Podcast
Questions and Answers
A nurse provides care for a patient who has been on prolonged bedrest and now has shortening and tightening of the muscles due to disuse. The nurse includes interventions in the plan of care to address which condition?
A nurse provides care for a patient who has been on prolonged bedrest and now has shortening and tightening of the muscles due to disuse. The nurse includes interventions in the plan of care to address which condition?
A nurse provides care to a patient who proper flexion of the ankle is lost, and permanent plan tarflexion of the foot develops. The nurse includes interventions in the plan of care to address which condition?
A nurse provides care to a patient who proper flexion of the ankle is lost, and permanent plan tarflexion of the foot develops. The nurse includes interventions in the plan of care to address which condition?
A nurse is assisting a patient out of bed to a chair for the first time post operatively.The patient becomes pale and dizzy during the transfer. What is the best explanation for this presentation?
A nurse is assisting a patient out of bed to a chair for the first time post operatively.The patient becomes pale and dizzy during the transfer. What is the best explanation for this presentation?
A nurse is caring for a post operative patient who had a surgical repair of an abdominal hernia and hasa history of chronic pulmonary obstructive disease (COPD). Which is the best position for the nurse to place the patient in to facilitate respiratory expansion?
A nurse is caring for a post operative patient who had a surgical repair of an abdominal hernia and hasa history of chronic pulmonary obstructive disease (COPD). Which is the best position for the nurse to place the patient in to facilitate respiratory expansion?
Signup and view all the answers
A nurse is caring for a post operative patient who had abdominal surgery and is preparing to use an incentive spirometer (IS) for the first time. What instruction should the nurse provide for use of this device?
A nurse is caring for a post operative patient who had abdominal surgery and is preparing to use an incentive spirometer (IS) for the first time. What instruction should the nurse provide for use of this device?
Signup and view all the answers
A nurse plans care for hospitalized patients.When planning care for a patient,then use includes intervention to prevent which preventable condition that is responsible for the most preventable deaths during hospitalization?
A nurse plans care for hospitalized patients.When planning care for a patient,then use includes intervention to prevent which preventable condition that is responsible for the most preventable deaths during hospitalization?
Signup and view all the answers
A nurse is caring for a post operative patient who had abdominal surgery 24 hours ago.Bowel sounds are hypoactive, and the patient’s abdomen is slightly distended. What priority action should the nurse take to prevent gastrointestinal complications?
A nurse is caring for a post operative patient who had abdominal surgery 24 hours ago.Bowel sounds are hypoactive, and the patient’s abdomen is slightly distended. What priority action should the nurse take to prevent gastrointestinal complications?
Signup and view all the answers
A nurse reinforce seducation to a patient who is at risk for thrombosis.Which patient action indicates correct understanding of the information presented?
A nurse reinforce seducation to a patient who is at risk for thrombosis.Which patient action indicates correct understanding of the information presented?
Signup and view all the answers
A nurse is taking care of an abdominal surgery patient on the secondday postop.The patient is receiving intravenous fluids infusing at 200 cc an hour for 12 hours. Which assessment warrants immediate nursing action?
A nurse is taking care of an abdominal surgery patient on the secondday postop.The patient is receiving intravenous fluids infusing at 200 cc an hour for 12 hours. Which assessment warrants immediate nursing action?
Signup and view all the answers
A student nurse is preparing to transfer a patient from bed to chair for the first time during the hospitalization for pneumonia. Which finding if noted by the nursing instructor requires immediate action
A student nurse is preparing to transfer a patient from bed to chair for the first time during the hospitalization for pneumonia. Which finding if noted by the nursing instructor requires immediate action
Signup and view all the answers
A nurse has received an order to administer a saline enema to an 85-year-old patient. Which is the best position for the nurse to position the patient?
A nurse has received an order to administer a saline enema to an 85-year-old patient. Which is the best position for the nurse to position the patient?
Signup and view all the answers
A nurse is taking care of amorbidly obese patient admitted for control of diabetes.The patient requires assistance to transfer from the bed to a chair. Which is the best option for the nurse to use when assisting the patient to transfer?
A nurse is taking care of amorbidly obese patient admitted for control of diabetes.The patient requires assistance to transfer from the bed to a chair. Which is the best option for the nurse to use when assisting the patient to transfer?
