Fundamentals: Unit 1
A nurse is educating a client on the effects of immobility. Which of the following, if stated by the patient, indicated they needs additional teaching?
"I may develop diarrhea which can lead to skin breakdown" (peristalsis is reduced with immobility so they would likely experience constipation not diarrhea)
Assistive devices should be used with elbows bent at?
30 degrees always
The nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
Apply 4 to 5 mL of liquid soap to the hands
The nurse is providing nail care for a client. Which of the following actions should the nurse take?
Clean under the nail with an orange stick.
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time?
Determine the client's ability to help with the transfer
Walkers with no wheels are used for pt who?
Have balance issues, but can still lift
A nurse notes that a client's bed has a frayed cord that plugs into the outlet. Which of the following is the best response?
Put a sign on the bed that says, "do not use", call engineering, and find a different bed
When using walkers the handles bars should be level with?
The patient's waist
The nurse on a medical unit is teaching a group of unlicensed assistive personnel (UAP) about handling clients' bed linens safely. Which of the following instructions should the nurse include?
Tie linen bags securely at the top.
You should replace the accela pads of the crutches when they are worn.
True
pc
after meals
noc
at night (nocturnal)
BRP
bathroom privileges
BP
blood pressure
swing through gait
both legs move forward past the placement of the crutches
BM
bowel movement
As the nurse, you have provided her with orientation to the unit. You are trying to get Ms. Rose comfortable in the bed. Which of the following should the nurse do to make Ms. Rose comfortable?
call light, fall precautions, how to operate the room lights
When using a cane for min support, what is the process?
move cane with weak leg
peri
perineal, perineum
What is gait?
the way someone walks
What are trochanter rolls used for?
used to prevent pt from balling hands up (nails can dip into the hands)
Walkers are used for?
weakness or balance problems
Assistive devices should always be placed how many inches in front of the pt?
6 inches
A patient needs to go up the stairs while using crutches. What finding by the nurse demonstrates the patient understands how to ambulate upstairs with crutches?
A. The patient moves the crutches forward up the step, then the injured and non-injured leg. B. The patient moves the on-injured leg forward onto the step and then moves the injured leg and crutches up. C. The patient moves the injured leg forward onto the steps, then moves the crutches, and then moves the non-injured leg. D. The patient moves the crutches and non-injured leg forward to the step together, and then the non-injured leg. B is correct.
When a patient uses a cane to ambulate, the patient will hold the cane on the?
A. weak side B. strong side C. It does not matter. The patient should choose what side is the most comfortable for them. B is correct.
Walkers with four wheels are used for pt who?
Have partial paralysis or cannot tolerate activities well
Walkers with front wheels are used for pt who?
Have trouble lifting
The nurse is teaching a newly hired group of unlicensed assistive personnel (UAP) about infection-control measures on the unit. It is crucial for the nurse to remind the UAPs that which of the following is the most effective way to prevent the spread of pathogens during client care?
Performing hand hygiene frequently and consistently
A nurse is caring for a client in restraints. When reviewing the order, what should the nurse question?
The provider says to only use wrist restraints when the patient shows signs of physical aggression
A client who needs maximum support is ambulating with a cane for the first time. After educating the client on proper ambulation with a cane, you assess how well the client understood the instructions. Which findings below demonstrate the proper technique? Select all that apply.
The top of the cane should be level with the hip joint
When using a cane and going up steps the pt should always?
lead with their strong side
When using a walker when one leg is weaker (min support), what is the process?
move walker and weak leg at the same time
NG
nasogastric
UTI
urinary tract infection
What is a footboard used for?
used to prevent foot from dropping (plantarflexion)
The nurse is providing discharge education for the patient who is going home with a walker. Which statements by the patient indicate a good level of understanding of safety in the home? Select all that apply.
"I need to remove the throw rugs."
A nurse is educating a client with diabetes about proper foot care. Which statement indicates the client needs additional teaching?
"I will cut my nails in a rounded manner so the nail is not sharp." (Rational: Diabetics should cut toenails straight across. Rounded increases the incidence of tears/cuts which predisposes them to infection. They should really be seeing a good podiatrist.)
The nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?
"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."
Hand washing: Soap and Water Method
1. Introduce self and educate the patient regarding hand washing if procedure is taking place within a patient room. 2. Turn on warm water at a medium flow. 3. Wet the wrists and hands; with fingers pointing downward. 4. Apply soap. 5. Lather; rub using a circular movement; wash for 15 to 20 seconds in this order: a. Palms of hands with fingertipb. Backs (dorsum) of handc. Wristsd. Between fingers (interlaced, including thumbs)e. Fingersf. Fingertips; cleaned under nails6. Rinse from wrist to fingertips, keeping hands with fingers pointing downward, hands slightly apart. 7. Using clean paper towels, dry thoroughly in the same order (from wrists to fingers) using a patting motion. 8. Throw the paper towels in an appropriate receptacle. 9. Turn off the water by holding the faucet with a clean, dry paper towel. 10. Throw the paper towel in an appropriate receptacle.
What is the process of ambulating a pt?
1. assess if the patient can bear weight 2. implement fall precautions (nothing in the walkway) 3. NON skid footwear on patient 4. Lock the bed and wheelchair 5. ensure supplies are available (walker or cane, etc. are close by) 6. Gait belts should be used for min support and are wrapped around the pt waist (feed teeth through belt) 7. assess how many people need to be used to lift the patient (2-assist or 3-assist) or if a mechanical lift needs to be used 8. use good body mechanics (bend from knees, push, DO NOT pull, work w/ gravity) 9. When 1 person is lifting always stand on weaker side, 10. when 2 people are lifting, a person stands on either side and lifts from the armpit
How many fingers should be able to fit in between the rest of the crutch and armpit of the pt?
2-3 fingers
As the nurse, how would you correctly demonstrate to the patient the proper gait while using a walker?
A. Hold onto the walker's hand grips, take a step forward with the strong side, then move the walker forward, and then take a step with the weak side. B. Hold onto the walker's hand grips, move the walker forward, then take a step forward with the weak side, and then take a step forward with the strong side. C. Hold onto the walker's hand grips, move the walker forward, then take a step forward with the strong side, and then take a step forward with the weak side. D. Hold onto the walker's hand grips, take a step forward with the weak side, then move the walker forward, and then take a step with the strong side. B is correct.
While the patient ambulates in the hallway with a walker, the nurse will make it priority to?
A. Stand on the patient's strong side B. Stand behind the patient. C. Stand in front of the patient. D. Stand on the patient's weak side. D is correct.
Your patient is using a cane for the first time. Before using the cane, you assess that the cane properly fits the patient. Which findings below demonstrate the cane properly fits the patient? Select all that apply:
A. The arm that is holding the cane is flexed at about a 40-degree angle. B. The cane's top is at the greater trochanter's level. C. When the patient dangles their arms, the top of the cane is even with the crease of the wrist closest to the hand. D. There is a 1.5 inch gap between the top of the cane and the axillae. B & C are correct A is wrong because the arm should be flexed at a 15-30 degree angle. D is wrong because there's nothing to do with the axillae region.
Your patient will be using crutches for mobility. After educating the patient on how to adjust the crutches to fit correctly, you assess how well the patient understood the instructions. What findings demonstrate that the crutches were adjusted correctly by the patient?
A. The hand grips of the crutches are even with the mid-forearm. B. When the patient grips the crutches' hand grips, the elbow bends at about 30 degrees. C. The patient has a 2-3 finger width distance between the axillae and crutch rest pad. D. The patient places weight on the axillae rather than the hands while ambulating. B & C are correct A is wrong because the hand grips should be even with the hip-line, not the forearm. D is wrong because the weight is placed on the hands not the axillae area.
Which demonstration by the patient below shows that the patient knows how to properly ambulate a cane?
A. The patient holds the cane on the strong side and moves the cane and weak side forward together, and then moves the strong side. B. The patient holds the cane on the strong side and moves the can forward, then moves the weak side, and then moves the strong side. C. The patient holds the cane on the weak side and moves the can forwards, then moves the weak side, and then moves the strong side. D. The patient holds the cane on the weak side and moves the cane and weak side forward together, and then moves the strong side. A is correct.
