Chapter 16 Moving and Positioning Patients PDF

Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Chapter 16: Moving and Positioning Pa...

Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Chapter 16: Moving and Positioning Patients Multiple Choice Identify the choice that best completes the statement or answers the question. 1. 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? 1. Footdrop 2. Contractures 3. Osteoporosis 4. Thromboembolism 2. A 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? 1. Footdrop 2. Contractures 3. Osteoporosis 4. Thromboembolism 3. A nurse is assisting a patient out of bed to a chair for the first time postoperatively. The patient becomes pale and dizzy during the transfer. What is the best explanation for this presentation? 1. Dehydration 2. Bradycardia 3. Orthostatic hypotension 4. Hypoglycemia 4. A nurse is caring for a postoperative patient who had a surgical repair of an abdominal hernia and has a history of chronic pulmonary obstructive disease (COPD). Which is the best position for the nurse to place the patient in to facilitate respiratory expansion? 1. Side-lying 2. Lateral recumbent 3. High Fowler’s 4. Head of bed to 45 degrees 5. A nurse is caring for a postoperative 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? 1. “Take a deep breath and hold for 60 seconds.” 2. “Use IS after meals.” 3. “IS provides a numerical indicator of lung expansion.” 4. “Balls rise in response to lung expansion.” 6. A nurse plans care for hospitalized patients. When planning care for a patient, the nurse includes intervention to prevent which preventable condition that is responsible for the most preventable deaths during hospitalization? 1. Embolism 2. Skin breakdown 3. Urinary tract infection 4. Hospital-acquired pneumonia 7. A nurse is caring for a postoperative 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? ______________________________________________________________________________________________ 241 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 1. 2. 3. 4. Use a straw when drinking fluids. Maintain adequate fluid and fiber intake. Administer a laxative. Administer an enema. 8. A nurse reinforces education to a patient who is at risk for thrombosis. Which patient action indicates correct understanding of the information presented? 1. Crossing the legs at the knee 2. Limiting movement of the extremities 3. Performing active range-of-motion exercises 4. Refusing to wear sequential compression devices 9. A nurse is taking care of an abdominal surgery patient on the second day postop. The patient is receiving intravenous fluids infusing at 200 cc an hour for 12 hours. Which assessment warrants immediate nursing action? 1. Urinary output is 100 cc during shift. 2. Abdomen is soft and slightly distended. 3. Patient complains of occasional nausea. 4. Patient states pain is 4 out of 10 at present time. 10. 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? 1. Ensure oxygen via nasal cannula is in place. 2. Bed is in lowest position. 3. Bed is not locked. 4. Call bell is in reach. 11. 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? 1. Supine 2. Left Sims 3. Lateral 4. Dorsal recumbent 12. A nurse is taking care of a morbidly 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? 1. Use a facility-designated lift device. 2. Place the patient in a Geri chair and use a locked tray. 3. Get additional staffing to help move the patient. 4. Elevate the head of the bed to high Fowler’s position to simulate sitting in a chair. 13. A group of nurses are preparing to logroll a patient who is recovering from spinal surgery. Which finding requires immediate intervention if observed by the nurse manager? 1. Nurse at head of bed (HOB) providing directions 2. Nurses supporting head and neck area 3. Maintaining alignment of body during turn 4. Not acting in unison during turn 14. A nurse observes a caregiver positioning a patient in the bed. Which caregiver action requires an intervention by the nurse? 1. Locking the wheels on the bed 2. Elevating the bed to a comfortable working height ______________________________________________________________________________________________ 242 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 3. Changing a patient’s position at least every 2 hours 4. Allowing a patient’s arm to dangle over the side of the bed 15. 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? 1. Use a draw sheet to move the patient in bed. 2. Place the patient in a hospital gown with snap closure. 3. Place nonskid socks on the patient’s feet. 4. Position the wheelchair on the patient’s right side. 16. 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? 1. Take vital signs prior to ambulation. 2. Use a transfer belt. 3. Obtain pulse oximetry readings pre- and postambulation. 