Signup and view all the answers
A group of nurse sarepreparing to log roll a patient who is recovering from spinal surgery.Which finding requires immediate intervention if observed by the nurse manager?
A group of nurse sarepreparing to log roll a patient who is recovering from spinal surgery.Which finding requires immediate intervention if observed by the nurse manager?
Signup and view all the answers
A nurse observes a care giver positioning a patient in the bed.Which caregiver action requires an intervention by the nurse?
A nurse observes a care giver positioning a patient in the bed.Which caregiver action requires an intervention by the nurse?
Signup and view all the answers
A nurse is preparing to transfer a patient with right-side weakness from the bed to a wheelchair.When planning for the transfer, which option should be included in the plan of care?
A nurse is preparing to transfer a patient with right-side weakness from the bed to a wheelchair.When planning for the transfer, which option should be included in the plan of care?
Signup and view all the answers
A 48-year-old patient is complaining of occasional dizziness upon position change and has been admitted to the hospital for observation. Which action should the nurse take when attempting to ambulate the patient for the first time to the bathroom?
A 48-year-old patient is complaining of occasional dizziness upon position change and has been admitted to the hospital for observation. Which action should the nurse take when attempting to ambulate the patient for the first time to the bathroom?
Signup and view all the answers
A nurse delegates the task of assisting patients with ambulation to a nursing assistant.Then urse intervenes when observing the nursing assistant implementing which action?
A nurse delegates the task of assisting patients with ambulation to a nursing assistant.Then urse intervenes when observing the nursing assistant implementing which action?
Signup and view all the answers
While assisting the primary nurse who is manually transferring a patient from a bed to a chair,anurse intervenes when the primary nurse implements which action during the transfer?
While assisting the primary nurse who is manually transferring a patient from a bed to a chair,anurse intervenes when the primary nurse implements which action during the transfer?
Signup and view all the answers
A nurse provides care to a patient who begins to fall during ambulation.Which priority nursing action ensures safety for the nurse and the patient in this situation?
A nurse provides care to a patient who begins to fall during ambulation.Which priority nursing action ensures safety for the nurse and the patient in this situation?
Signup and view all the answers
A nurse manager is making rounds on the medical unit and come across two nurses holding on to a patient who has fainted in the patient’s room. Which priority action should the nurse manager take?
A nurse manager is making rounds on the medical unit and come across two nurses holding on to a patient who has fainted in the patient’s room. Which priority action should the nurse manager take?
Signup and view all the answers
A nurse is providing passive range-of-motion(ROM)exercises to an 86-year-old patient in a long-term care facility who is bedridden. Which finding indicates that the nurse should immediately contact the health-care provider (HCP)?
A nurse is providing passive range-of-motion(ROM)exercises to an 86-year-old patient in a long-term care facility who is bedridden. Which finding indicates that the nurse should immediately contact the health-care provider (HCP)?
Signup and view all the answers
A nurse is preparing to move a patient up in bed to improve comfort.Which step should be included in preparation for this action?
A nurse is preparing to move a patient up in bed to improve comfort.Which step should be included in preparation for this action?
Signup and view all the answers
A patient lies in a special type of bed frame that allows the entire bed to turn from side to side. The mattress is low air loss, and the bed can be programmed to turn by degrees at set intervals. Which term would the nurse use when documenting information about this bed in the patient’s medical record?
A patient lies in a special type of bed frame that allows the entire bed to turn from side to side. The mattress is low air loss, and the bed can be programmed to turn by degrees at set intervals. Which term would the nurse use when documenting information about this bed in the patient’s medical record?
Signup and view all the answers
A nurse provides care to a patient who has a casted left leg and has anxiety about mobility restrictions.Which interventions should the nurse include in the patient’s plan of care based on this information? Select all that apply.
A nurse provides care to a patient who has a casted left leg and has anxiety about mobility restrictions.Which interventions should the nurse include in the patient’s plan of care based on this information? Select all that apply.
Signup and view all the answers
A nurse provides care for an immobile patient.Which interventions should the nurse include in the patient’s plan of care to prevent psychological complications for this patient? Select all that apply.
