Question 1

The nurse identifies which instruction to be appropriate to delegate to the UAP (Unlicensed assistive personnel)?&#10;A) Assess the patient's skin during a bath.&#10;B) Reposition the patient using the trapeze.&#10;C) Assess the patient's ability to perform range-of-motion exercises.&#10;D) Notify the health care provider of any changes.

Accepted Answer

Repositioning a patient can be delegated to unlicensed assistive personnel (UAP); the nurse should provide proper instruction regarding specific positioning techniques, individualized patient concerns, and circumstances that require notifying a nurse. UAP may not perform assessments or evaluations but should notify the nurse about any skin or musculoskeletal issues (not the health care provider).

Question 2

The nurse knows that manual lifting should only be done in which situation?&#10;A) Patients who are less than 150 lb&#10;B) Life-threatening situations&#10;C) Postsurgical patients&#10;D) Patients who are less than 200 lb

Accepted Answer

Many manual patient handling tasks are unsafe, because the weights lifted and movements required are beyond the ability of most caregivers. The key is to identify the task to be accomplished, and then use the required equipment and personnel so that the task fits the capabilities of the staff (U.S. Department of Veterans Affairs, 2016). The patient's level of cooperation is taken into consideration when using the safe patient-handling and mobility (SPHM) algorithms to decide the best method of moving the patient. The patient's weight, medical conditions, and ability to assist are also considered (U.S. Department of Veterans Affairs, 2016). Postsurgical patients as well as patients less than 150 or 200 lb may not fit the criteria.

Question 3

The nurse is implementing generalized falls precautions for patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions?&#10;A) The bed is placed in the low position.&#10;B) The patient is wearing socks.&#10;C) The patient's cell phone is by the bedside.&#10;D) The patient's call light is within reach.

Accepted Answer

If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. Keep the call light in reach and remind the patient to use it and keep the bed in the low position.

Question 4

The nurse is preparing to reposition the patient in bed. What is the first step in this process?&#10;A) Position the patient's arms across his/her chest.&#10;B) Lower the side rails.&#10;C) Grasp the draw sheet.&#10;D) Raise the bed to a working height.

Accepted Answer

Raising the bed to a working height is the first step before beginning the procedure. Proper positioning of equipment prevents provider discomfort and reduces the chance of possible injury. Then lower the side rails as appropriate and safe and ensure that the bed wheels are locked. Then you can have the patient position his/her arms and/or grasp the draw sheet.

Question 5

Which explanation by the nurse best describes active assistive range of motion?&#10;A) The patient independently moves all joints.&#10;B) The patient to partially moves all joints.&#10;C) The caregiver must move the patient's joints.&#10;D) The patient performs isotonic exercises.

Accepted Answer

Active assistive range of motion occurs when the caregiver minimally assists the patient, or the patient minimally assists himself/herself in the movement of joints through a full motion. Active range of motion occurs when the patient has full independent movement of all joints; this is also known as isotonic exercise. Passive range of motion occurs when the caregiver moves the patient's joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy.

Question 6

The nurse is preparing to assist the patient to walk to the bathroom after medicating the patient with a narcotic for pain management. What possible adverse effect should the nurse be immediately aware?

A) Constipation
B) Depression
C) Dizziness
D) Pain relief

Accepted Answer

Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and dizziness. The nurse should be immediately aware of dizziness during ambulation because of the safety risks. Pain relief is expected. Depression is not an immediate adverse side effect. Constipation will not impact the nurse's ability to safely ambulate the patient.

Question 7

The nurse correctly teaches the patient to rise from a chair using crutches when which intervention is used?&#10;A) Patient starts from the back of the chair.&#10;B) The weak leg is closest to the chair.&#10;C) The hand on the strong side holds the hand bar of the crutch.&#10;D) The strong leg is closest to the chair.

Accepted Answer

The patient's strongest leg needs to be closest to the chair. The patient's hand on the weak side holds the hand bar of the crutches, and the hand on the patient's strong side holds onto the armrest of the chair. The patient moves to the front edge of the chair.

Question 8

The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired mobility?&#10;A) Patient will interact with others.&#10;B) Patient will ambulate to the bathroom with assistance.&#10;C) Patient will have no skin breakdown.&#10;D) Patient will have a physical therapy consult.

Accepted Answer

Patients with a diagnosis of Impaired mobility should have a goal aimed at improving their mobility. Although immobility can impact social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal but an intervention.

Question 9

The nurse is educating the family of a patient on falls risk precautions. Which statement by the family indicates a need for further education?&#10;A) &#34;I should keep the wheelchair locked unless using it to move Mom.&#34;&#10;B) &#34;I should leave the bathroom light on as she does at her home.&#34;&#10;C) &#34;I should leave her slippers by the wheelchair.&#34;&#10;D) &#34;I should keep her cell phone close to her bed.&#34;

Accepted Answer

Leave lights on or off at night, depending on the patient's cognitive status and personal preference. Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position. Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient's reach. If the patient is ambulatory, require the use of nonskid footwear (socks or shoes).

Question 10

The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis impaired skin integrity?&#10;A) Patient will ambulate twice a day.&#10;B) Patient will eat 50% of meals.&#10;C) Patient will have no further skin breakdown.&#10;D) Patient will interact with others.

Accepted Answer

The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility. Although nutrition is important to wound healing, it is not the focus of this Nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.

Question 11

The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed?&#10;A) Using an airflow bed&#10;B) Using a slide board&#10;C) Using a trochanter roll&#10;D) Using a gel mattress

Accepted Answer

The answer of The nurse correctly selects which intervention to...