4. Perform a mini mental status examination. 17. While assisting the primary nurse who is manually transferring a patient from a bed to a chair, a nurse intervenes when the primary nurse implements which action during the transfer? 1. Twisting at the torso 2. Standing farther away from the patient 3. Using proper body mechanics 4. Bending at the back 18. A nurse delegates the task of assisting patients with ambulation to a nursing assistant. The nurse intervenes when observing the nursing assistant implementing which action? 1. Holding the transfer belt loosely near the patient’s body while ambulating 2. Instructing the patient to move from supine to standing positions in stages 3. Assisting the patient to a dangling position with feet firmly on the floor 4. Raising head of bed and assisting the patient with sitting on side of bed 19. 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? 1. Holding the patient upright 2. Keeping the back bent while lowering the patient 3. Allowing the patient to slide down the nurse’s leg to the floor 4. Maintaining the knees in a straight position while lowering the patient 20. A nurse manager is making rounds on the medical unit and comes across two nurses holding onto a patient who has fainted in the patient’s room. Which priority action should the nurse manager take? 1. Call a rapid response. 2. Have the nurses lower the patient to the floor. 3. Tell the nurses to place the patient back in bed. 4. Provide supplemental oxygen. 21. 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)? 1. Slight resistance noted when turning the patient’s neck to the right side. 2. No complaints of pain elicited upon ROM of extremities. 3. Patient complains about morning stiffness. 4. Observed internal rotation of the hip with abduction. ______________________________________________________________________________________________ 243 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 22. A nurse is preparing to move a patient up in bed to improve comfort. Which step should be included in preparation for this action? 1. Use a draw sheet. 2. Use logrolling technique. 3. Raise the head of the bed. 4. Raise one side rail. 23. 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? 1. Mattress overlay 2. Combination bed 3. Specialized mattress 4. Continuous lateral-rotation bed Multiple Response Identify one or more choices that best complete the statement or answer the question. 24. 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. 1. Provide distraction activities. 2. Encourage participation in self-care. 3. Encourage periods of sleep during the day. 4. Limit the number of visitors. 5. Maintain an interactive environment. 25. 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. 1. Making all decisions about the patient’s care 2. Distracting the patient by turning on the television 3. Encouraging the patient to stay awake most of the day 4. Talking to the patient about photographs of the adult children 5. Closing blinds to decrease natural lighting in the patient’s room ______________________________________________________________________________________________ 244 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Chapter 16: Moving and Positioning Patients Answer Section MULTIPLE CHOICE 1. ANS: 2 Chapter: Chapter 16, Moving and Positioning Patients Objective: 1. Define various terms associated with moving and positioning patients. Page: 272 Heading: Effects of Immobility > Physiological Effects Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Mobility | Professionalism Difficulty: Moderate Feedback 1 This is incorrect. If the toes are allowed to fall toward the foot of the bed, the proper flexion of the ankle is lost, and permanent plantar flexion of the foot results in a condition known as footdrop. 2 This is correct. Contractures, or shortening and tightening of the muscles, are due to disuse. 3 This is incorrect. Osteoporosis is a condition that occurs because of loss of bone minerals that leads to an increased risk for skeletal fractures. 4 This is incorrect. A patient confined to bed may develop a venous thromboembolism (VTE), or the formation of a blood clot that may dislodge and travel through the vein. One type of VTE is called deep vein thrombosis, which is a clot that develops in the deep veins of the legs. PTS: 1 CON: Mobility | Professionalism 2. ANS: 1 Chapter: Chapter 16, Moving and Positioning Patients Objective: 1. Define various terms associated with moving and positioning patients. Page: 272 Heading: Effects of Immobility > Physiological Effects > Effects of Immobility on the Musculoskeletal System Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Mobility | Professionalism Difficulty: Moderate Feedback 1 This is correct. If the toes are allowed to fall toward the foot of the bed, the proper flexion of the ankle is lost, and permanent plantar flexion of the foot results in a condition known as footdrop. 