Your patient is prescribed to use crutches for ambulation. The patient can bear partial weight and needs to be taught how to use the two-point gait while using crutches. Which description below best describes this type of gait with crutches?
A. The patient moves both crutches forward and then moves both legs forward to the same point as the crutches. B. The patient moves the right crutch (injured side), then moves the left foot (non-injured side), then moves the left crutch (non-injured side), and then moves the right foot (injured side). C. The patient moves both the right crutch (injured side) and left foot (non-injured side) forward together and then moves the left crutch (non-injured side) and right foot (injured side) forward together. D. The patient moves both crutches and the injured leg forward together and then moves the non-injured leg forward. C is correct.
Your patient attempts to sit down in the bedside chair after ambulating in the hallway with crutches. What finding requires you to re-educate the patient on how to sit down in the chair correctly while using crutches?
A. The patient places both crutches on the non-injured side before sitting down in the chair. B. The patient backs up to the chair's seat until he feels with his non-injured leg and stops. C. The patient keeps the injured leg extended out in front of him while sitting down. D. The patient holds both crutches on one side and reaches for the hand grips on the crutches and places weight on them while sitting down. A is correct. Reasoning: The patient should place both crutches on the injured side. the crutches will provide support to the injured side.
A patient will be using a walker for the first time. You adjust the walker to fit the patient. Which finding below demonstrates that the walker properly fits the patient?
A. There is a 2-3 finger width distance between the hand grips of the walker and the wrists. B. The elbows bend at about a 15-30 degree angle when the patient holds onto the hand grips of the walker. C. the patient's back is mid-line with the crossbar of the walker. D. The crossbar of the walker is even with the greater trochanter. B is correct.
While using crutches the patient moves both crutches forward and then moves both legs forward past the placement of the crutches. This is known as the:
A. Two-point gait B. Swing-to gait C. Swing-through gait D. Three-point gait C is correct.
While your patient is ambulating with crutches, he moves both crutches forward along with the injured leg and then moves the non-injured forward. When you document you will note that the patient used what type of gait while ambulating with crutches?
A. Two-point gait B. Three-point gait C. Four-point gait D. Swing-to-gait B is correct.
While going down the stairs with crutches the patient will move the crutches down onto the step followed by?
A. moving the non-injured leg down onto the step. B. moving the injured leg down onto the step. C. moving both legs down onto the step. B is correct.
As the nurse providing care for Ms. Rose, you are aware that she is confused and keeps saying that she wants to leave. You are aware that of you use restraints to keep Ms. Rose from leaving the unit, you will be committing?
False imprisonment
A nurse is caring for a patient that is unconscious. The nurse knows that in order to promote drainage of secretions when performing oral care, which position is best to place them in?
Lateral Position
Ms. Rose needs to be moved from the bed to the chair. In order to properly move the client to the chair, the nurse should?
Lock all wheels to the bed
A nurse is ambulating a client in the hallway that experiences a sudden onset of a tonic-clonic seizure. Which of the following is the nurse's priority action?
Lower the patient carefully to the ground
If a stroke pt who has suffered weakness on the left side needs to use a cane, what side would the assistive device be placed on?
On the pt right side (because the left side is the weak side and the assistive device should always be placed on the pt stronger side)
The nurse in a long-term care facility is observing an unlicensed assistant personnel (UAP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the UAP understands the principles of infection control?
Places clean linen that touched the floor in the soiled linen bag
A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? Select all that apply.
Shave the client's hair in the direction of the hair growth, check for personal items when changing the bed linens, and keep the bath water temperature between 43.3 degrees C (110 degrees Fahrenheit) and 46.2 degrees C (115 degrees Fahrenheit)
As you are providing care to Ms. Rose, she is becoming more confused. Which of the following can the nurse do to assist the client with confusion without a doctor's order? Select all that apply.
Talk to the charge nurse to move client closer to nurses' station, Ask a family member to sit with the client, reorient the client frequently
A nurse is assessing a group of clients for those at risk for falls. Which of the following clients is most at risk?
