Fundamentals Mobility/Safety EAQ
Which statement made by nursing assistive personnel (NAP) assigned to care for a patient with dementia requires the nurse to follow up? "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." "He can't see his Foley because it's covered by his boxer shorts." "I'll ask the patient every hour or so whether he needs to use the bathroom." "He doesn't understand much of what anyone says to him today, so I didn't put in his hearing aids."
"He doesn't understand much of what anyone says to him today, so I didn't put in his hearing aids."
What instruction might the nurse give to nursing assistive personnel (NAP) regarding postoperative exercises? "Find out if the patient has any language barriers." "Let me know when the patient actually begins exercising." "Please review a copy of the preoperative literature with the patient." "Assess the method of learning the patient would prefer."
"Let me know when the patient actually begins exercising."
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? "When I count to three, please rock yourself into a standing position." "Please hold on to my waist while I help you stand." "Please tell me how I can best help you get up off the bed and stand up." "Please push down onto the mattress with both hands and stand when I count to three."
"Please push down onto the mattress with both hands and stand when I count to three."
What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint? "Tell me if the patient's pulse changes." "Tell me if the skin under the restraint becomes abraded or raw." "Let me know if you think she's ready for them to come off." "Let me know if the patient needs anything for pain."
"Tell me if the skin under the restraint becomes abraded or raw."
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?" "I'm sure you don't want him to fall again." "Can you suggest an alternative?" "What did you do to prevent him from falling when he was at home?" "We will try all other alternatives before using physical restraints."
"We will try all other alternatives before using physical restraints."
Before teaching a patient postsurgical exercises, the nurse premedicates the patient for pain. What benefit does this have specific to the patient's learning? Reduced pain Improved focus Decreased relaxation Decreased irritability
Improved focus
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? Place both feet together on the floor. Place your weaker foot forward and your stronger leg toward the back. Extend both of your legs and feet. Place your stronger leg forward and your weaker leg toward the back.
Place your stronger leg forward and your weaker leg toward the back.
To which patient might the nurse apply a physical restraint? An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt. A 74-year-old patient confined to bed who is at risk of pressure ulcers. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning.
A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt.
Which patient is most at risk of developing permanently impaired mobility? A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) A 55-year-old woman with mental illness who had become malnourished An 11-year-old boy who sustained a fractured pelvis during a fall from his tree house A 79-year-old man recovering from surgery to release a contracture of the connective tissue in his hand
A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease)
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? Weekly pet therapy with a golden retriever A jigsaw puzzle of an appropriate level of difficulty A crossword puzzle book of an appropriate level of difficulty Frequent card games with other patients
A jigsaw puzzle of an appropriate level of difficulty
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 patient who has refused most meals for the past week and whose weight has dropped by 10% in the past month. A patient who has become verbally combative with staff in recent weeks. A patient who was returned to the unit last week by staff in an adjacent assisted living facility. A patient whose abdominal feeding tube is covered with an abdominal binder.
A patient who was returned to the unit last week by staff in an adjacent assisted living facility
Which action would decrease a patient's pain before a transfer with a hydraulic lift? Stop the transfer if the patient expresses or displays physical signs of pain. Explain the procedure to the patient before beginning the transfer. Administer a prescribed analgesic 30 to 60 minutes before the transfer. Postpone the transfer if the patient reports having physical pain or anxiety before the transfer.
Administer a prescribed analgesic 30 to 60 minutes before the transfer.
Which condition is not associated with venous stasis, part of Virchow's triad? Pregnancy Obesity Anxiety Immobility
Anxiety
When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve? After the patient crosses the arms over the chest After the patient's eyeglasses are removed As soon as the patient has been placed in the chair When the nurse removes the straps
As soon as the patient has been placed in the chair
The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse to determine how far to walk? Ask the patient how far she would like to go Review the healthcare provider's order Review the medical record to see how far the patient has walked during the past several therapeutic ambulations Review the records of other patients who are at a similar point in their stroke rehabilitation
Ask the patient how far she would like to go
When preparing to move a patient in bed, what will the nurse do first? Assemble adequate help to move the patient Assess the patient's ability to help with moving Determine the patient's weight Decide on the most effective means of moving the patient
Assess the patient's ability to help with moving
When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first? Coordinate extra help. Assess the patient's vital signs. Assess the patient's physiological capacity to transfer. Determine whether to transfer the patient to a wheelchair or chair.