2 This is incorrect. Contractures, or shortening and tightening of the muscles, are due to disuse. 3 This is incorrect. Osteoporosis is a condition that occurs because of loss of bone minerals that leads to an increased risk for skeletal fractures. ______________________________________________________________________________________________ 245 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 4 This is incorrect. A patient confined to bed may develop a venous thromboembolism (VTE), or the formation of a blood clot that may dislodge and travel through the vein. One type of VTE is called deep vein thrombosis, which is a clot that develops in the deep veins of the legs. PTS: 1 CON: Mobility| Professionalism 3. ANS: 3 Chapter: Chapter 16, Moving and Positioning Patients Objective: 12. Discuss assisting patients with ambulation and potential complications. Page: 274 Heading: Orthostatic Hypotension Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Safety Difficulty: Difficult Feedback 1 This is incorrect. There is insufficient evidence to support dehydration. It is more likely that the patient has orthostatic hypotension that occurs when changing from a reclining or flat position to an upright position, such as sitting or standing. 2 This is incorrect. With an episode of orthostatic hypotension, one would expect an increase in heart rate to compensate for decreased blood pressure. 3 This is correct. Orthostatic hypotension, also known as postural hypotension, is a decrease in blood pressure that occurs when a patient changes from a reclining or flat position to an upright position, such as sitting or standing. This can cause the patient to become dizzy, pale, clammy, or nauseated because the blood pressure drops more than normal, and the heart rate increases more than normal in an effort to pump blood to the head. If the blood pressure falls too far, the patient may experience syncope, or fainting. 4 This is incorrect. There is insufficient evidence to support hypoglycemia. It is more likely that the patient has orthostatic hypotension that occurs when changing from a reclining or flat position to an upright position, such as sitting or standing. PTS: 1 CON: Clinical Judgment | Safety 4. ANS: 4 Chapter: Chapter 16, Moving and Positioning Patients Objective: 5. Discuss the importance of positioning patients correctly and performing frequent position changes. Page: 275 Heading: Nursing Measures to Prevent Respiratory Complications Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Clinical Judgment | Perfusion Difficulty: Moderate Feedback 1 This is incorrect. A side-lying position will not help to promote lung expansion. 2 This is incorrect. Lateral recumbent position will not help to promote lung expansion. 3 This is incorrect. A high Fowler’s position will place pressure on the diaphragm; therefore, it will not promote lung expansion. ______________________________________________________________________________________________ 246 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 4 This is correct. Elevate the head of the bed 45 degrees or more to promote lung expansion. PTS: 1 CON: Clinical Judgment | Perfusion 5. ANS: 4 Chapter: Chapter 16, Moving and Positioning Patients Objective: 16. Answer questions about performing skills in the chapter. Page: 275 Heading: Nursing Measures to Prevent Respiratory Complications Integrated Processes: Teaching and Learning Client Need: Health Promotion and Maintenance Cognitive Level: Application [Applying] Concept: Oxygenation | Teaching and Learning Difficulty: Moderate Feedback 1 This is incorrect. It is not necessary to hold breath for 60 seconds during use of IS but rather to inhale deeply and then exhale to promote lung expansion. 2 This is incorrect. IS does not have to be performed after meals but can be done repeatedly throughout the day to promote lung expansion. 3 This is incorrect. IS provides a visual indicator of lung expansion, not a numerical indicator. 4 This is correct. With effective IS, the balls rise in response to increased volume and lung expansion. PTS: 1 CON: Oxygenation | Teaching and Learning 6. ANS: 1 Chapter: Chapter 16, Moving and Positioning Patients Objective: 2. Describe the effects of immobility on seven body systems. Page: 274 Heading: Effects of Immobility on the Cardiovascular System Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Perfusion Difficulty: Difficult Feedback 1 This is correct. An embolism has been identified as the most preventable cause of death during hospitalization; therefore, the nurse plans interventions to prevent this condition from occurring. 