Question 12

The nurse knows which findings indicate orthostatic hypotension?&#10;A) A decrease in systolic blood pressure by 30 mm Hg&#10;B) A decrease in diastolic blood pressure by 10 mm Hg&#10;C) An increase in heart rate by 30 beats/min&#10;D) An increase in systolic blood pressure by 20 mm Hg&#10;E) A decrease in heart rate by 20 beats/min

Accepted Answer

The answer of The nurse knows which findings indicate orthostatic...

Question 13

The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding of these exercises?&#10;A) &#34;An example of this type of exercise is walking.&#34;&#10;B) &#34;An example of this type of exercise is running.&#34;&#10;C) &#34;An example of this type of exercise is Kegels.&#34;&#10;D) &#34;An example of this type of exercise is weight lifting.&#34;

Accepted Answer

The answer of The nurse is providing education to the...

Question 14

The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education?&#10;A) &#34;I should report any complaints of soreness to the nurse.&#34;&#10;B) &#34;I should watch for indications that the patient has difficulties using the cane.&#34;&#10;C) &#34;I should let the nurse or PT know if the cane doesn't seem to fit correctly.&#34;&#10;D) &#34;I should teach the patient how to walk with the cane.&#34;

Accepted Answer

The answer of The nurse has delegated to the UAP...

Question 15

The nurse is teaching a patient about ways to decrease risk of bone fractures. Which statements by the patient indicate a good understanding of decreasing this risk?&#10;A) &#34;I should do weight-bearing exercises.&#34;&#10;B) &#34;I should get adequate intake of calcium and vitamin D.&#34;&#10;C) &#34;I should exercise regularly.&#34;&#10;D) &#34;I need to do yoga exercises.&#34;&#10;E) &#34;I wish I could reduce my risk but I can't do anything.&#34;

Accepted Answer

The answer of The nurse is teaching a patient about...

Question 16

What response would the nurse give the patient when questioned about the effect of rheumatoid arthritis on the musculoskeletal system?&#10;A) Muscle weakness&#10;B) Muscle wasting&#10;C) Joint inflammation&#10;D) Joint spasticity

Accepted Answer

The answer of What response would the nurse give the...

Question 17

The nurse is educating the patient about the effects of immobility on the body. Which statements by the patient indicate a need for further education?&#10;A) &#34;I can become very weak.&#34;&#10;B) &#34;I will gain weight.&#34;&#10;C) &#34;I will lose muscle tone.&#34;&#10;D) &#34;I can get bed sores.&#34;&#10;E) &#34;I won't have any lung problems.&#34;

Accepted Answer

The answer of The nurse is educating the patient about...

Question 18

The nurse knows which items are included in the documentation for a patient on fall precautions?&#10;A) History of any falls&#10;B) Falls risk assessment scores&#10;C) Patient and family education&#10;D) Use of assist devices&#10;E) Any fall or reported fall&#10;F) None of above

Accepted Answer

The answer of The nurse knows which items are included...

Question 19

The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of which conditions?&#10;A) Decreased tissue perfusion&#10;B) Loss of sensation&#10;C) Hemiparesis&#10;D) Diminished respiratory capacity&#10;E) Muscle weakness

Accepted Answer

The answer of The nurse knows that a patient with...

Question 20

The nurse is performing passive range-of-motion exercises on a patient when the patient begins to complain of pain. What is the first thing the nurse should do?&#10;A) Notify the health care provider.&#10;B) Hyperextend the joint.&#10;C) Stop the range of motion.&#10;D) Switch to active range of motion.

Accepted Answer

The answer of The nurse is performing passive range-of-motion exercises...

Question 21

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?&#10;A) &#34;I need to remove the throw rugs.&#34;&#10;B) &#34;I should make sure I only take a bath.&#34;&#10;C) &#34;I cannot use the stairs.&#34;&#10;D) &#34;I need to place a nonskid mat in front of the kitchen sink.&#34;&#10;E) &#34;I wish I had two ways of leaving the house.&#34;

Accepted Answer

The answer of The nurse is providing discharge education for...

Question 22

The nurse appropriately delegates care of the unit's patients to the properly trained UAP when that UAP is assigned which tasks?&#10;A) UAP assigned to reposition the patient.&#10;B) UAP assigned to complete the MORSE falls risk scale.&#10;C) UAP assigned to provide range-of-motion exercises.&#10;D) UAP assigned to ambulate the patient in the hallway.&#10;E) UAP assigned to time the patient on a TUG test.

Accepted Answer

The answer of The nurse appropriately delegates care of the...

Question 23

The nurse is correctly assisting the patient in using a cane when the patient demonstrates which activities?&#10;A) The top of the cane is level with the patient's bent elbow.&#10;B) The patient holds the cane on his/her weaker side.&#10;C) The patient moves the cane forward first.&#10;D) The patient's arm is comfortably bent when walking.&#10;E) The patient moves the strong leg forward first.

Accepted Answer

The answer of The nurse is correctly assisting the patient...

Question 24

The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions?&#10;A) The belt is placed around the patient's hips.&#10;B) The belt is secure, leaving only enough room for the nurse to grasp the belt.&#10;C) The nurse stands on the weaker side.&#10;D) The nurse holds the belt on the side of the patient.&#10;E) The nurse stands behind the patient while ambulating.

Accepted Answer

The answer of The nurse is correctly demonstrating the use...

Question 25

The nurse identifies that knee-high SCD (Sequential Compression Device) sleeves are correctly placed on the patient when which conditions are met?&#10;A) Both sleeves are connected to the SCD device.&#10;B) Two fingers fit inside when the SCDs are inflated.&#10;C) There are no kinks in the tubing.&#10;D) The ankle pressure is 55 to 65 mm Hg.&#10;E) The cooling control is on.

Accepted Answer

The answer of The nurse identifies that knee-high SCD (Sequential...

Deck 28: Activity, Immobility, and Safe Movement