Funds 18,19,20,21,22
As a nurse helping an 85 year old man to stand and ambulate, he complains that he feels that he has lost all his strength in the last several years
"As we age our muscle cells are lost and replaced by fat, which leads to loss of strength".
The charge nurse on the night shift of a skilled nursing facility is orienting a new aide to the unit. The LPN's most accurate information relative to moving patients is
"Get one other aide to help and use a mechanical lift when you get Mr. A out of the bed in the morning
When instructing a nursing assistant about hygiene needs of a frail elderly patient , the nurse correctly educated the nursing assistant to
"Use warm, not hot, water and be sure the room is warm before hand to avoid chilling".
A stage III pressure ulcer is indicated by (select all)
-Full-thickness of skin loss -drainage of the ulcer - warmth of surrounding tissue
Fall risk assessment (select all)
-age -medication -balance
Legal implications for using a protective device (select all)
-alternative methods and actions used -education done for the patient and family -type of device and placement
Standard of the joint commission state the pain in the fifth vital sign and should be documented by assessments of (select all)
-location -duration -character -intensity
Complications from incorrect alignment and positioning include (select all)
-pressure ulcer -contractures -fluid in the lungs
The nurse would refrain from applying blood pressure cuff on the affected arm of a patient who has (select all)
-previous mastectomy -patent IV line -dialysis shunt
Main function of the skin (select all)
-protection -excretion -sensation -secretion (PESS)
A certified nursing assistant (CNA) places a confused, weak patient in a wheelchair and applies a vest protective device. The nurse should instruct the CNA to (select all)
-secure the ties in the back to prevent patient from falling -use a half bow knot to secure the device to a chair -provide passive range of motion to the upper extremities as needed
A 70 year old immobile patient, who has right sided weakness caused by a recent stroke, weighs approximately 25 pounds needs to be moved up in bed (select all)
-summon at least one other person to assist -obtain a lift sheet -place the patient flat on her back
A nurse would document a patient as being febrile if the patient's temperature was over
100.5
The nurse is aware that the use of a oral glass thermometer would be contraindicated in a
12 year old patient with a recent seizure
In assessing the skin condition of an elderly patient, the nurse notes that, over the sacral area, there is a 2-cm 3cm area that is reddened, does not blanch around the perimeter and is open at the center.
2 cm 3 cm reddened area on sacrum with open center. Does not blanch
A nurse would record a pulse as bradycardiac if the rate were
59 beats/min
The nurse stages a pressure ulcer as a a stage II based on the knowledge that such lesions have
A deep pink area of unblanchable skin
The nurse caring for a 30 year old post surgical patient would assess that the patient is in pain as indicated by
A pulse rate of 120 beats/min
A patient in the skilled nursing facility has left-sided paralysis from a stroke several years before, as well as generalized weakness. The nurse should ensure that which of the following devices is in place to prevent flexion contractures?
A rolled washcloth in the palm of her left hand or a hand splint
Because the older adults blood vessels are non elastic, they are prone to orthostatic hypotension
Allow the patient to sit on the side of the bed for a minute before standing
A patient with dry itchy dermatitis will most likely benefit from
An oatmeal or starch therapeutic bath with tepid water
A nurse and an assistant are preparing to get a patient out of bed for the first time after a week of bed rest. They begin by having the patient dangle on the edge of the bed. The nurse should
Assess the patients response to the changes position looking for orthostatic, hypotension, nausea, or dizziness before proceeding
A frail older patient is able to stand but not to ambulate. She has an order to be up in a wheelchair as desired during the day. A safe and appropriate way to assist her up to a chair is to ...
