Question 1

The nurse is caring for a patient after a motor vehicle accident and instructs the patient to avoid turning independently because the spine is unstable.Which explanation should the nurse use to explain the purpose of the safeguards in relation to the patient's injury?

Accepted Answer

The nurse does not allow the patient to turn to the side unassisted because an unstable spine cannot maintain normal alignment since the integrity of one or more vertebrae is disrupted.If the patient moves,he or she risks exacerbating the spinal cord injury by abnormal movements of vertebral bone fragments.To maintain patient safety,the nurse turns the patient by logrolling and thereby keeps the head,neck,and spine in straight alignment,thus preventing bone fragments from shifting and potentially increasing the damage.Keeping the patient in the supine position is ideal for maintaining hemodynamic stability and facilitating assessments.The primary purpose of logrolling is to maintain alignment of the neck and spine.

Question 2

A 225-pound patient is unconscious and needs to be transferred from the bed to the stretcher.Which action is most critical for the nurse to initiate before moving the patient?

Accepted Answer

The nurse effectively manages patient safety by using a friction-reducing device and at least three people to move a patient who is this weight.Suspending the Foley catheter from the stretcher is fine,but the IV lines must be hung from the stretcher for proper infusion.The patient must be observed closely during the transfer; wrapping the patient in a sheet obscures critical observations that can prevent accidents and injury to the patient.

Question 3

While transferring a patient who has been bedridden for several weeks,the nurse notes that the patient becomes fatigued rapidly.What assessment data does the nurse expect to find to validate the patient's changing status?

Accepted Answer

The patient's body is responding to the increased workload on the heart and lungs and is manifested by elevations in both the pulse and respirations.

Question 4

The nurse is teaching other caregivers about using a mechanical lift.What should the nurse include in the instructions focusing on patient safety?

Accepted Answer

The nurse ensures patient safety while transferring a patient with a mechanical lift by securing the base of the lift under the side of the bed.The base will also be set at its widest point for stability.The longer chain is used to support the patient's legs.The patient lies in a supine position with the head relaxed on a small pillow if necessary.The nurse instructs the patient to cross the arms on the chest because the sling wraps around the patient very tightly,potentially resulting in injury.

Question 5

The nurse and an assistant are moving a dependent patient from the supine to the lateral position.Which should the nurse implement to begin repositioning?

Accepted Answer

The nurse and assistant move the patient to one side of the bed to create space on the bed for turning and avoid dangling the patient's arms and legs over the side of the bed.The nurse supports the upper arm and leg after the patient is turned.Usually one pillow under the head is suitable for the lateral position; two or three pillows hyperflex the patient's head.If necessary,a pillow is wedged under the patient's chest and hips to support the patient in the lateral position,allowing him or her to relax in this position.

Question 6

You are moving a patient onto a stretcher using a slide board.Two nurses are positioned on the side of the stretcher.Where is the third nurse positioned?

Accepted Answer

Two nurses position themselves on the side of the stretcher while the third nurse positions self on the side of the bed without the stretcher.

Question 7

The nurse is helping a patient set a goal for ambulating after surgery.Which outcome statement for this patient with generalized postoperative weakness is best?

Accepted Answer

The best goal for a patient with postoperative weakness is that the patient transfers safely 4 times a day within 2 days because it is specific,patient oriented,measurable,and time limited.Any nurse who reads this outcome knows the specific expectations for the patient.In addition,the outcome focuses on improving the patient's ability and strength.Transferring 3 times daily is a reasonable outcome but lacks a time limit.Altered physical mobility and at risk for falls are nursing diagnoses; the nurse lacks specific data to support these diagnoses.

Question 8

A weak but motivated patient is ambulating for the first time.Which nursing intervention is most likely to facilitate patient participation in ambulation and ensure patient safety?

Accepted Answer

An assessment of the patient will give the nurse a better idea of how stable he or she is.It is better to go a shorter distance and return safely.Even if the patient has been weak before,the nurse must focus on his or her status at the present time.Pulse,respiration,and blood pressure can give a baseline,but temperature does not need to be taken at this time.There is more to the assessment than this before ambulating a patient for the first time.The nurse does not encourage the patient to hold onto him or her because it increases the risk of the nurse's injury.The patient can use the handrails if present,but they do not guarantee safety.