Assess the patient's physiological capacity to transfer
When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first? Assesses the patient for weakness, dizziness, or postural hypotension Arranges for at least three healthcare personnel to assist in the transfer Makes sure the patient agrees to the intervention Applies clean gloves
Assesses the patient for weakness, dizziness, or postural hypotension
A patient who weighs 200 lbs. needs to be moved up in the bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? A minimum of two None, since the device does all the lifting during the move At least 3 The nurse can carry out this move without assistance
At least 3
When turning a patient to place a slide board, where do the assistants stand? At the side of the bed to which the patient will be turned At the side of the bed from which the patient will be turned At the head and foot of the bed At the foot of the bed only
At the side of the bed to which the patient will be turned
The nurse is concerned that a patient will not be able to turn independently in bed after having surgery. What must the nurse do to help this patient? Reinstruct the patient in proper turning techniques. Document that the patient refuses to turn independently. Communicate that the staff must turn the patient after surgery. Restrict turning unless absolutely necessary.
Communicate that the staff must turn the patient after surgery.
Which of the following are basic guidelines when assisting a patient with passive range of motion? Exercises should be continued until the point of fatigue and pain Exercises should be done frequently to lessen pain for the patient Each joint is exercised to the point of resistance but not pain Exercises should be performed without the support of each joint
Exercises should be done frequently to lessen pain for the patient
The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to NAP. Which statement made by NAP requires the nurse to follow up? I will be sure to put nonskid slippers on the patient before getting him up to ambulate I will use the under-axillae technique to help him up to a standing position Rocking the heavier patient into a standing position seems to work really well for me I will grasp the gait belt in the middle of the patient's back
I will use the under-axillae technique to help him to a standing position
What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? Lower the head of the bed. Remove the patient's eyeglasses. Have the patient cross the arms over the chest. Elevate the head of the bed.
Elevate the head of the bed
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? Stand with the knees locked Stand with the feet together Flex the hips and knees Shift the body weight form the back leg to the front leg
Flex the hips and knees
To which position would the nurse assist the patient who is experiencing difficulty with breathing? Fowler's position 30-degree lateral position Sims' position Prone position
Fowler's position
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? Hold the slide board stationary. Pull the draw sheet. Hold the patient's head stationary. Lock the brakes on the stretcher.
Hold the slide board stationary.
After determining the proper size stocking and assessing the patient's circulatory status, a nurse delegates the application of elastic stockings to nursing assistive personal (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? Explain that the moisturizer may cause excessive skin softening, which can lead to skin breakdown Instruct NAP to use a small amount of cornstarch or powder Ask the patient if he or she is allergic to the moisturizer Inspect the patient's skin for color variations
Instruct NAP to use a small amount of cornstarch or powder
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? Remove the wheelchair leg rests. Ask the patient to rate his or her pain level. Lower the foot rests, and place the patient's feet on them. Remove the transfer belt.
Lower the foot rests, and place the patient's feet on them
The nurse is preparing to move a patient from the bed to a stretcher. What will the nurse do first? Cross the patient's arms over his or her chest. Lower the side rails of the bed. Make sure the bed brakes are locked. Fanfold the draw sheet.
Make sure the bed brakes are locked.
Which nursing action is most therapeutic in response to a cognitively impaired patient who demands to know when his daughter is coming to visit? Marking the date of the visit on the patient's wall calendar Evaluating the patient's understanding of the concept of time and date Telling the patient when his daughter will be visiting and ensuring that he verbalizes his understanding Calling the daughter to suggest that she visit sooner than she had planned
Marking the date of the visit on the patient's wall calendar
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? On the patient's strong side On the patient's weak side Behind the patient In front of the patient
On the patient's weak side
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? Move the joint through the full range of motion exercises Perform range of motion to the left elbow until resistance is met Omit all range of motion exercises until the health care provider is notified Inform the health care provider that the patient is uncooperative with exercising
Perform range of motion to the left elbow until resistance is met
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? Place a small pillow under the shoulder Use the affected arm as a guide during rolling Place a pillow on the abdomen Place rolled bath blankets along the dependent leg
Place a pillow on the abdomen
When repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward? Apply therapeutic boots to the feet Place sandbags along the legs Place a small pillow at the lumbar region of the back Place a pillow under the calves
Place sandbags along the legs
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? Help the patient put on skid-resistant footwear. Raise the head of the bed 30 degrees. Place the transfer belt over the patient's clothing. Position the chair so that the patient will move toward his or her stronger side.
