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Week 4

Nursing Concepts

QuestionAnswer
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 weak side
The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk? Ask the patient how far she would like to go.
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 leans heavily on the nurse. What would be the nurse's initial response? Slowly lower the patient to the floor.
The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to nursing assistive personnel (NAP). Which statement made by NAP requires the nurse to follow up? I will use the under-axillae technique to help him up to a standing position.
The nurse is ambulating a patient with a gait belt when he says he feels sick to his stomach. What would the nurse do? Return the patient to the bed or chair (whichever is closer).
When preparing to apply elastic stockings, why does the nurse assess for skin discoloration? To identify the potential risk for deep vein thrombosis (DVT)
Which condition is not associated with venous stasis, part of Virchow's triad? Anxiety
Why does the nurse remove the patient's elastic stockings at least once per shift? To check the skin for irritation or breakdown.
Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient's legs? The patient's skin is irritated.
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? Instruct NAP to use a small amount of cornstarch or powder.
Which of the following techniques is used to assess muscle strength in a patient? Apply an opposing force or resistance.
What is an increased thoracic curvature, common in older adults, called? Kyphosis
Neck flexion and extension should be: 45 Degrees
Which of the following findings in a musculoskeletal assessment would be considered abnormal? Nodules and Bogginess
What does a goniometer measure? Angles of extension and flexion
When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first? Assess the patient's physiological capacity to transfer.
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? Please push down onto the mattress with both hands and stand when I count to three.
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? Raise the head of the bed 30 degrees.
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 your stronger leg forward and your weaker leg toward the back.
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? Lower the foot rests, and place the patient's feet on them.
When preparing to move a patient in bed, what will the nurse do first? Assess the patient's ability to help with moving.
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
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? Roll the patient from side to side, and place the device under the draw sheet.
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
Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift? Supine
Which action would decrease a patient's pain before a transfer with a hydraulic lift? Administer a prescribed analgesic 30 to 60 minutes before the transfer.
What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? Elevate the head of the bed.
When using a hydraulic lift to transfer a patient from the bed to a chair, when does the nurse turn off the check valve? As soon as the patient has been placed in the chair
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)
The nurse is performing passive shoulder and elbow exercises for a patient. Why does the nurse cup one hand around the patient's elbow and support the forearm and wrist during the ROM exercises? To ensure stability while exercising the joint
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? Perform range of motion to the left elbow until resistance is met.
Which of the following are basic guidelines when assisting a patient with passive range of motion? Each joint is exercised to the point of resistance but not pain.
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 has orthopedic trauma.
Created by: shid1851
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