A nurse provides care for an immobile patient.Which interventions should the nurse include in the patient’s plan of care to prevent psychological complications for this patient? Select all that apply.
Signup and view all the answers
Study Notes
Contractures
- Contractures: Shortening and tightening of muscles due to disuse, often seen in patients on prolonged bedrest.
Foot Drop
- Foot Drop: Occurs when proper flexion of the ankle is lost and permanent plantar flexion of the foot develops.
Postoperative Dizziness
- Postoperative Dizziness: Caused by a sudden drop in blood pressure upon sitting up or standing up, often due to a decrease in blood flow to the brain.
Positioning for Respiratory Expansion
- High Fowler's Position: Recommended for patients with COPD after abdominal surgery to facilitate respiratory expansion.
Incentive Spirometer
- Incentive Spirometer: Used to encourage deep breathing and prevent atelectasis (collapse of lung tissue).
- Instructions: Inhale slowly and deeply through the mouthpiece, hold the breath for several seconds, then exhale normally.
Preventable Hospital Deaths
- Hospital-Acquired Infections (HAIs): Most preventable cause of death during hospitalization.
Postoperative Bowel Sounds
- Hypoactive Bowel Sounds: A sign of delayed gastric emptying, a potential complication after abdominal surgery.
Prevention of Gastrointestinal Complications
- Early Ambulation: Encouraged to stimulate bowel activity and prevent constipation.
Thrombosis Prevention
- Anticoagulation Therapy: Reduces the risk of blood clots, often prescribed for patients at risk for thrombosis.
Assessment of Intravenous Fluid Infusion
- Edema: Excessive fluid intake can lead to edema, requiring immediate nursing action to adjust fluid volume.
Transferring Patients
- Transferring a Patient for the First Time: Requires close monitoring for signs of orthostatic hypotension, such as dizziness.
- Pneumonia: Patients with pneumonia may require oxygen therapy, which could impact their ability to tolerate transfer.
Saline Enema Positioning
- Sims' Position: Best for administering a saline enema.
Assisting Morbidly Obese Patients
- Mechanical Lift: The safest option for transferring patients, especially those who are morbidly obese.
Log-rolling
- Spinal Surgery: Log-rolling is a technique for turning patients who have undergone spinal surgery to minimize pain and avoid spinal injury.
- Instability: The nurse manager should intervene if log-rolling a patient causes instability or discomfort.
Patient Positioning
- Pressure Ulcers: Improper positioning can lead to pressure ulcers, requiring intervention.
Transferring Patients with Right-Side Weakness
- Support the Patient's Weak Side: The nurse should stand on the patient's weak side during transfer to provide support.
Ambulating Patients
- Dizziness: Watch for dizziness when ambulating patients for the first time, especially those with recent position changes.
- Support the Patient: Offer support during the first ambulation.
Nursing Assistant's Responsibilities
- Ambulation: Nursing assistants can assist with ambulation but should be supervised for safe practice.
Manual Transfer
- Assisting a Nurse During a Transfer: It's crucial to be prepared to assist the nurse during a manual patient transfer to minimize the risk of injury for both the nurse and the patient.
Preventing Falls During Ambulation
- Lower the Patient to the Floor: The nurse should lower the patient to the floor if they begin to fall to prevent injury.
Patient Fainting
- Clear the Area: The nurse manager should clear the area around the patient and ensure clear airways for breathing.
Passive ROM Exercises
- Pain: Passive ROM exercises should not cause pain, if pain occurs, contact the health care provider.
Moving a Patient Up in Bed
- Use a Lift Sheet: A lift sheet is used to move patients up in bed safely.
Specialty Beds
- Turning Bed: A bed that can be programmed to turn at set intervals using specialized mattresses.
Preventing Complications of Immobility
- Anxiety and Depression: Immobility can lead to feelings of anxiety and depression, address these concerns.
- Social Isolation: Promote social interaction to combat social isolation.
- Cognitive Impairment: Engage in cognitive stimulation activities to minimize cognitive impairment.
- Skin Breakdown: Use pressure-relieving devices as needed to prevent skin breakdown.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
In this quiz, you'll learn about the nursing interventions for a patient who has developed muscle shortening and tightening due to prolonged bedrest. Test your knowledge of disuse atrophy and its effects on the patient.