Assist her to stand and pivot to a chair at right angles to the bed , using a transfer belt
There is evidence that a resident in a home care environment might have accidentally ingested gasoline left by the gardeners. The nurse should first
Call poison control center and describe the situation
The accuracy in measuring the apical pulse is enhanced when the nurse:
Counts the beats for a minute
because the elderly patient lies curled up in a side lying position most of the time, the nurse, seeking to avoid a pressure ulcer
Ilium
The nurse instructs the patient that any injury to the skin initially puts the patient at risk for
Infection with bacteria or viruses that may affect the person systemically
An example of the principles of good body mechanics applied to patient care occurs when the nurse
Keeps his feet fixed, spread one in front of the other, and turns his upper body to move the patient up in bed with a rocking movement
Material safety data sheet (MSDS) are required by occupational safety and health administration (OSHA). The nurse must
Know the location of the MSDS and comply with their guidelines
The doctor has written an order to place a resident in the nursing home in a vest protective device. It is the nurse's responsibility to
Remove the device every 2 hours and change patients position
A patient complains of not being able to sleep because of the noise in the hall at night the nurse should
Request that co-workers limit hallway conversations
A nurse caring for a patient with a chair arm will do which of the following interventions as recommended by the 2016 national safety goals to prevent alarm fatigue
Respond promptly to alarm
When providing perineal care for an uncircumcised male patient, the nurse
Retracts the foreskin and then cleans the glans, being sure to replace it at the end of the procedure
The nurse assisting a weak patient from a bed to the wheelchair to go to physical therapy would
Seat the patient on the side of the bed with feet touching the floor
To ensure an accurate reading when using a glass oral thermometer, it is necessary to
Shake down the galinstan alloy to below normal
A nurse is ambulating an unsteady patient from the bed to a chair in the patient's home. To do so safely, the nurse applies a gait belt and
Slides hand from the bottom under the gait belt at the middle of the patients back
A usual routine for providing nail care to a patient includes
Soaking nails in warm soapy water to soften before cleaning under the nail edge with orangewood stick
While the nurse is assisting to a patient to ambulate, the patient suddenly says "I'm dizzy. I can't stand up." As the patient begins to fall, the nurse should:
Step behind the patient, grasp her around the waist of chest, and slide her down her leg gently to the floor
Regarding blood pressure in children, the diastolic pressure is assessed by the auscultation of a
Sudden change or muffling of the sound
The nurse taking an apical pulse is would place the stethoscope at
The left midclavicular line at the fifth intercostal space
The nurse explains to the unlicensed assistive personnel (UAP) that shearing force is applied to the patient when
The patient is pulled up in bed without being lifted
Complete bath to an unconscious patient. After performing the standard steps done before any procedure, the nurse
Wash each eye with fresh area of washcloth before washing the rest of the patients face
The nurse anticipates that if the stroke volume of a patient is reduced, the pulse will be
Weaker
the nurse documents vital signs on a newly admitted patient as : "blood pressure is 148/94 mm HG, the pulse is 80 beats/min and the respirations are 16 breaths/min". The nurse would record the pulse pressure
54mm hg
A physician orders the nurse to place a patient in Fowler position. The nurse should elevate the head of the patients bed
60 to 90 degrees
The patient for whom passive range-of-motion exercises would be most beneficial would be the
66- year old patient with loss of mobility related to a recent cerebrovascular accident (CVA)
The patient most at risk for a pressure ulcer
A 56 year old overweight man who is unconscious from a stroke
A patient who is terminally ill is described during shift report as having Cheyenne strokes breathing. On assessment, the nurse anticipates finding
A breathing pattern of dyspnea followed by a short period of apnea
The nurse would anticipate a patient diagnosed with damage to the hypothalamus after suffering a head injury from a fall to exhibit
A temperature abnormality
A patient who is weak from inactivity following a car accident benefits most if the nurse provides for
Active ROM exercises to and legs several times a day
A diabetic patient had chronic peripheral vascular disease, which results in edema and poor circulation to her feet. She is constantly complains of cold legs
Additional blankets and encourage the use of warm bed socks
The nurse uses professional knowledge about body mechanics to prevent the most common occupational disorder in nurses which is ...
