ch 33 activity, ch. review and prepu

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. Fowler's position promotes maximal breathing space in the thoracic cavity and is the position of choice when someone is having difficulty breathing. Lying flat on the back or side or Sims' position would not facilitate respiration and would be difficult for the patient to maintain.

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? a) prone b) Fowler's c) supine d) Sims'

d) sims Sims' position, a semi-prone position, can be used for certain examinations of the rectum and vagina. The other positions do not allow adequate examination of this area.

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. When a patient complains of fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the nursing care plan, and assess the patient for further symptoms. The exercises could then be scheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day.

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) have the client fold the arms across the chest. Positioning the arms across the chest improves assistance, reduces friction, and prevents hyperextension of the neck. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. This validates the correct client and correct procedure, identification of limitation, and ability. Reviewing the medical record and plan of care also identifies use of an algorithm to prevent injury and assists in determining the best plan for client movement. The head of the bed should be flat or as low as the client can tolerate; this will help to decrease the gravitational pull of the upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from under the client's head; this facilitates movement.

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? a) predisposition to renal calculi b) increased metabolic rate c) increase in circulating fibrinolysin d) increase in the movement of secretions in the respiratory tract

a) predisposition to renal calculi In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

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. a) facing the client when speaking b) providing instructions one at a time c) being positive in statements when providing instructions d) calling the client by the preferred name e) using a forceful tone in the voice when providing instructions

a, b, c, d,

A nurse is preparing an excercise program for a patient who has COPD. Which instructions would the nurse include in teaching plan for this patient? SAP 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. f) Recommend that the patient consume a high-carb, low-protein diet.

a, d. Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to provide for adequate hydration, respect fatigue by not pushing to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.

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. Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and movement should be documented but are not the primary focus of interventions related to injury prevention.

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. The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.

Using proper body mechanics, which motions would the nurse make to move an object? a) The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object. b) 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. c) The nurse uses the muscles of the back to help provide the power needed in strenuous activities. d) 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 internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach muscles or use the muscles of the back when moving an object. The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled.

During range-of-motion exercises, the nurse turns the sole of a client's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions? a) flexion and extension of the ankle b) inversion and eversion of the ankle c) internal and external rotation of the ankle d) dorsiflexion and plantar flexion of the ankle

b) inversion and eversion of the ankle Inversion and eversion are movements of the ankle. Inversion is the movement of the sole of the foot inward. Eversion is the movement of the sole of the foot outward. Internal rotation is the turning of a body part on its axis toward the midline of the body. External rotation is the turning of a body part on its axis away from the midline of the body. Dorsiflexion is the backward bending of the hand or foot. Plantar flexion is flexion of the foot. Flexion is the state of being bent. Extension is the state of being in a straight line.

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) pull the client to the edge of the bed to which the patient will be turning b) move the client to edge of the bed opposite the side that client will be turning c) push the client to the edge of the bed to which the client will be turning d) push the client to the opposite side of the bed

b) move the client to edge of bed opposite the side that client will be turning When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

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) to the nondominant side of the client, with legs together and one foot near the head of the bed. b) near the client's hip, with legs shoulder width apart and one foot near the head of the bed c) to the dominant side of the client, with legs together and one foot d) near the head of the bed near the client's hip, with legs together

b) near the client's hip, with legs shoulder width apart and one foot near the head of the bed When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight to assist the client to a sitting position safely. The dominant or nondominant side is not relevant when moving a client with equal strength but would be helpful with a client who has had a stroke.

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 the legs to the back muscles. b) Shift their weight back and forth, from back leg to front leg. c) Turn the client from side to side while pushing upward. d) Rock the client back and forth to raise the client up in bed.

b) shift there weight back and forth from back leg to front leg The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. Rocking the client or turning the client from side to side is not used to move a client.

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) leans over the walker when walking. b) steps into the walker when walking. c) uses the sides of the walker to rise from a chair. d) places the walker far in front when walking.

b) steps into the walker when walking. A walker is mechanical aid that enhances the client's balance and ability to bear weight. Education is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client's ability to use the walker properly. The client should step into the walker when walking rather than walking behind it. When the client is rising from a seated position, the arms of the chair, not the walker, should be used for support. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker but should instead stay upright while moving.

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 24-month-old child who is unable to walk unassisted c) the 18-month-old child who is unable to stack blocks d) the 3-month-old child who is unable to raise the head when prone

b) the 24-month-old child who is unable to walk unassisted At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early.

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) roller sheet b) transfer belt c) mechanical lift d) transfer boards

b) transfer belt A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady. The other options are inappropriate for this client.

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care? a) pull sheets b) trapeze bar c) trochanter rolls d) log rolling

b) trapeze bar 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 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. Breathing in and out smoothly during quadriceps drills maximizes lung inflation. The patient should perform quadriceps two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling. The nurse should also encourage the patient to be as independent as possible to prepare for return to normal ambulation and ADLs.

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. By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.

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. For a patient who has footdrop, the nurse should support the feet in dorsiflexion and use a footboard or high-top sneakers to further support the foot. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions would not be used to prevent footdrop.

