CHP. 38&39 Activity and movement: Implement and Take action; Evaluate

Questions and Answers

Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed?

Place the patient on complete bed rest.

Initiate a fall prevention plan for the patient. (correct)

Start passive range-of-motion exercises twice a day.

Make sure the patient only ambulates with a walker

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair?

Allow the patient to dangle. (correct)

Stand the patient up with assistance.

Transfer the patient with a slide board.

Place the transfer belt after the patient stands.

Match each type of exercise to its example.

Ambulating = Isotonic Kegel exercises = Isometric Heavy weight-lifting = Anaerobic Repeated stair-climbing = Aerobic

Which interventions would the nurse implement for a patient with lower extremity Paralysis?

Turn every 2 hours/Arrange for a special bed. Signup and view all the answers

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving?

Has a pulse oximetry reading of 94% when standing to brush teeth Signup and view all the answers

Which instruction would the nurse share with the patient about coughing techniques?

Take two deep breaths in and out to start. Signup and view all the answers

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)?

Monitor the patient’s toes for impaired circulation. Signup and view all the answers

Which action would the nurse take to improve an immobile patient’s nutritional intake?

Allow the patient to make food choices. Signup and view all the answers

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining? Select all that apply

Has a Braden Scale score that indicates a high risk for skin breakdown Signup and view all the answers

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle?

Open the window blinds during the day. Signup and view all the answers

Question 1 of 21

To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity?

Unlicensed assistive personnel Signup and view all the answers

Question 2 of 21 In which area would the nurse place a pillow for a patient in the supine position?

Under the calves Signup and view all the answers

Question 3 of 21

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed?

Trapeze bar Signup and view all the answers

Question 4 of 21

Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation?

Walker Signup and view all the answers

Question 5 of 21 Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement?

Promotes muscle strength Signup and view all the answers

Question 6 of 21

In which position would the nurse place the patient to perform coughing and deep breathing?

Fowler’s Signup and view all the answers

Question 7 of 21

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility?

Obtains two unlicensed assistive personnel to help Signup and view all the answers

Question 8 of 21

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills?

Notify the health care provider that the patient may have pneumonia. Signup and view all the answers

Question 9 of 21

Which action would the nurse take for a patient on bed rest who is concerned about developing constipation?

Increase the patient’s dietary fiber and fluid intake. Signup and view all the answers

Question 10 of 21

Which interventions would the nurse select for a patient who is on bed rest? Select all that apply.

Have the patient shift weight every 15 minutes while awake. Signup and view all the answers

Question 11 of 21

Which actions would the nurse take for a patient who is immobile? Select all that apply.

Suggest drinking at least 2000 mL during a 24-hour period./Encourage passive range-of-motion exercises. Signup and view all the answers

Question 12 of 21

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility? Select all that apply.

Use the incentive spirometer 5 to 12 times every 1 to 2 hours./Deep breathe 10 times every hour. Signup and view all the answers

Question 13 of 21

Which safety measures would the nurse implement for a patient who is a fall risk? Select all that apply.

Use a low bed. Signup and view all the answers

Question 14 of 21

Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse? Select all that apply.

Places a gait belt on a patient with osteoporosis to assist with ambulation/Allows the patient’s elbows to be bent at a 45-degree angle when using a cane Signup and view all the answers

Question 15 of 21

Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating? Select all that apply.

Experiences a pulmonary embolus Signup and view all the answers

Question 16 of 21

Which cues alert the nurse that the patient with Paralysis is declining? Select all that apply.

Develops disuse osteoporosis Signup and view all the answers

Question 17 of 21

Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving? Select all that apply.

Needs no assistance to transfer/Ambulates unassisted down the corridor and back Signup and view all the answers

Question 18 of 21

Which actions would the nurse take if the patient falls while ambulating in the hall? Select all that apply.

Call for help./Assess the patient’s physical and neurologic status. Signup and view all the answers

Question 19 of 21

When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient? Select all that apply.

Leave top side rails up./ Bend at the knees. Signup and view all the answers

Question 20 of 21

The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? Record your answer as a whole number. hour(s) Use numbers only.

2 Signup and view all the answers

Question 21 of 21 Place the steps in the order the nurse would follow to teach a patient how to use a cane.

Move the cane. = 2 Move the weaker leg. = 3 Move the stronger leg. = 4 Place cane on the patient’s stronger side. = 1 Signup and view all the answers

Study Notes

Patient Mobility and Transfer

For a newly admitted patient unsteady transferring from wheelchair to bed, first ensure safety using gait belts or assistive devices.
When assisting a patient post-surgery to transfer from bed to chair, first assess the patient’s ability to move and provide assistance accordingly.
Use slide sheets or transfer boards for patients needing help repositioning in bed after a femur surgery.

Exercise Types and Examples

Aerobic exercise improves cardiovascular fitness; walking or cycling are common examples.
Strength training focuses on building muscle; using resistance bands or weights embodies this type.
Range-of-motion exercises enhance flexibility; stretching specific muscle groups serves as an illustration.

Patient Care Interventions

For patients with lower extremity paralysis, implement positioning to prevent contractures and promote circulation.
Evaluate signs of recovery in a patient with Activity Intolerance by observing increased endurance during activities.
Instruct patients on effective coughing techniques, including inhaling deeply and using controlled force to expel air.