2 This is incorrect. While it is appropriate to plan intervention to prevent skin breakdown, this condition is not noted as being responsible for the most preventable deaths during hospitalization. 3 This is incorrect. While it is appropriate to plan intervention to prevent urinary tract infection, this condition is not noted as being responsible for the most preventable deaths during hospitalization. 4 This is incorrect. While it is appropriate to plan intervention to prevent hospitalacquired pneumonia, this condition is not noted as being responsible for the most preventable deaths during hospitalization. ______________________________________________________________________________________________ 247 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ PTS: 1 CON: Clinical Judgment | Perfusion 7. ANS: 2 Chapter: Chapter 16, Moving and Positioning Patients Objective: 2. Describe the effects of immobility on seven body systems. Page: 276 Heading: Nursing Measures to Prevent Gastrointestinal Complications Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Clinical Judgment | Elimination Difficulty: Moderate Feedback 1 This is incorrect. Drinking liquids with a straw can increase gas retention. 2 This is correct. Encourage fluid and fiber intake to help prevent constipation. 3 This is incorrect. Because the patient is only 24 hours postsurgery, there is no immediate need to administer a laxative. 4 This is incorrect. Because the patient is only 24 hours postsurgery, there is no immediate need to administer an enema. PTS: 1 CON: Clinical Judgment | Elimination 8. ANS: 3 Chapter: Chapter 16, Moving and Positioning Patients Objective: 3. Enumerate nursing measures to prevent complications of immobility in these body systems. | 16. Answer questions about performing the skills in the chapter. Page: 274 Heading: Effects of Immobility on the Cardiovascular System Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analysis] Concept: Perfusion | Teaching and Learning Difficulty: Difficult Feedback 1 This is incorrect. This action increases the risk of thrombosis and indicates the need for additional teaching. 2 This is incorrect. This action increases the risk of thrombosis and indicates the need for additional teaching. 3 This is correct. To prevent the formation of venous thrombosis, it is important to keep the blood from pooling in the legs, where clots most commonly form. To do so, the patient should perform active range-of-motion exercises. 4 This is incorrect. To prevent the formation of venous thrombosis, it is important to keep the blood from pooling in the legs, where clots most commonly form. To do so, a nurse will apply ordered devices to prevent pooling of blood in the legs. These include antiembolism stockings, which are close-fitting elastic stockings that usually cover the whole leg, and sequential compression devices (SCDs). SCDs are air-filled sleeves that are wrapped around the patient’s lower legs and connected to a pump that inflates and deflates each area of the sleeve in a sequence that moves blood in the legs toward the heart. PTS: 1 9. ANS: 1 CON: Perfusion | Teaching and Learning ______________________________________________________________________________________________ 248 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Chapter: Chapter 16, Moving and Positioning Patients Objective: 2. Describe the effects of immobility on seven body systems. Page: 276-277 Heading: Nursing Measures to Prevent Urinary Complications Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Elimination Difficulty: Difficult Feedback 1 This is correct. Because the patient has received 2,400 cc of fluid during the shift with a urinary output of 100, this requires intervention. The nurse should obtain an order from the health-care provider (HCP) for a bladder scan to detect urinary retention. 2 This is incorrect. These would be considered normal findings after abdominal surgery. Continued monitoring is needed but no immediate action is required. 3 This is incorrect. This would be considered a normal finding after abdominal surgery. Continued monitoring is needed but no immediate action is required. 4 This is incorrect. Pain assessment is a critical part of patient assessment, but the findings reported do not require immediate action at this time. Continued monitoring is needed. PTS: 1 CON: Clinical Judgment | Elimination 10. ANS: 3 Chapter: Chapter 16, Moving and Positioning Patients Objective: 9. Enumerate guidelines for performing a manual patient transfer. 15. Identify safety information related to moving and positioning patients. Page: 280 Heading: Positioning Patients > Assisting Patients With Position Changes Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Clinical Judgment | Mobility | Safety Difficulty: Moderate Feedback 1 This is incorrect. Because the patient has a clinical diagnosis of pneumonia, maintaining oxygen therapy is essential. 