The 80 y.o. client who had a stroke with left-sided weakness and urinary frequency. (This patient has 3 risk factors whereas the others only have 1 or 2. This patient is elderly, has reduced sensation/weakness, and urinary frequency)
A nurse is observing an unlicensed assistive personnel (UAP) provide care to a client. Which of the following observations requires follow-up?
The UAP puts the arms of a client at their side as they prepare them for transfer. (Rational: The UAP should ask the client or place the client's arms crisscross over their chest. This will help prevent injury or manipulation to the client's arms.)
A nurse is observing an unlicensed assistive personnel (UAP) change the linens of a client's bed. Which of the following observations requires follow-up?
The UAP reaches across the bed to straighten the fitted sheet. (Rational: Poor body mechanics is being used when reaching over bed rails or client. Never twist, reach, bend, and/or lift anything heavier than 35 lbs without assistance. Placing the bed at working height, lowering bed rail on the side closest to you, using drawl sheet to lift or roll patient, ask for assistance when needed.)
A nurse is educating a client who has excessively dry skin. Which of the following recommendations indicates good nursing judgment?
The nurse encourages the client to bathe less frequently, only a few times a week.
A nurse is changing a client's bed linens. Which action, if observed, requires follow up by the preceptor?
The nurse puts all 4 side rails up prior to leaving the room. (4 side rails constitute a restraint. Can only ever have 3 up at time and we prefer to leave the one down on the bottom and closest to the bathroom for convenience reasons.)
The nurse preceptor is observing a new nurse wash their hands. Which of the following, if observed, would require the preceptor to intervene?
The nurse rinses from fingertips to wrists, keeping hands with fingers pointing upward, hands slightly together.
The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions? (Select all that apply.)
The nurse stands on the weaker side; The belt is secure, leaving only enough room for the nurse to grasp the belt.
A nurse is educating a new graduate nurse on body mechanics. Which of the following statements indicated a good use of body mechanics?
The nurse suggests the nurse sleep on a firm mattress as opposed to a soft one.
After instruction, which actions by a patient who can bear weight on both feet but has left-side weakness indicates an understand of the proper use of a walker?
The patient moves the walker and the left leg forward at the same time, then takes a step with the right leg forward.
The nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
Turn the client on his side before starting oral care (placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking)
The charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching?
Use chlorhexidine to wash hands if the client is immunosuppressed
Ms. Rose has a risk for falls. Which of the following are appropriate interventions due to her risk for falls? Select all that apply.
Use fall-risk alerts, such as labels in doors, and/ or color-coded wristbands, provide regular toileting and orientation, provide hourly rounding
When a patient cannot lift themselves up and is essentially dead weight, you should always use?
a mechanical lift
swing-to gait
both legs move forward to the same point as the crutch placement
per
by or through
When using crutches and going down steps what should the pt lead with?
lead with a crutch and then the injured leg
When using crutches and going up steps what should pt lead with?
lead with good leg and then moves the injured leg and crutches up
When using a walker for max support, what is the process?
lift walker, place ahead 6 inches, right foot then left foot
When using a cane for max support, what is the process?
move cane first, weak leg, then strong leg
When using crutches at a 2-point gait, what is the process?
move on crutch at the same time as opposite leg and alternate; use when pt is partial weight bearing, either one or both lower extremities
When using crutches at a 4 point gait, what is the process?
move on crutch forward, opposite leg, crutch forward, opposite leg; use when pt is partial weight bearing on both lower extremities
While going down the stairs with crutches the client will move the crutches down onto the step followed by
moving the injured leg down onto the step
N&V
nausea and vomiting
NKDA
no known drug allergies
NWB
non-weight bearing
NS
normal saline
NPO
nothing by mouth
OT
occupational therapy
OR
operating room
OOB
out of bed
Ped(s)
pediatrics
PE
physical exam
When using crutches at a 3 point gait, what is the process?
place both crutches forward and swing injured leg forward; use when pt has injury to one leg
P
pulse
Na
sodium
TED hoses are used for?
to keep perfusion int he legs and prevent swelling
bid
twice daily
UAP
unlicensed assistive personnel
URI
upper respiratory infection
U/A, UA
urinalysis
