MS LAB MIDTERM 116

b. Ensure that the patients feet are protected during the transfer

A basic principle associated with transferring a patient using a mechanical lift: a. Keep the wheels of the mechanical lift locked throughout the transfer. b. Ensure that the patients feet are protected during the transfer c. Raise the lift so that the patient is 6 inches off the mattress d. Lock the base lever in open position when moving the mechanical lift.

c. The absence of gastrointestinal motility

A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should realize this is a result of: a. Proper functioning of nasogastric suction b. Intestinal edema following surgery c. The absence of gastrointestinal motility d. A pre surgical decrease in fluid intake

b. Observe the client demonstrating the transfer.

A client with multiple sclerosis tells a home health care nurse that she is having difficulty in transferring from bed to a chair. The home health care nurse would initially: a. Start a restorative nursing program before an injury. b. Observe the client demonstrating the transfer. c. Document the number of falls that the client has had in recent weeks. d. Discuss potential nursing home placement

c. The client uses mirror to inspect the skin.

A female client who is paralyzed on the left side has been receiving teaching sessions about safety. Which behavior indicates that client accurately understands safety measures related to paralysis? a. The client leaves the side rails down. b. The client reposition only after being reminded. c. The client uses mirror to inspect the skin. d. The client touches the left arm over the side of the wheelchair.

d. Apply knee splints to stabilize the joints during transfer.

A nurse is caring for a client with a C6 spinal cord injury during the spinal shock phase. The nurse implements which of the following when preparing the client to sit in a chair? a. Administer vasodilator in order to improve circulation of the lower limbs. b. Teach the client o lock the knees during the pivoting stage of the transfer. c. Raise head of the bed slowly to decrease orthostatic hypotension episodes. d. Apply knee splints to stabilize the joints during transfer.

a. Near the clients right leg

A nurse is preparing to transfer an average sized client with right-sided hemiplegia from bed to the wheelchair. The client is able to support weight on the unaffected side. The nurse plans to use the hemiplegic transfer technique. The client is dangling on the side of the bed. For the safest transfer, the wheelchair should be positioned: a. Near the clients right leg b. As space in the room permits c. Next to either leg d. Near the clients left leg

b. X ray confirmation

After insertion of the NGT, Nurse Eloisa can best confirm the proper placement of the tube through: a. Gastric aspiration b. X ray confirmation c. Air insufflations d. None of the above

b. True

After the insulin is drawn into the syringe, the fluid should be inspected for air bubbles. One or two quick flicks of the forefinger against the upright syringe should allow the bubbles to escape. Air bubbles themselves are not dangerous but can cause the injected dose to be increased. a. False b. True c. Maybe d. Undecided

b. 5 & 6

Before performing suctioning, which of the following nursing actions are not included in the preparation for the procedure? 1. Check the physicians order. 2. Check the function of the suction machine. 3. Label the containers for sterile saline according to the route to be suctioned. 4. Assess the patients respiratory condition. 5. Insert the catheter gently through a nostril with your thumb away from the suction control. 6. Apply your finger to the suction control part and gently rotate the catheter for 5 to 10 seconds. a. 2 & 4 b. 5 & 6 c. 1 & 2 d. 3 & 4

b. All of the above

During the early or immediate signs of death, you will notice some changes: a. Muscular relaxation and loss of reflexes b. All of the above c. Cessation of circulation d. Cessation of respiration

d. First syringe

For a mixed dose, putting sufficient air into both bottles before drawing up the dose is important. When mixing rapid- or short acting insulin with intermediate or long-acting insulin, the clear rapid or short-acting insulin should be drawn into the: a. None of the above b. Third syringe c. Second syringe d. First syringe

c. Lubricating the tube.

For the insertion to be effective, which of the following should be avoided? a. Removing all the obstructions in the nostrils. b. Measuring the length of the tube properly. c. Lubricating the tube. d. Positioning patients for a Fowlers position.

d. Preserving the body

Give the purpose of taking care a dead patient or post mortem care, EXCEPT: a. To aid in preserving the physical appearance of the deceased. b. To cleanse the patients body and prepare it for removal from the hospital after death. To prevent discoloration and damage of the corpse skin. c. To support family members during the initial hours of their bereavement. d. Preserving the body

b. Subcutaneous tissue

Insulin injections are administered into the: a. Intravenous tissue b. Subcutaneous tissue c. Intradermal tissue d. Intramuscular tissue

c. Algor mortis, rigor mortis, livor mortis

It is the physician who is authorized to pronounce the patient is dead. After 2 to 3 hours the body physically starts to change during the immediate period. Arrange these changes in order: a. Rigor mortis, algor mortis, livor mortis b. Livor mortis, algor mortis, rigor mortis c. Algor mortis, rigor mortis, livor mortis d. Algor mortis, livor mortis, rigor mortis

c. Log rolling

It is used to turn patients to the side while stabilizing their spine. a. Splint b. Positioning c. Log rolling d. Restraints

b. Secure that foot brake of the bed is locked before moving the patient.