2 This is incorrect. Having the bed in the lowest position is a procedure consistent with safe transfer of patients. 3 This is correct. The bed not being locked can lead to the patient falling. For safe patient handling, always lock the wheels of the equipment. 4 This is incorrect. Providing the patient with a call bell is a procedure consistent with patient safety. PTS: 1 CON: Clinical Judgment | Mobility | Safety 11. ANS: 2 Chapter: Chapter 16, Moving and Positioning Patients Objective: 6. Identify commonly used patient positions. | 15. Identify safety information related to moving and positioning patients. Page: 281 Heading: Selecting Appropriate Positions and Positioning Devices ______________________________________________________________________________________________ 249 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Clinical Judgment | Safety Difficulty: Easy Feedback 1 This is incorrect. Supine position is used for physical examination, resting in bed, and patients undergoing anesthesia. 2 This is correct. Left Sims can be used for rectal examinations and for administering enemas. 3 This is incorrect. Lateral position can be used to promote patient comfort, promote lung and cardiac function, and relieve pressure on bony prominences of the coccyx and sacrum. 4 This is incorrect. Dorsal recumbent position is used for physical examination of abdomen and genitalia, perineal care, and examination during labor. PTS: 1 CON: Clinical Judgment | Safety 12. ANS: 1 Chapter: Chapter 16, Moving and Positioning Patients Objective: 7. Explain the purposes and focus of the Handle With Care campaign established by the American Nurses Association. | 15. Identify safety information related to moving and positioning patients. Page: 287 Heading: Lifting and Moving Obese Patients Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Clinical Judgment | Safety Difficulty: Moderate Feedback 1 This is correct. Based on the American Nurses Association (ANA) Handle With Care campaign, nurses are encouraged to use hospital-appropriate lifting devices to prevent musculoskeletal injuries. 2 This is incorrect. Placing the patient in a Geri chair with a locked table is a form of a restraint. There is no indication that the patient requires this type of restriction. 3 This is incorrect. Based on the American Nurses Association (ANA) Handle With Care campaign, nurses are encouraged to use hospital-appropriate lifting devices to prevent musculoskeletal injuries. “No lifting” policies are in place in clinical facilities to prevent injury. 4 This is incorrect. This action imposes mobility restrictions on the patient. PTS: 1 CON: Clinical Judgment | Safety 13. ANS: 4 Chapter: Chapter 16, Moving and Positioning Patients Objective: 15. Identify safety information related to moving and positioning patients. | 16. Answer questions about performing the skills in the chapter. Page: 284 Heading: Moving Patients in Bed > Logrolling a Patient Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analysis [Analyzing] ______________________________________________________________________________________________ 250 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ Concept: Leadership and Management |Mobility Difficulty: Moderate Feedback 1 This is incorrect. The nurse at the HOB should be providing directions for the logrolling procedure. 2 This is incorrect. Supporting head and neck during the logrolling procedure is a critical element. 3 This is incorrect. Maintaining body alignment during the logrolling procedure is a critical element. 4 This is correct. The nurses must act in unison. It is very important that all staff members turn the patient at the same time. Failure to do so can cause damage to the patient’s spine, which could potentially result in paralysis. PTS: 1 CON: Leadership and Management | Mobility 14. ANS: 4 Chapter: Chapter 16, Moving and Positioning Patients Objective: 13. Identify proper body mechanics for protecting yourself and the patient. Page: 280 Heading: Positioning Patients > Assisting Patients With Position Changes Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Clinical Judgment | Safety Difficulty: Moderate Feedback 1 This is incorrect. It is important to maintain good body mechanics when positioning patients to prevent injury to the patient and staff. For safe patient handling, the caregiver should always lock the wheels of the equipment. 2 This is incorrect. It is important to maintain good body mechanics when positioning patients to prevent injury to the patient and staff. For safe patient handling, the caregiver should elevate the bed to a comfortable working height. 