Back injuries from lifting and twisting
The nurse explains that one method of environmental heat loss is convection, which is exemplified by body heat being reduced by
Being removed by fast air currents from a fan
The health care provider orders wrist protective devices for an agitated patient. To safely use this protective device the nurse
Checks the circulation is not impaired by evaluating color, warmth, and pulses distal to the device
The nurse using either a regular or an electronic sphygmomanometer would ensure that the cuff is the correct size by:
Confirming that the bladder goes around three fourths of the arm
What nursing interventions related to hygiene are appropriate for a patient who has had a recent stroke that caused right-sided (dominant) paralysis and inability to speak?
Encourage the patient to use his non Dominant hand to wash his face
A nurse in a long term facility who is making a fall assessment would identify the person most at risk for a fall to be resident who
Had a stroke with right-sided weakness 2 weeks ago and is confused
a nurse notes that her patient has an area of red skin that does not blanch with fingertip pressure. The nurse documents this finding as a stage ______ pressure ulcer
I (one)
A nurse is instructing one of the facility's unlicensed assistant personnel (UAPs) regarding body mechanics for moving and lifting. The nurse recognizes that further instruction is warranted when the UAP states "I will:
Lift using my back muscles
The nurse assessing for pressure ulcer in a patient with darkly pigment skin
Look for a purple hue under natural light
Best way to maintain safety measures relative to helping a patient get into bed is to
Make sure that the bed wheels are locked
An appropriate environmental nursing intervention for a patient with respiratory congestion is to:
Moisten the respiratory passages with the use of an air humidifier
The nurse caring for a patient who is not taking any food or fluids by mouth because he is unconscious is aware that the patient
Needs to have his mouth swabbed to moisten and remove secretion every 4 hours
When the patient returns from the physical therapy department, he is diaphoretic and his skin is flushed out but cool. Nursing intervention in this situation should be for the nurse to
Offer additional fluids
During an admission assessment to a skilled care facility, the nurse notes that a 76 year old man is thin and unsteady on his feet and has dry flaky skin on his arms and legs. An appropriate hygiene goal for this patient is that the
Patient will shower or tub bathe with assistance twice a week
An emaciated semiconscious bed-bound patient does not remain in a side-lying position and repeatedly turns onto her back, where she is developing a pressure area over her sacrum. The nurse should add to the nursing care plan to...
Place the client on her stomach (prone position) using a small pillow below her diaphragm
The nurse caring for a patient with a nursing diagnosis of injury, risk for, related to right-sided weakness as evidence by unsteady gait, would accommodate the patient by
Placing the wheelchair on the left side of the patient before transfer
A patient has left sided paralysis following a right-sided cerebrovascular accident (CVA) after completing a bed bath, the nurse should begin to change the sheets by
Positioning the patient in a side lying position on his left side with the near side rails raised
When the post-stroke patient complains to the nurse, "I don't see why you are wasting your time doing the passive range-of-motion exercises on my legs," the nurse's most informative response would be based on the knowledge that the exercises:
Prevent contracture of the hips
To perform oral care for an unconscious patient, the nurse takes which action first?
Raise the bed to a comfortable working position, patient in flat side lying position
To place a client in the Sims' or lateral-lying position, the nurse would initially
Raise the bed to a waist-high working level
When the nurse is making an occupied bed, back safety indicates that the nurse should initially
Raise the bed to the proper working height before starting
A patient with a nursing diagnosis of Skin integrity, risk for impaired, is noted to have reddened areas on his right shoulder and hip when he is repositioned on a 2-hour turning schedule. The nurse should:
Reassess the area after 30 to 45 minutes for reactive hyperemia
An important factor to consider when assessing the hygiene needs of a patient is that :
The patient may not have the same hygiene practice as the nurse
To provide correct body alignment for physically immobile patient in the bed in the supine position, the nurse
Use a footboard or place high top sneakers on the patients feet to maintain dorsiflexion
A culturally sensitive nurse caring for a Muslim woman who had a noticeable body odor as well as abundant underarm hair should
Use soap and water under the arms
A patient who has had spinal surgery is not permitted to bend at the waist or to sit in a chair. To position the patient correctly in bed, the nurse
Uses logrolling to accomplish position changes from side to side
