Question 1

The nurse plans care for hospitalized patients.When planning care for this patient, the nurse includes intervention to prevent which preventable condition that is responsible for the most preventable deaths during hospitalization?

Accepted Answer

Pulmonary embolism, often resulting from deep vein thrombosis, is a leading cause of preventable hospital deaths. Nurses implement interventions like early mobilization and anticoagulant therapy to prevent it.

Question 2

The nurse provides care to a bedbound patient who is at increased risk for the formation of a blood clot.When planning care for this patient, the nurse includes intervention to address which condition?

Accepted Answer

Thromboembolism is a condition where blood clots form in the blood vessels, which can then travel to other parts of the body and cause blockages. Bedbound patients are at increased risk for blood clots due to decreased movement, which can lead to poor blood circulation and clot formation.

Question 3

The nurse reinforces teaching for the caregiver on an immobile patient who will be discharged home soon.Which caregiver action when supervising care indicates the need for the nurse to intervene?

Accepted Answer

Massaging directly on reddened bony prominences can cause further damage to already compromised skin and underlying tissues, increasing the risk of pressure ulcers.

Question 4

The nurse encourages a patient to take full, deep breaths to keep the alveoli open to prevent which complication from occurring?

Accepted Answer

Taking full, deep breaths helps to keep the alveoli, the tiny air sacs in the lungs, open and can prevent atelectasis, which is the collapse of part or all of a lung.

Question 5

A nurse delegates the task of assisting patients with ambulation to a nursing assistant.The nurse intervenes when observing the nursing assistant implements which action?

Accepted Answer

Holding the transfer belt loosely near the patient's body while ambulating is incorrect because the belt should be held securely to provide proper support and prevent falls.

Question 6

The nurse plans care for a patient who has a history of becoming dizzy, pale, clammy, and nauseated when moving from a lying position to a sitting position.The nurse plans interventions to prevent which condition?

Accepted Answer

The symptoms described are characteristic of orthostatic hypotension, a condition where blood pressure drops significantly upon standing up from a lying or sitting position, leading to dizziness, paleness, clamminess, and nausea.

Question 7

The nurse observes a caregiver positioning a patient in the bed.Which caregiver action requires an intervention by the nurse?

Accepted Answer

Allowing a patient's arm to dangle over the side of the bed can compromise circulation and potentially cause nerve damage or discomfort. Proper positioning is crucial for patient safety and comfort.

Question 8

A nurse reinforces education to a patient about how to avoid developing osteoporosis.Which patient statement indicates to the nurse a need for additional teaching?

Accepted Answer

Remaining in bed, especially for extended periods, can contribute to bone loss or prevent the improvement of bone density, which is counterproductive in preventing osteoporosis. Weight-bearing exercises, such as walking, and adequate intake of calcium and vitamin D are beneficial for bone health.

Question 9

Which term does the nurse include in the plan of care for skin that slides over another surface in the opposite direction, which increases the risk of abrasions and open skin areas?

Accepted Answer

Shearing occurs when the skin slides over another surface in the opposite direction, which can lead to increased risk of abrasions and open skin areas, particularly in bedridden or immobile patients.

Question 10

While assisting the primary nurse who is manually transferring a patient from a bed to a chair, the nurse intervenes when the primary nurse implements which action during the transfer?

Accepted Answer

Twisting at the torso can cause back injuries.

Question 11

When educating a student about how to correctly logroll a patient, the nurse recognizes that additional teaching is necessary when the student makes which statement?

Accepted Answer

The correct technique for logrolling a patient involves coordination and support along the patient's entire body, not just from the feet. Standing at the patient's feet and controlling the turn does not provide adequate support for the spine and could lead to injury, indicating a misunderstanding of the proper logrolling technique.

Question 12

Which term does the nurse document in the patient's medical record for the movement of the intestines?

Accepted Answer

Peristalsis is the term used to describe the wave-like muscle contractions of the intestines that move food along the digestive tract.

Question 13

While caring for a patient who has a spinal cord injury, the nurse obtains assistance to logroll the patient.The nurse intervenes when observing the assistant prepare for the logroll by standing at which patient location?

Accepted Answer

The nurse should intervene if the assistant stands at the feet because during a logroll, the assistant should be positioned at the head, waist, and thighs to maintain spinal alignment and ensure the patient's safety.

Question 14

The nurse provides care for a patient who has been on prolonged bedrest and is now experiencing shortening and tightening of the muscles due to disuse.The nurse includes interventions in the plan of care to address which condition?

Accepted Answer

Contractures are the result of shortening and tightening of muscles due to disuse, which can occur with prolonged bedrest.

Question 15

The nurse provides care to a patient who begins to fall during ambulation.Which nursing action ensures safety for the nurse and the patient in this situation?

Accepted Answer

Allowing the patient to slide down the nurse's leg to the floor is a technique used to safely lower a patient to the ground during a fall, minimizing injury to both the patient and the nurse. This method helps control the descent and reduces the impact of the fall.

Question 16

The nurse provides care to a patient who develops respiratory distress.The patient needs to be positioned to allow for the chest to expand to maximum capacity for moving air in and out of the lungs.In which position does the nurse place the patient?

Accepted Answer

The orthopneic position, where the patient sits up and leans forward over a table or similar surface, is designed to maximize chest expansion, facilitating breathing for those in respiratory distress.

Question 17

The nurse reinforces education to a patient who is at risk for thrombosis.Which patient action indicates correct understanding of the information presented?

Accepted Answer

Performing active range-of-motion exercises helps prevent thrombosis by promoting blood circulation, which is crucial for patients at risk.

Question 18

The nurse provides care to a patient who is diagnosed with a loss of bone minerals increasing the risk for fractures.When planning care for this patient, the nurse includes interventions to address which condition?

Accepted Answer

Osteoporosis is characterized by a loss of bone minerals, leading to weakened bones and an increased risk for fractures. The other options do not directly relate to bone mineral density or the risk of fractures.

Question 19

The nurse provides care to a patient whose proper flexion of the ankle is lost, and permanent plantar flexion of the foot develops.The nurse includes interventions in the plan of care to address which condition?

Accepted Answer

Footdrop is a condition where there is difficulty in lifting the front part of the foot, leading to permanent plantar flexion.

Question 20

The nurse reinforces education for a patient with a history of orthostatic hypotension.Which patient statement indicates the need for additional teaching?

Accepted Answer

Remaining flat in bed can exacerbate orthostatic hypotension by promoting venous stasis and reducing the effectiveness of the body's natural mechanisms to adjust blood pressure upon standing. The other options (B, C, D) are beneficial practices to help mitigate the effects of orthostatic hypotension.

Quiz 16: Moving and Positioning Patients