3 This is incorrect. As a general rule, patients who need assistance with positioning will need position changes at least every 2 hours when on bedrest. 4 This is correct. When positioning patients, it is very important that limbs and areas of the body that are not in contact with the bed be supported. This is accomplished by using pillows and other positioning devices. PTS: 1 CON: Clinical Judgment | Safety 15. ANS: 3 Chapter: Chapter 16, Moving and Positioning Patients Objective: 15. Identify safety information related to moving and positioning patients. | 16. Answer questions about performing the skills in the chapter. Page: 295-296 Heading: Skill 16.5 Transferring a Patient From a Bed to a Stretcher, Chair, or Wheelchair Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Safety Difficulty: Difficult Feedback ______________________________________________________________________________________________ 251 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 1 2 3 4 This is incorrect. A draw sheet is used to move the patient in bed but is not required to transfer a patient from the bed to a wheelchair. This is incorrect. There is no need to place the patient in a hospital gown that has snap closures. This is correct. Providing nonskid socks to the patient helps to promote patient safety. This is incorrect. The wheelchair should be placed on the patient’s strong side rather than the weak side to prevent a possible fall during transfer. PTS: 1 CON: Clinical Judgment | Safety 16. ANS: 1 Chapter: Chapter 16, Moving and Positioning Patients Objective: 15. Identify safety information related to moving and positioning patients. | 16. Answer questions about performing the skills in the chapter. Page: 298 Heading: Skill 16.7 Assisting a Patient to Dangle Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Safety Difficulty: Difficult 1 2 3 4 Feedback This is correct. Because the patient has been admitted for occasional dizziness upon position change, the nurse should prepare to dangle the patient rather than do a straight transfer. The patient’s blood pressure should be assessed while seated, then while standing, and then after ambulation so as to detect any postural hypotension event. This is incorrect. The use of a transfer belt is not indicated at this time but rather to follow the process of dangling and a sequenced ambulation plan. This is incorrect. There is no need to obtain pulse oximetry readings at this time. This is incorrect. There is no need to perform a mini mental status examination at this time. PTS: 1 CON: Clinical Judgment | Safety 17. ANS: 1 Chapter: Chapter 16, Moving and Positioning Patients Objective: 9. Enumerate guidelines for performing a manual patient transfer. Page: 286 Heading: Transferring Patients > Manual Transfers Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Mobility| Safety Difficulty: Difficult 1 2 Feedback This is correct. Proper body mechanics include avoiding twisting the torso. This is incorrect. Proper body mechanics include using a wide base of support. ______________________________________________________________________________________________ 252 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 3 4 This is incorrect. Proper body mechanics include using a wide base of support and standing close to the object being moved, keeping the back straight, and avoiding twisting the torso. This is incorrect. Proper body mechanics include using a wide base of support and keeping the back straight. PTS: 1 CON: Clinical Judgment | Mobility| Safety 18. ANS: 1 Chapter: Chapter 16, Moving and Positioning Patients Objective: 11. Summarize the importance of assisting a patient to dangle prior to transfer or ambulation. | 15. Identify safety information related to moving and positioning patients. Page: 281 Heading: Moving and Lifting Patients Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Mobility| Safety Difficulty: Difficult Feedback 1 This is correct. A transfer belt may be helpful because it provides a place to grasp the patient. If a transfer belt is used, hold the belt tightly near the patient’s body. 2 This is incorrect. Patients who need assistance should move from the supine to standing positions in stages to avoid possible dizziness, orthostatic hypotension, and syncopal episodes. 3 This is incorrect. To safely move a patient from the supine to the standing positions, a nurse will raise the head of the bed, then assist the patient with sitting on the side of the bed to ensure that the patient is able to tolerate the change in position. The patient’s feet should be firmly on the floor or on a footstool. This process is referred to as dangling. 