Equipment and Nutritional Guidance

Sequential Compression Devices (SCDs) need to be checked for proper placement and functioning regularly.
To enhance nutritional intake in immobile patients, encourage small, frequent meals and monitor dietary preferences.
Alert indicators of declining health in an immobile patient with a stage 1 pressure injury include increased redness or warmth at the injury site.

Sleep-Wake Cycle Maintenance

For an immobile patient struggling with sleep, implement a routine schedule, limiting daytime naps and promoting evening activities.
Delegate the task of moving an immobile patient focusing on skin integrity to physical therapy team members.

Patient Positioning and Safety

Place a pillow under the knees of a supine patient to reduce strain and improve comfort.
Suggest a walker for patients with a history of falls, generalized weakness, and requiring ambulation assistance.

Respiratory Care and Mobility Improvement

Emphasize the importance of regular exercise in maintaining normal movement patterns for patients with limited mobility.
Position patients upright when performing coughing and deep breathing exercises to facilitate lung expansion.

Usage of Mechanical Aids

Employ mechanical lifts cautiously, maintaining a steady grip and following the manufacturer’s guidelines to ensure patient safety.
For an immobile patient with thick secretions and chills, implement chest physiotherapy and encourage hydration.

Addressing Constipation and Bed Rest Considerations

For bed rest patients concerned about constipation, initiate a diet high in fiber and suggest hydration strategies.
Select interventions such as range-of-motion exercises and frequent position changes for patients on bed rest.

Mobility Assistance and Respiratory Measures

Encourage respiratory exercises and regular range-of-motion activities to combat muscle atrophy.
Implement safety precautions for patients identified as fall risks, including bed alarms and non-slip footwear.

Performance Corrections and Observational Cues

Charge nurses should correct improper body mechanics or unsafe practices by staff when caring for mobility-challenged patients.
Indicators of deterioration for a patient at risk for Deep Vein Thrombosis include swelling, pain, or color changes in extremities.

Monitoring Progress in Paralysis and Mobility

Signs of decline in patients with paralysis include loss of muscle tone or new areas of skin breakdown.
Encouraging patient self-assessment of mobility needs helps identify improvements requiring one-person assist.

Response to Patient Falls

Immediate actions taken when a patient falls include assessing the situation for injuries, calling for assistance, and documenting the incident.
Ensure proper use of ergonomic techniques during patient transfers to prevent injury to both nurse and patient.

Routine Care for Skin Integrity

Inform unlicensed assistive personnel to turn patients every two hours to maintain skin integrity.
Instruct on the proper sequence of teaching a patient to use a cane, focusing on correct stance and movement.

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Description

This quiz focuses on the appropriate nursing actions for transferring a newly admitted patient who is unsteady. It emphasizes safety measures and best practices to ensure patient comfort and security during transfers from a wheelchair to a bed.

CHP. 38&39 Activity and movement: Implement and Take action; Evaluate

Questions and Answers

Which action would the nurse take for a newly admitted patient who is unsteady when transferring from the wheelchair to the bed?

Which action would the nurse take first when assisting a patient who has been in bed for several days after surgery to transfer from the bed to the chair?

Match each type of exercise to its example.

Which interventions would the nurse implement for a patient with lower extremity Paralysis?

Which evaluative cue alerts the nurse that a patient with Activity Intolerance is improving?

Which instruction would the nurse share with the patient about coughing techniques?

Which action would the nurse take when caring for a patient with sequential compression devices (SCDs)?

Which action would the nurse take to improve an immobile patient’s nutritional intake?

Which evaluative findings will alert the nurse an immobile patient with a left hip stage 1 pressure injury is declining? Select all that apply

Which action would the nurse take for an immobile patient who needs help maintaining a normal sleep-wake cycle?

Question 1 of 21 To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity?

Question 2 of 21 In which area would the nurse place a pillow for a patient in the supine position?

Question 3 of 21 Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed?

Question 4 of 21 Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation?

Question 5 of 21 Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement?

Question 6 of 21 In which position would the nurse place the patient to perform coughing and deep breathing?

Question 7 of 21 Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility?

Question 8 of 21 Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills?

Question 9 of 21 Which action would the nurse take for a patient on bed rest who is concerned about developing constipation?

Question 10 of 21 Which interventions would the nurse select for a patient who is on bed rest? Select all that apply.

Question 11 of 21 Which actions would the nurse take for a patient who is immobile? Select all that apply.

Question 12 of 21 Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility? Select all that apply.

Question 13 of 21 Which safety measures would the nurse implement for a patient who is a fall risk? Select all that apply.

Question 14 of 21 Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse? Select all that apply.

Question 15 of 21 Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating? Select all that apply.

Question 16 of 21 Which cues alert the nurse that the patient with Paralysis is declining? Select all that apply.

Question 17 of 21 Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving? Select all that apply.

Question 18 of 21 Which actions would the nurse take if the patient falls while ambulating in the hall? Select all that apply.

Question 19 of 21 When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient? Select all that apply.

Question 20 of 21 The nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? Record your answer as a whole number. hour(s) Use numbers only.