Question 9

The nurse teaches the caregiver to maintain the patient's safety when transferring to a chair.Which teaching should the nurse include to address the weakness of the patient's right side?

Accepted Answer

The nurse instructs the caregiver to place the chair on the patient's strong side for safety and support.

Question 10

The nurse assists the patient with transferring from bed to chair by using a transfer belt.Which is the first instruction that the nurse gives to the patient after properly positioning him or her?

Accepted Answer

A rocking motion and pushing up with the hands moves the patient's body in the direction of the transfer.The nurse is also rocking,and together they move as a unit.Having the patient hold the nurse around the neck increases the risk of injuring the nurse during a transfer.The nurse flexes at the knees and hips to lower his or her center of gravity; this is a more powerful force for transferring and decreasing the risk of back injury than standing upright and leaning toward the patient.The patient wears the transfer belt,and the nurse grabs the belt from underneath as the patient rocks forward.The nurse's force on the belt and the nurse's and patient's weight shifting work as a unit to assist the patient to a standing position.

Question 11

After 3 hours in the supine position,an older patient tells the nurse that he or she is stiff and too uncomfortable to move.Which is the best nursing intervention to maintain skin integrity?

Accepted Answer

Lying motionless is common behavior for patients in pain.This older patient is likely to have thin,fragile skin and by not moving for 3 hours,has an increased risk of skin breakdown from tissue hypoxia.The nurse assesses the patient's pain and determines a need for pain medication before attempting to reposition him or her.To preserve skin integrity and promote patient comfort,the nurse moves the patient to another position to facilitate the flow of oxygen-rich blood to the tissue,to assess the entire back for skin breakdown,and to provide hygiene if necessary.Expressing concern about the pain does nothing to assess or treat the discomfort.Explaining the need to reposition to prevent pneumonia is helpful when the patient is comfortable enough to pay attention to what is being said.

Question 12

The nurse transfers the patient from the bed to the chair using a mechanical lift.Which should the nurse do before leaving the patient's room to ensure patient safety?

Accepted Answer

To prevent patient injury from unnecessary reaching or attempts to get up,the nurse places the call bell close to the patient,makes sure that the patient can use the call bell,asks what the patient needs,and assesses the patient for safety before leaving the room.The sling remains under the patient while the patient is sitting in the chair as long as it does not increase the risk of skin breakdown or patient discomfort.With the sling in place,the nurse facilitates transferring the patient to the original position.The base may be left open and stored over the bed while the patient is in the chair.Once the patient is back in bed,the lift is returned to the original position and removed from the room.

Question 13

The patient will be transferred to the chair an hour after receiving pain medication.Which activity should the nurse delegate to nursing assistive personnel (NAP)?

Accepted Answer

The NAP can place the gait belt on the patient.Whenever there is doubt about a safe transfer,the transfer or gait belt should be used.The nurse determines the patient's pain level because it requires nursing assessment and nursing judgment after medication is given.The nurse checks the vital signs because the patient just had medication and a lot of assessment must be completed before ambulating the patient.Socks afford little protection for ambulation,especially in a hospital where many potentially dangerous substances and equipment are used.The patient needs either shoes or special socks with nonslip strips.

Question 14

The nurse is preparing to place a patient in the prone position.What action should the nurse take during the positioning?

Accepted Answer

The nurse places a small pillow under the patient's abdomen when the patient is in the prone position to relieve stress on the lower back.The knees are not elevated with a pillow in the prone position.If excessive pressure on the knees occurs,the entire anterior surface is padded to relieve the pressure,maintain normal body alignment,and prevent hyperextension at the knees.A footboard is used for patients in the supine position to prevent footdrop.The nurse flexes the patient's arms and positions them at the shoulder level.

Question 15

The nurse wants to transfer a patient from the bed to the chair by using a mechanical lift.The patient has difficulty following directions,and the nurse cannot find help.Which is the most important action for the nurse to implement?