4 This is incorrect. To safely move a patient from the supine to the standing positions, a nurse will raise the head of the bed, then assist the patient with sitting on the side of the bed to ensure that the patient is able to tolerate the change in position. PTS: 1 CON: Clinical Judgment | Mobility| Safety 19. ANS: 3 Chapter: Chapter 16, Moving and Positioning Patients Objective: 9. Enumerate guidelines for performing a manual patient transfer. | 12. Discuss assisting patents with ambulation and potential complications. | 15. Identify safety information related to moving and positioning patients. Page: 286 Heading: Moving and Lifting Patients > Manual Transfers Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Clinical Judgment | Mobility| Safety Difficulty: Moderate Feedback 1 This is incorrect. The patient should not be held upright when losing consciousness or falling. This will only injure the health-care provider and possibly injure the patient. 2 This is incorrect. While lowering the patient to the floor, bend at the knees but keep the back straight. ______________________________________________________________________________________________ 253 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 3 4 This is correct. If a patient begins to fall, pull the patient toward your body and allow the patient to slide down your leg to the floor. This is incorrect. While lowering the patient to the floor, bend at the knees but keep the back straight. PTS: 1 CON: Clinical Judgment | Mobility| Safety 20. ANS: 2 Chapter: Chapter 16, Moving and Positioning Patients Objective: 15. Identify safety information related to moving and positioning patients. Page: 286-287 Heading: Assisting With Ambulation Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Coordinated Care Cognitive Level: Analysis [Analyzing] Concept: Leadership and Management | Safety Difficulty: Difficult Feedback 1 This is incorrect. Maintaining patient and nurse safety, the patient should be lowered to the floor. Then an assessment can be made about whether or not a rapid response is indicated. 2 This is correct. Maintaining patient and nurse safety, the patient should be lowered to the floor. If the patient begins to fall, pull them toward your body and allow the patient to slide down your leg to the floor. As you lower the patient, bend your knees. Keep your back straight as you lower the patient to the floor. Safety: Do not attempt to hold a patient upright if they lose consciousness or are falling. This will only injure you and possibly injure the patient. 3 This is incorrect. Maintaining patient and nurse safety, the patient should be lowered to the floor. Further injury can occur to the nurses and/or patient if additional movement is taken. 4 This is incorrect. Maintaining patient and nurse safety, the patient should be lowered to the floor. Then an assessment can be made about whether or not supplemental oxygen is needed. PTS: 1 CON: Leadership and Management | Safety 21. ANS: 4 Chapter: Chapter 16, Moving and Positioning Patients Objective: 16. Answer questions about performing the skills in the chapter. Page: 289 Heading: Skill 16.1 Performing Passive Range-of-Motion Exercises Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Clinical Judgment | Mobility Difficulty: Difficult Feedback 1 This is incorrect. This finding is not significant although it should be documented as a minor deficit. 2 This is incorrect. Absence of pain in an older patient can be a normal finding. Further assessment may be warranted. ______________________________________________________________________________________________ 254 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 3 4 This is incorrect. Occurrence of morning stiffness can be a finding seen in an older patient due to aging changes of the musculoskeletal system. This is correct. This finding indicates a potential hip fracture, and the health-care provider (HCP) should be notified. PTS: 1 CON: Clinical Judgment |Mobility 22. ANS: 1 Chapter: Chapter 16, Moving and Positioning Patients Objective:13. Identify proper body mechanics for protecting yourself and the patient. | 16. Answer questions about performing the skills in the chapter. Page: 292 Heading: Skill 16.3 Moving a Patient Up in Bed Integrated Processes: Clinical Problem-Solving Process (Nursing Process) Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Clinical Judgment | Mobility | Safety Difficulty: Moderate Feedback 1 This is correct. Use of a draw sheet will help to move the patient up in bed and prevent injury to the nurse. 2 This is incorrect. Logrolling technique is not indicated to move the patient up in bed but is used for moving patients who have neurological deficits to help prevent further injury. 