Mr. Dee is scheduled for an invasive, when transferring him to the stretcher, your initial reaction would be: a. Instruct the patient to cross arm in the chest before moving the patient. b. Secure that foot brake of the bed is locked before moving the patient. c. Instruct the patient to bend head close to chest before moving the patient. d. Make sure that the side-rails are up before moving the patient.

a. Have the client put her arms around the nurses neck

Ms. Fe suffered from stroke and has right-sided hemiparesis. The nurse is going to transfer her from bed to wheelchair. Which of the following is the best method to do? a. Have the client put her arms around the nurses neck b. Put the wheelchair at 45 degree angle to the bed c. Place the wheelchair about a foot away from the bed d. Position the wheelchair closer to the weaker foot

b. Paraplegics

Non weight bearing transfer are applicable to clients having these conditions: a. Hemiplegics b. Paraplegics c. Clients with hip fractures d. Clients with numbness of extremities

True

Rapid acting insulin cannot be mixed with NPH, lente, and ultralente.

a. Forensic medicine

The branch of medicine dealing with the application of medical knowledge to establish facts in civil or criminal legal cases, such as an investigation into the cause and time of a suspicious death. a. Forensic medicine b. Internal medicine c. Medical technology d. Forensic pathology

b. Put client on a flat position at 6am to 8am, then on the right side at 8am to 10 am, followed by flat position at 10 am to 12 noon, the left side 12 noon to 2 pm and continue doing it round clock.

The doctor ordered turn to sides every two hours to a client with cardio vascular disease. Which of the following statements identified a correct instruction of the doctors order? a. Positioning starts at the prone position then to the sides every 2 hours keep client at flat and back position. b. Put client on a flat position at 6am to 8am, then on the right side at 8am to 10 am, followed by flat position at 10 am to 12 noon, the left side 12 noon to 2 pm and continue doing it round clock. c. Its just a waste of time; anyway the client can move her extremities. d. Place client first on either of the sides and turn client to other side with an interval of 2 hours.

a. Osteoporosis

The effect of bone demineralization in an immobile patient is: a. Osteoporosis b. Disuse syndrome c. Contractures d. All of the above e. Stiffness and pain in the joints

a. Osteoporosis

The effect of bone demineralization in an immobile patient is: a. Osteoporosis b. Stiffness and pain in the joints c. Disuse syndrome d. Contractures

b. Body image, disturbed

The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care? a. Fear related to poor diagnosis b. Body image, disturbed c. Sexual dysfunction d. Nutrition: more than body requirements, imbalanced

a. Position the wheelchair nearest to the bed with the wheelchairs back facing the foot part.

The nurse is preparing to move an adult who has right-sided paralysis from a bed into a wheelchair. Which statement describes the best action for the nurse to take? a. Position the wheelchair nearest to the bed with the wheelchairs back facing the foot part. b. Bend at the waistline while helping the patient during transfer. c. Protect the clients arm with arm sling during transfer. d. Keep the head of the bed elevated at 10 degree.

b. Importance of holding still and letting the staff members do all the work so that they don't twist or turn at the spine.

The nurse is teaching a client about the log rolling procedure. Which of the following indicates that the client understands the procedure? a. Hold the staff members shoulder so that they don't twist or turn at the spine. b. Importance of holding still and letting the staff members do all the work so that they don't twist or turn at the spine. c. Move along the side of the bed when told to do. d. Importance of side lying at all times to prevent twisting, bending, or turning the spine.

c. Obtain a blood pressure

The nurse is transferring a patient from a bed to a wheelchair. To quickly assess this patients tolerance to the change in position, the nurse should: a. Determine if the patient feels dizzy b. Monitor a bradycardia c. Obtain a blood pressure d. Put the patients feet flat on the floor

a. 2,3,1,4,

The nurse should know the different techniques in moving the client. In moving the client to the edge of the bed, the following steps are followed: 1. Place both arms under the client's hips. 2. Move the head and shoulder at the edge of the bed. 3. Move the client feet at the edge of the bed. 4. Striaghten your back while moving the client towards you. a. 2,3,1,4, b. 1,2,3,4 c. 2,1,3,4 d. 3,2,1,4

d. Safety measures before, during and after patient transfer

The primary concern of a nurse when transporting patient in and out of the bed. a. All of the above b. Positioning of patient during transfer. c. Body alignment of patient when being transferred. d. Safety measures before, during and after patient transfer. e. Use of body mechanics to prevent back injury.