Accepted Answer

To maneuver the patient safely with a mechanical lift,the nurse must find an assistant to help on the opposite side of the bed and help hold the chair as the nurse lowers the patient onto it.Whenever a patient has difficulty comprehending or following directions,additional help needs to be obtained.Reassuring the patient about the safety of the lift is appropriate but is less important than ensuring his or her safety on the lift.The chains attach to the sling,providing a strong bond between the lift and the sling,but they are not specifically designated as safety devices.Double-checking the wheel locks on the lift is important to patient safety,but the nurse should not even begin this transfer until an assistant is available.

Question 16

While the nurse is attempting to transfer a patient to a standing position,the patient cannot get off the bed.Which is the initial intervention for the nurse to implement?

Accepted Answer

The initial intervention for the nurse is to return the patient to a safe position.This follows Maslow's hierarchy of needs.The nurse would then reassess for weakness because this action decreases the risk for patient injury and frees the nurse to evaluate the problem.The nurse should assess the patient's fatigue,pain and discomfort,muscle strength,understanding of the patient's role in standing,and willingness to participate.The nurse organizes the data that he or she gathers,draws conclusions,and plans care.Further assessment is indicated after the patient is safe.

Question 17

A patient's physical mobility is impaired because of paralysis of both lower extremities.Which is the best method for the nurse to use to place the patient in semi-Fowler's position?

Accepted Answer

With the assistance of another staff member and using a drawsheet,the nurse bends the patient's knees to reposition the legs,pulls the patient to the HOB,elevates the HOB to 45 degrees,and removes wrinkles from the drawsheet.The patient is unable to push up because of paralysis.Elevating the HOB first increases the force needed to move the patient up in the bed and the risk of injury.Rolling the patient to the side achieves Sims' or lateral position or assists with logrolling; rolling the patient may be necessary to place the drawsheet under him or her before moving the patient up in bed.

Question 18

The patient with a hemiparesis is very hesitant to transfer from the bed to the chair with a new nurse's help.Which action should this nurse take first to accomplish the transfer?

Accepted Answer

By applying the nursing process,the nurse probes gently to gather information about the patient's reluctance to transfer,including the methods used to complete other transfers,how many transfers have occurred,and events during the transfers that left the patient fearing or dreading further transfers.The nurse takes these data and plans nursing care in response.If the nurse assumes that the problem is fear,the patient's true needs may not be met by even the most detailed explanation of safety measures.The first response should be to assess the problem and develop a plan of action.Refusal to transfer should be documented only if,after every effort to understand and address the patient concerns,the patient continues to refuse.By stating that the healthcare provider ordered a transfer,the nurse passes responsibility for transferring to the healthcare provider.This is unprofessional.The patient can feel coerced to transfer by the nurse's implication that the patient has no choice; this is a legally tenuous position for the nurse to assume.

Question 19

The nurse is teaching a patient's family how to maintain personal safety and prevent injury when lifting or moving the patient.Which concept should the nurse include in the instructions?

Accepted Answer

Decrease the force required to lift or move a patient by keeping the patient close to the person moving the patient.The mover provides a more stable base for moving a patient by keeping the patient close to the mover's center of gravity; if the patient's weight is higher than that of the mover,the mover becomes top heavy and more unstable and needs more force to move the patient.Bending at the waist increases the distance between the mover and the patient,making the mover's foundation less stable and less powerful.To move a significant weight without injury,the nurse tightens the abdominal and gluteal muscles in preparation for work.

Question 20

The nurse successfully transfers a patient from the bed to the chair and back.What information is most vital for the nurse to include in the progress notes?

Accepted Answer

The nurse documents the patient's response to each transfer in objective terms to record the events and subjective terms to relate the patient's response to communicate information.Factors to consider in the documentation are breathing difficulties,dizziness,balance,muscle strength,patient complaints,type and degree of assistance the patient requires to transfer,and progress toward goals and outcomes.To prevent patient and visitor injuries,visitors should not assist the patient to transfer.Home care instructions are suitable before discharge.Patient blood pressure is recorded on the graphic flow or vital signs sheet.

Quiz 15: Safe Patient Handling, transfer, and Positioning