3 This is incorrect. The head of bed (HOB) should be lowered, not raised, to assist with moving a patient up in bed. 4 This is incorrect. Raising one side rail is an example of a restraint. PTS: 1 CON: Clinical Judgment | Mobility | Safety 23. ANS: 4 Chapter: Chapter 16, Moving and Positioning Patients Objective: 10. Contrast types of specialty beds and their purposes. Page: 287 -279 Heading: Table 16.2 Support Surfaces and Specialty Beds Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Basic Care and Comfort Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate Feedback 1 This is incorrect. Mattress overlays are applied to the top of the mattress and may be filled with air or gel or made of foam. 2 This is incorrect. A combination air-fluidized and low-air-loss bed is a combination bed in which the lower part is an air-fluidized type and the upper section is a low-air-loss type. 3 This is incorrect. Specialized mattresses contain special foam, such as memory foam, or chambers that contain air that can be controlled with a dial. 4 This is correct. A continuous lateral-rotation bed is 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. ______________________________________________________________________________________________ 255 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ PTS: 1 CON: Communication MULTIPLE RESPONSE 24. ANS: 1, 2, 5 Chapter: Chapter 16, Moving and Positioning Patients Objective: 4. Describe the psychological effects of immobility and nursing measures to prevent psychological complications. Page: 280 Heading: Nursing Measures to Prevent Psychological Complications Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Caring | Stress and Coping Difficulty: Moderate 1 2 3 4 5 Feedback This is correct. Minimize sensory deprivation by ensuring that the patient has distractions to occupy them. These include television, radio, books, magazines, newspapers, and puzzles. This is correct. Encourage and allow the patient to do as much as possible during patient care, such as helping with their bath, performing active ROM exercises when able, and making decisions about their care. This is incorrect. Help improve the patient’s sleep pattern by encouraging them to remain awake and alert most of the day. Keep window curtains or blinds open in the daytime to allow natural light into the room. This is incorrect. Encourage visits with family and friends. Try to schedule care around visitors if the patient has few guests. Allow visitors to participate in care if they wish to do so and the patient wishes them to be involved. This is correct. Maintain an interactive environment to foster patient engagement. PTS: 1 CON: Caring | Stress and Coping 25. ANS: 2, 3, 4 Chapter: Chapter 16, Moving and Positioning Patients Objective: 4. Describe the psychological effects of immobility and nursing measures to prevent psychological complications. Page: 280 Heading: Nursing Measures to Prevent Psychological Complications Integrated Processes: Caring Client Need: Psychosocial Integrity Cognitive Level: Application [Applying] Concept: Caring | Stress and Coping Difficulty: Moderate Feedback ______________________________________________________________________________________________ 256 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year? Stuvia.com - The Marketplace to Buy and Sell your Study Material Test Bank - Fundamentals of Nursing Care: Concepts, Connections and Skills, 4th Edition (Burton, 2023) ______________________________________________________________________________________________ 1 2 3 4 5 This is incorrect. Nursing measures to prevent psychological complications include encouraging and allowing the patient to do as much as possible for oneself during patient care, such as helping with the bath, performing active range-of-motion exercises when able, and making decisions about care. This is correct. Nursing measures to prevent psychological complications include minimizing sensory deprivation by ensuring that the patient has distractions to keep occupied, including television, radio, books, magazines, newspapers, and puzzles. A nurse should try to involve the patient’s senses with pleasant smells, tastes, sounds, and sights. This is correct. Nursing measures to prevent psychological complications include helping improve the patient’s sleep patterns by encouraging them to remain awake and alert most of the day. This is correct. Nursing measures to prevent psychological complications include involving the patient’s senses with pleasant smells, tastes, sounds, and sights. This is incorrect. Nursing measures to prevent psychological complications include keeping window curtains or blinds open in the daytime to allow natural light into the room. PTS: 1 CON: Caring | Stress and Coping ______________________________________________________________________________________________ 257 | P a g e Downloaded by: allen1330636306 | [email protected] Distribution of this document is illegal Want to earn $1.236 extra per year?