VNSG 1323: Chapter 23 Prep U Questions

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

Supine Explanation: Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. Other positions are inappropriate for placing the infant to sleep.

When assessing correct body alignment when the client is standing, the nurse would be document which abnormal findings? Select all that apply.

The arms are bent at the elbows. The knees are bent Explanation: Correct alignment permits optimal musculoskeletal balance and operation and promotes optimal physiologic functions. With the client standing, the nurse would be concerned if the arms were bent at the elbows. The arms should hang comfortably at the sides. Also, the nurse would be concerned if the knees were bent. The knees should be in a slightly flexed position, not bent and not in the knee-locked position. It is a normal finding for the head to be held erect and in the midline position. It is also a normal finding for the feet to be at right angles to the lower legs. It is a normal finding for the chest to be held upward and forward.

The nurse observes an unlicensed assistive personnel (UAP) placing a client in the Fowler's position. To prevent complications to the client, in which situation should the nurse intervene? Select all that apply.

There is a large pillow under the client's head. The knee gatch on the bed is engaged. The client's foot is in the plantar flexion position. Explanation: In the Fowler's position, the client's head should be against the mattress or supported by a small pillow only. Using a large pillow may cause flexion contracture of the neck. The knee gatch should be avoided to prevent pressure on the popliteal artery that may compromise lower extremity circulation. When the client's foot is in the plantar flexion position, the client is at risk for developing footdrop. A footboard, high top sneakers, or improvised firm foot support should be used. It is appropriate to place the client's forearms on pillows. This will prevent pull on the shoulders and help to prevent dislocation of the shoulder. A rolled towel or trochanter roll will help prevent external rotation of the hips.

When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the client. What is the rationale for using a transfer board in this procedure?

To reduce friction as the client is pulled laterally onto the stretcher Explanation: The transfer board or other lateral-assist device reduces friction, easing work load to move the client. It is positioned partially under the client, across the space between the bed and stretcher.

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

Trapeze bar Explanation: Promoting client independence with movement and activity is an important intervention for clients with musculoskeletal problems. Unlike log rolling and pull sheets, which are nurse-initiated methods, the overhead trapeze is used by the client.

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?

Trochanter rolls Explanation: Trochanter rolls prevent the legs from turning outward. The trochanters are the bony protrusions at the head of the femur near the hip. Placing a positioning device at the trochanters helps to prevent the leg from rotating outward. Other devices are inappropriate for this client.

Which type of mobility aid would be most appropriate for a client who has poor balance?

A cane with four prongs on the end (quad cane) Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold, but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

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.

Adjust the height of the work area. Face the direction of the activity he is performing. Use a wide stance and lift with the large leg muscles. Explanation: Breath holding is a sign of muscle strain and an inefficient use of body mechanics.

The nurse is assisting the client who has dementia from the bed to the chair for mealtime. What actions by the nurse would facilitate cooperation from the client? Select all that apply

Call the client by the preferred name. Face the client when speaking. Provide instructions one at a time. Be positive in statements when providing instructions. Explanation: For the client who has dementia, the nurse would facilitate cooperation by calling the client by the preferred name, facing the client when speaking, and providing instructions one at a time. The nurse would use a calm and reassuring tone with the voice, not a forceful tone. Clients with dementia respond better to statements that are positive, rather than those statements that have a negative connotation or the word "don't."

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when she states that back injuries:

Can occur when repositioning uncooperative clients. Explanation: Many nurses believe that back pain is a routine consequence of the job, but it need not be. Employing principles of body mechanics, use of algorithms, and guidelines for transferring or lifting clients contributes to the prevention of back injuries and pain. Back injuries can occur when repositioning uncooperative clients. Back injuries cannot be prevented by use of a gait belt. Inappropriate use of the gait belt and other factors can contribute to back injuries. Standing, not sitting, for long periods of times can contribute to back injuries.

The nurse is moving a client from bed to a wheelchair using a powered full-body sling lift. Where would the nurse position the frame of the lift?

Centered over the client Explanation: The nurse would lower the side rail on the wheelchair side of the bed, roll the base of the lift under the side of the bed nearest to the chair, and center the frame over the client. Centering the frame helps maintain the balance of the lift.

What is a benefit of regular exercise over time?

Decreased heart rate Explanation:Regular physical activity over time results in cardiovascular conditioning, thus decreasing heart rate. Regular exercise increases circulating fibrinolysin that serves to breakup small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.

A nurse uses proper body mechanics to move a client up in bed. Which action is a guideline for using these techniques properly?

Face the direction of movement. Explanation:When using body mechanics, the nurse should face the direction of movement and avoid twisting the body. Maintaining balance involves keeping the spine in vertical alignment, body weight close to the center of gravity, and feet spread for a broad base of support

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client?

Fowler's Explanation: Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The client's risk of aspiration would be extreme in a supine position. Low-Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high-Fowler's position.

A nurse is caring for a client with a leg fracture. The client is placed on an adjustable bed in the Trendelenburg position. How will this position help the client?

It prevents sliding down toward the foot of the bed. Explanation: The Trendelenburg position will prevent the client from sliding down toward the foot of the bed. Raising the head of the bed would help the client to look around without twisting and bending. It also promotes drainage of the upper lobes of the lungs and prepares the client for standing and walking.

A nurse knows that use of a trapeze would be contraindicated for a client:

On lifting restrictions. Explanation:A trapeze is a triangular piece of metal hung by a chain over the head of the bed. The client grasps the trapeze to lift the body and move about in bed. Unless arm movement or lifting is undesirable, a trapeze is an excellent device for helping a bedridden client to increase his or her activity.

A nurse is caring for a client with demobilized respiratory secretions. Which device will best mobilize respiratory secretions?

Oscillating support bed Explanation: An oscillating support bed would be useful for this client. It slowly and continuously rocks the client from side to side in a 124 arc. Oscillation relieves skin pressure and helps to mobilize respiratory secretions. An air-fluidized bed drains excretions and secretions away from the body and through the beads, thereby preventing skin irritation and maceration from moisture. A static air mattress suspends the client on a buoyant surface, distributing the pressure on the underlying tissue. A circular bed supports the client on a 6- or 7-foot anterior or posterior platform suspended across the diameter of the frame.

A nurse is caring for an immobile client who is required to spend long hours in bed. What should the nurse do to prevent the occurrence of footdrop?

Place a slanting footrest at the foot of the bed to support the client's feet. Explanation :A nurse caring for an immobile client should place a slanting footrest at the foot of the bed to support the client's feet. It is as comfortable for the feet as standing, and it prevents the occurrence of a foot drop. A pillow is placed between the mattress and the foot of the bed to prevent the mattress from slipping when the head of the bed is raised. Trochanter rolls are placed on each side of the client's legs to keep the legs and feet from rotating outward, causing deformities later on. A pad is placed under the client's ankles to prevent pressure on the heels.

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?

Plantar flexion of the feet. Explanation:It is important to be aware of client positioning and nursing actions required to prevent complications. The client who is in the prone position is at risk for footdrop (plantar flexion of the feet) because of the pull of gravity on the feet—unless the legs and feet are positioned carefully. The client in the prone position is not at risk for flexion contracture of the neck because the body is straight—the shoulders, head, and neck are in an erect position. The client would be at risk for flexion contractures of the hips when in the supine or Fowler's position. The client in the prone position is lying on his abdomen and thus would be at risk for skin breakdown of the sacrum. The client in the Fowler's position would be at risk for skin breakdown of the sacrum. When in the prone position, the hips are prevented from flexing or hyperextending.