a. Place pillow on both lateral side from hip part to the legs

To prevent external abduction of the lower extremities, the nurse would place supportive pillows to what specific area of the body? a. Place pillow on both lateral side from hip part to the legs b. Place pillow in between the feet and legs c. Place pillow on both lateral side of the feet d. Place pillow on both side of the body or trunk

a. Paraplegics

Transfer of client is started as soon as the client is permitted to be out of bed. Weight- bearing transfer are carried out by clients who have at least one stable extremity. Weight bearing transfer is applicable to: a. Paraplegics b.Hemiplegics c.Amputees of both extremities d.All of the above

b. Keeps the body balanced over a wide base of support.

When moving patients up in bed, strain to the nurse can be reduced when the nurse: a. Holds the breath and tenses pelvic muscles. b. Keeps the body balanced over a wide base of support. c. Keeps the elbows and knees straight. d. Faces the side of the bed while using the arms to move the patient.

b. Have the patient put their arms on the top of their head.

When performing log rolling, which technique done by the nurse is not appropriate? a. Have 3 to 4 team members b. Have the patient put their arms on the top of their head. c. Explain procedure to patient d. Perform hand hygiene

a. Force the catheter against an obstruction.

When performing nasopharyngeal suctioning, which technique done by the nurse is NOT APPROPRIATE? a. Force the catheter against an obstruction. b. Insert the catheter gently through a nostril with your thumb away from the suction control. c. If one nostril is obstructed, try the other. d. Direct the catheter along the floor of the nasal cavity.

a. Left shoulder protracted

When positioning a patient on the left side, the nurse should position the: a. Left shoulder protracted b. Knees in 90 degrees of flexion c. Right leg resting on top of the left leg d. Ankles in plantar flexion

d. The patient holds the cane on the strong side and moves the cane forward, then moves the weak side, and then moves the strong side.

Which demonstration by the patient below shows that the patient knows how to properly ambulate a cane? a. The patient hold the cane on the weak side and moves the cane forward, then moves the weak side, and then moves the strong side. b. The patient holds the cane on the strong side and moves the cane and weak side forward. c. The patient holds the cane on the weak side and moves the cane and weak side forward together, and then moves the strong side. d. The patient holds the cane on the strong side and moves the cane forward, then moves the weak side, and then moves the strong side.

d. Center the sling under the patient from the shoulders to just above the knees.

Which safety measure is most important when using a mechanical lift to move a patient from a bed to a wheelchair? a. Hook the shorter chains on the sling closes to the patients feet. b. Release the hydraulic valve on the lift swiftly while lowering the patient on the chair. c. Cross the patient's arms across the chest throughout the transfer. d. Center the sling under the patient from the shoulders to just above the knees.

c. Ascending colostomy

Which stoma would you expect a malodorous, enzyme-rich, caustic liquid output that is yellow, green, or brown? a. Ileostomy b. Transverse colostomy c. Ascending colostomy d. Descending colostomy

b. Moving the injured leg down onto the step

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 the body then both the legs d. Moving both legs down onto the step

d. Three point gait

While your patient is ambulating with crutches he moves both crutches forward along with the injured leg and then moves the non-injured leg forward. When you document you will note that the patient used what type of gait while ambulating the crutches? a. Four point gait b. Swing to gait c. Two point gait d. Three point gait

c. Yogurt

You are advising a 21 year old with a colostomy who reports problems with flatus. What food should your recommend? a. Broccoli b. Cabbage c. Yogurt d. Peas

b. bloody drainage from the colostomy

You are preparing a patient with a malignant tumor for colorectal surgery and subsequent colostomy. The patient tells you hes anxious. What should your initial step be in working with this patient? a. Arrange for someone who has a colostomy b. bloody drainage from the colostomy c. Show the patient some pictures of colostomies. d. Determine what the patient already knows about colostomies.

d. Snuggly fit around the stoma

You have to teach ostomy self care to a patient with colostomy. You tell the patient to measure and cut the wafer: a. About 1 inch larger than the stoma b. one fourth larger to the exact size of the stoma c. About one eight larger than the stoma d. Snuggly fit around the stoma

d. The patient places both crutches on the non-injured side before sitting down in the chair.

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 backs up to the chairs seat until he feels it with his non injured leg and stops. b. The patient keeps the injured leg extended out in front of him while sitting down. c. 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. d. The patient places both crutches on the non-injured side before sitting down in the chair.