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. In a nonerect patient, the kidneys and ureters are level. In this position, urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder, resulting in urinary stasis. Urinary stasis favors the growth of bacteria that may cause urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to increased levels of urinary calcium and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.

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. The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg to prevent weight bearing when rising from a chair, and advance the unaffected leg first when climbing stairs.

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. The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding.

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) Apply the stockings at night when the client is going to bed. b) Apply the stockings after the client has been sitting up for an hour. c) If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. d) Avoid the use of powders on the legs before applying stockings.

c) If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Be prepared to apply the stockings in the morning before the client is out of bed. Assist the client to a supine position. If the client has been sitting or walking, have him or her lie down with legs and feet well elevated for at least 15 minutes before applying the stockings. Powder the leg lightly unless client has a breathing problem, dry skin, or sensitivity to the powder. If the skin is dry, a lotion may be used. Powders and lotions are not recommended by some manufacturers; check the package material for manufacturer specifications.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? a) Put the chair at the foot of the bed. b) Make sure the bed brakes are unlocked. c) Raise the head of the bed to a sitting position. d) Place the bed in the highest position.

c) Raise the head of the bed to a sitting position. When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.

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) trochanter roll b) bed cradle c) bed trapeze d) foot board

c) bed trapeze A trapeze bar is a handgrip suspended from a frame near the head of the bed. A client can grasp the bar with one or both hands and raise the trunk from the bed. The trapeze makes moving and turning considerably easier for many clients and facilitates transfers into and out of bed. A foot board helps reduce the risk of foot drop. A bed cradle is usually a metal frame that supports the bed linens away from the client while providing privacy and warmth. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward.

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 the graduate states that back injuries: a) can be prevented with the use of a gait belt. b) are related to sitting for long periods. c) can occur when uncooperative clients are being repositioned. d) are a routine consequence of the job.

c) can occur when uncooperative clients are being repositioned. 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 uncooperative clients are being repositioned. Back injuries cannot be prevented with the 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 can contribute to back injuries.

Which type of mobility aid would be most appropriate for a client who has poor balance? a) a single-ended cane with a half-circle handle b) a single-ended cane with a straight handle c) a cane with four prongs on the end (quad cane) d) axillary crutches

c) cane w/ 4 prongs on the end (quad cane) 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 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) requires crutches for mobility. c) is demonstrating a common gait for the older adult. d) should have an orthopedic consultation.

c) is demonstrating a common gait for the older adult. Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support.

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. If a patient being ambulated starts to fall, you should place your feet wide apart with one foot in front, rock your pelvis out on the side nearest the patient, grasp the gait belt, support the patient by pulling her weight backward against your body, gently slide her down your body toward the floor while protecting her head, and stay with the patient and call for help.

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. If a patient becomes faint and knees buckle when moving from bed to a chair, the nurse should not continue the move to the chair. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. Another attempt should be made with the assistance of another staff member if vital signs are stable. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position, and avoid hypotension related to a sudden change in position.

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. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses.

c. The procedure for logrolling a patient is: (1) Have the patient cross the arms on the chest and place a pillow between the knees; (2) have two nurses stand on one side of the bed opposite the direction the patient will be turned with the third helper standing on the other side and if necessary, a fourth helper at the head of the bed to stabilize the neck; (3) fanfold or roll the drawsheet tightly against the patient and carefully slide the patient to the side of the bed toward the nurses; (4) have one helper move to the other side of the bed so that two nurses are on the side to which the patient is turning; (5) face the patient and have everyone move on a predetermined time, holding the drawsheet taut to support the body, and turn the patient as a unit toward the two nurses

A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response? a) "To avoid contractures." b) "To preserve the client's functional ability to grasp and pick up objects." c) "To prevent foot drop." d) "To prevent the legs from rotating outward."

d) "To prevent the legs from rotating outward." Trochanter rolls prevent the legs from rotating outward. The other statements do not describe trochanter rolls. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop.

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) "When your crutches fit right, most of your body weight will be supported by your armpits." b) "We'll have the nursing assistant watch you while you walk around the unit the first time." 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) "Your elbows will be slightly bent when you are using your crutches." When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.

The nurse is assessing an ambulatory client for gait. Which documentation describes this mobility status? a) A straight line can be drawn from the ear through the shoulder and hip. b) Adequate muscle mass, tone, and strength are available to accomplish movement. c) Client displays full range-of-motion in arms and legs. d) Arms swing freely in alternation with legs.

d) Arms swing freely in alternation with legs. The client's movements while walking should be coordinated and the posture well balanced. The arms should swing freely in a rhythm alternating with the legs. Mobility would not be described by the drawing of a straight line from the ear through the shoulder and hip. This does not explain how the client moves. The documentation of full range-of-motion does not describe the client's mobility. The documentation of adequate muscle mass, tone, and strength could be important to include in the general documentation, but this description does not explain the client's mobility status.

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) skeletal contractures B) pooling of secretions C) oliguria D) thrombus formation

d) thrombus formation Prolonged sitting can increase a client's risk for thrombus formation. The nurse will emphasize this and teach stretching exercises. Skeletal contractures, pooling of secretions, and oliguria are not risk factors associated with flying (prolonged sitting).

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. The prone position is contraindicated in patients who have spinal problems because the pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.