ambulating a client. The client catches her foot on the bed frame and begins to fall. How should the nurse best prevent or minimize damage from this fall? a. The nurse should place his or her feet close together with one foot in front of the other. b. The nurse should rock his or her pelvis out on the opposite side of the client. c. The nurse should gently slide the client down his or her body to the floor. d. The nurse should grasp the gait belt and pull the client's body backward away from his or her body.
c
A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action? a. Wait a few minutes and then continue the move to the chair. b. Call for assistance and continue the move with the help of another nurse. c. Lower the patient back to the side of the bed and pivot her back into bed. d. Have the patient sit down on the bed and dangle her feet before moving.
c
A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident. Which action would the nurse perform when logrolling the patient to reposition him on his side? a. Have the patient extend his arms outward and cross his legs on top of a pillow. b. Stand at the side of the bed in which the patient will be turned while another nurse gently pushes the patient from the other side. c. Have the patient cross his arms on his chest and place a pillow between his knees. d. Place a cervical collar on the patient's neck and gently roll him to the other side of the bed.
c
A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? a. Dorsal recumbent position b. Lateral position c. Fowler's position d. Sims' position
c
A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response? a. "To prevent foot drop." b. "To preserve the client's functional ability to grasp and pick up objects." c. "To prevent the legs from rotating outward." d. "To avoid contractures."
c
An infant develops one extremity that is shorter than the other. This occurs with: a. hip fractures. b. bone tumors. c. hip dislocation. d. loss of calcium.
c
In an assessment for proper body alignment of a standing client, which finding is normal? a. The chest is downward and displaced slightly backward. b. The abdominal muscles are held downward and the buttocks upward. c. The weight of the body is distributed on the soles and heels. d. The line of gravity is deviated slightly to the left.
c
The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher? a. alongside the bed 2 in (5 cm) lower b. alongside the bed 1 in (2.5 cm) either lower or higher c. alongside the bed at the same height d. alongside the bed 2 in (5 cm) higher
c
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? a. increased metabolic rate b. increase in the movement of secretions in the respiratory tract c. predisposition to renal calculi d. increase in circulating fibrinolysin
c
The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? a. the 6-month-old child who is unable to roll over b. the 18-month-old child who is unable to stack blocks c. the 24-month-old child who is unable to walk unassisted d. the 3-month-old child who is unable to raise the head when prone
c
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? a. Make sure the bed brakes are unlocked. b. Place the bed in the highest position. c. Raise the head of the bed to a sitting position. d. Put the chair at the foot of the bed.
c
The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? a. transfer boards b. roller sheet c. transfer belt d. mechanical lift
c
The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should: a. teach the client to pull up with the headboard. b. use a pull sheet whenever moving the client. c. provide the client with an overhead trapeze. d. manually roll the client to the side of the bed.
c
The nurse is caring for a client who is postoperative from a hip fracture repair. The nurse must be careful to avoid: a. extension of the knee on the affected leg. b. hip abduction. c. adduction of the affected leg. d. flexion of the knee on the affected leg.
c
The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern? a. walking with a slow and uncoordinated movement b. joint stiffness after sitting for an hour c. shortness of breath after walking up five stairs d. a change in pulse from 80 to 84 after walking up 20 stairs
c
The nurse is preparing to transfer a client from the bed to a stretcher. What action should the nurse take to prevent injury to the client and nurse? a. grasp the friction-reducing sheet at the hips and knees of the client b. keep the client covered with the top covers and bedsheets c. leave the friction-reducing sheet in place once the client is transferred d. instruct the client to hold on to the side rails for support and reach for the stretcher
c
The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? a. "Your feet should be at 45-degree angles from the legs." b. "Sleep with your head tilted to one side to take pressure off your neck." c. "Picture yourself with good posture standing; that is how good lying posture works." d. "Keep knees and legs very straight."
c
The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager? a. Chairs have firm back support and allow the feet to touch the floor. b. Work is being carried out under sources of non-glare lighting. c. Equipment is positioned to the side, 50 degrees away. d. A small dolly is used to transport heavy items.
c
The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? a. A client who is confined to bed rest b. A client who has an abdominal incision c. A client who has leg strength and can cooperate with the movement d. A client with a thoracic incision
c
Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer? a. To ensure safety, do not allow the client to assist with the transfer. b. Use assistive devices if either of the nurses will need to lift more than 60 lb (27.2 kg). c. If the client is in pain, administer analgesics in advance of the transfer. d. Avoid using handling aids unless absolutely necessary.
c
When assessing correct body alignment when the client is standing, the nurse would document which abnormal findings? Select all that apply. a. The head is held erect. b. The feet are at right angles to the lower legs. c. The arms are bent at the elbows. d. The chest is held upward and forward. e. The knees are bent.
c, e
A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect the patient: a. Grasp the gait belt. b. Stay with the patient and call for help. c. Place feet wide apart with one foot in front. d. Gently slide patient down to the floor, protecting her head. e. Pull the weight of the patient backward against your body. f. Rock your pelvis out on the side of the patient.
c, f, a, e, d, b
A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate? a. The nurse discourages the client from helping with the transfer. b. The nurse administers pain medication following the transfer. c. The nurse grabs and holds the client by his arms. d. The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.
d
A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? a. "We'll have the nursing assistant watch you while you walk around the unit the first time." b. "When your crutches fit right, most of your body weight will be supported by your armpits." c. "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." d. "Your elbows will be slightly bent when you are using your crutches."
d
A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? a. It is acceptable to twist the client's head, but not the hips, while logrolling. b. Logrolling can be performed by one experienced nurse. c. Logrolling will maintain straight alignment when the client is sitting in a chair. d. Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.
d
A nurse is explaining to a caregiver the value of nonpharmacologic methods of pain management. Which statement best describes the proper rationale for using nonpharmacologic methods to help manage pain? a. Nonpharmacologic methods are more effective. b. Nonpharmacologic methods do not require a health care provider's prescription. c. Nonpharmacologic methods are less expensive. d. Use of nonpharmacologic methods can diminish the emotional component of pain.
d
A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position? a. Side-lying b. Fowler's c. Sims' d. Prone
d
As a part of his workout regimen, a 21-year-old college football player often engages in squats and lateral arm holds. These are examples of what type of exercise? a. aerobic b. isotonic c. anaerobic d. isometric
d
The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? a. push the client to the opposite side of the bed b. push the client to the edge of the bed to which the client will be turning c. pull the client to the edge of the bed to which the patient will be turning d. move the client to edge of the bed opposite the side that client will be turning
d
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? a. Fowler's b. prone c. supine d. Sims'
d
The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care? a. trochanter rolls b. log rolling c. pull sheets d. trapeze bar
d
The nurse observes an older adult client walks walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? a. requires a better walking shoe. b. should have an orthopedic consultation. c. requires crutches for mobility. d. is demonstrating a common gait for the older adult.
d
Using proper body mechanics, which motions would the nurse make to move an object? a. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity. b. The nurse uses the muscles of the back to help provide the power needed in strenuous activities. c. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. d. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
d
When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body? a. Long bones are relatively thin and contribute to shape. b. The wrist is classified as an irregular bone. c. Flat bones are found in the spinal column. d. Short bones contribute to movement.
d