Raise the head of the bed 30 degrees
After moving a patient from the bed to a stretcher, the nurse raises the head of the stretcher. What will the nurse do next? Lock the wheels on the stretcher. Cover the patient with a blanket. Raise the side rails on the stretcher. Unlock the wheels of the bed.
Raise the side rails on the stretcher
The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What should the nurse do? Return the patient to the bed or chair (whichever is closer) Encourage the patient to complete the distance of ambulation Help him to the restroom Ease him to the floor
Return the patient to the bed or chair (whichever is closer)
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? Lift the patient to place the device directly under him or her Remove the drawsheet, and replace it with the device Sit the patient up in the bed, and place the device behind the shoulders Roll the patient from side to side, and place the device under the drawsheet
Roll the patient from side to side, and place the device under the drawsheet
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 beings to lean heavily on the nurse. What would be the nurse's initial response? Slowly lower the patient to the floor Attempt to sit the patient down on a chair just a few steps away Try to hold the patient up until the dizziness passes Call for assistance in a loud but calm voice
Slowly lower the patient to the floor
Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift? Prone Side-lying Supine Sims
Supine
In which position will the nurse place the patient to move him or her up in bed? Supine with the head of the bed flat Sitting in the bed Supine with the head of the bed at a 30-degree angle Prone with the head of the bed flat
Supine with the head of the bed flat
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 leg? To reduce the risk for a fall while the side rails are down To reduce the risk of contracture To control pain To cushion the legs
To reduce the risk of contracture
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? To position the pillows To ease the patient back onto the support pillows To keep the spine in alignment To roll the patient as a unit
To roll the patient as a unit
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? The patient is an older adult or has a chronic condition The patient is reluctant to perform the exercises because the is worried about reinjury The patient has orthopedic trauma The patient has pain exacerbated by exercise
The patient has orthopedic trauma
Why might the nurse choose not to apply a pair of prescribed elastic stocking to a patient's legs? The patient will have a scheduled bath in a few hours The patient says they are too tight The patient's skin is irritated The patient has become fully ambulatory
The patient's skin is irritated
Why does the nurse remove the patient's elastic stockings at least once per shift? To permit the skin to breathe. To wash the legs with a disposable bath product To air out the stockings and allow sweat to evaporate. To check the skin for irritation or breakdown.
To check the skin for irritation or breakdown
Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours? To try a less restrictive type of restraint if a more confining restraint has proved effective To double-check the size by inserting one finger between the wrist and the restraint To check the skin integrity and range of motion of the wrist To comply with Joint Commission standards
To check the skin integrity and range of motion of the wrist
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? To keep the arm above the level of the heart To assess the patient's muscle tension To listen for crepitus in the joint To ensure stability while exercising the joint
To ensure stability while exercising the joint
When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? To identify the potential risk for DVT To identify improper patient positioning To select the proper stocking size To determine whether a sequential compression device is needed
To identify the potential risk for DVT
Why might a nurse teach a patient scheduled for surgery how to do postoperative exercises? To maximize a sense of well-being To minimize postoperative complications To identify cultural factors that reflect the patient's perception of pain To evaluate the patient's ability to participate in postoperative activities
To minimize postoperative complications
When caring for a patient with Alzheimer's disease, why does the nurse cover the external urinary collection catheter? To protect the bed from being soiled To avoid offending visitors who would otherwise see the device To reduce the patient's access to the device To keep the patient from trying to get out of bed alone
To reduce the patient's access to the device
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? Four Two One None
Two
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? Check the patient's blood pressure and pulse before smoothing the gown Untie the restraint and smooth the patient's gown Put on the call light for help Ask the patient what specific help she would like
Untie the restraint and smooth the patient's gown
Which instruction might a nurse give a patient in order to protect a surgical incision when turning in bed? Hold your breath when turning. Use a pillow to splint the incision. Take pain medication 30 minutes before turning. Keep both legs straight when turning.
Use a pillow to splint the incision.