SOLUTIONS SCORED A+
✔✔Preform the timed get up and go test. - ✔✔This determines wether the pt needs
assistance ambulating
✔✔You note that the patient takes an antihypertensive. - ✔✔specific classes of
medications may cause hypotension.
✔✔What is the purpose of a wedge cushion? - ✔✔protects patient from sliding out of
chair
✔✔You are evaluating the outcome of your care plan. The nursing diagnosis was "risk
for falls related to weakness and confusion." One of the expected outcomes was
"patient will not have a fall or an injury throughout hospital stay." Which of the evaluation
measures determines whether this expected outcome was met? - ✔✔Communicate
with nurse/charge nurse from previous shift to learn if patient experienced any falls
while on the unit.
✔✔Which of the following patients should the nurse assist and/or supervise when
transferring? (Select all that apply.)
1. A newly admitted patient with a spinal cord injury.
2. A patient who is weak from pneumonia and wants to get up to the bedside commode.
3. A patient who had a motor vehicle accident and is being transferred for the first time
after prolonged bed rest.
4. A patient who is 3 days postoperative and progressing well after having a repair of his
hip fracture. - ✔✔A patient who had a motor vehicle accident and is being transferred
for the first time after prolonged bed rest.
A newly admitted patient with a spinal cord injury.
✔✔You need to move a patient up in bed. What assessment measures should you
make before performing this procedure? - ✔✔The patient's ability to help with the
procedure (i.e., physical condition and cognition)
The patient's weight,
The patient's muscle strength, The presence of tubes, incisions, and equipment
✔✔the nurse is caring for a patient with a nursing diagnosis of "Activity intolerance
related to prolonged bed rest." What should the nurse assess prior to getting the patient
out of bed? - ✔✔Blood pressure
Pulse and respiratory rate
Patient's ability to follow instructions
,✔✔T/F When preparing equipment for a patient transfer from bed to chair, position a
wheelchair or supportive chair at a 45-degree angle close to bed. - ✔✔True
✔✔You are caring for a patient with a nursing diagnosis of "Activity intolerance related
to orthostatic hypotension." You raise the head of the patient's bed to a high-Fowler's
position and reassess the patient's blood pressure, which remains within acceptable
limits. You then have the patient sit on the side of the bed, and upon doing so, the
patient complains of feeling nauseous and dizzy. What action should you take at this
time? - ✔✔Help the patient back into bed and lower the head of the bed. Allow the
patient to rest and try again more gradually later.
✔✔The nursing students have started their clinical day. According to the patient's
record, the patient weighs 260 pounds and is weak. The staff nurse tells the student
nurse that the patient needs to be moved up in bed so he can eat breakfast. What
should the student nurse do at this time? - ✔✔Get additional assistance to move the
patient up in bed.
✔✔The nurse is delegating the feeding of dependent patients. Under which
circumstance should the nurse attend to the patient, rather than the NAP? - ✔✔A 76-
year-old who was just admitted to the unit after having a CVA (stroke).
✔✔The nurse is getting a pt with right-sided weakness up in a chair. On what side of the
bed should the nurse place the chair? - ✔✔On the pts left sideap
✔✔Assessment used to test muscle strength? - ✔✔applying an opposing force or
resistance
✔✔What is an increased thoracic curvature, common in older adults? - ✔✔Kyphosis
✔✔Neck flexion and extension should be? - ✔✔45 degrees
✔✔What does a goniometer measure? - ✔✔Angles of extension and flexion
✔✔A nurse is helping a pt with hemiparesis take a few steps. A gait belt has been
applied. Where should the nurse stand? - ✔✔on the pts weak side
✔✔The nurse is preparing to initiate ambulation with a pt who is recovering from a
stroke. what information will help the nurse determine how far to walk? - ✔✔ask the pt
how far they would like to go.
✔✔While walking, a pt begins to complain of dizziness and leans heavily on the nurse.
What would be the nurse's initial response? - ✔✔slowly lower the pt to the floor.
, ✔✔When preparing to move a pt in bed, what will the nurse do first? - ✔✔Assess the
pts ability to help with movin
✔✔when preparing to move a pt in bed with the help of an assistant, which posture will
both caregivers use to ensure safety? - ✔✔flex the hips and knees
✔✔A pt weighs 200 lbs and needs to be moved in bed with a friction-reducing device.
How many individuals will the nurse need to move this pt? - ✔✔at least three
✔✔In which position will the nurse place the pt to move him or her up in bed? -
✔✔supine with the head of the bed flat
✔✔A pt will be moved up in bed with the use of a friction-reducing device. how will the
nurse place this device under the pt? - ✔✔roll the pt from side to side, and place the
device under the draw sheet
✔✔The nurse notes that a pt left elbow is resistant to extension and flexion while
performing ROM exercises. what is the appropriate nursing action? - ✔✔perform ROM
to the left elbow until resistance is met
✔✔after determining the proper size stocking and assessing the patients circulatory
status a nurse delegates the application of elastic stockings to a nursing assistive
personnel. The nurse discovers that the nap has been using moisturizer on the patient's
legs before applying the stockings. What is the best action by the nurse? - ✔✔Instruct
the NAP to use a small amount of cornstarch or powder
✔✔The nurse is performing passive shoulder and elbow exercises for a patient who is
recovering from surgery to remove soft tissue tumor in her upper arm why does the
nurse cup one hand around the patient's elbow and support the forearm and wrist
during the range of motion exercises? - ✔✔To ensure stability while exercising the joints
✔✔Why would the nurse ask a physical therapist to perform passive range of motion
exercises for a patient with lower extremity injuries sustained in a motor vehicle crash? -
✔✔The patient has orthopedic trauma
✔✔When preparing to safely transfer a patient from a bed to a wheelchair using a
transfer belt the nurse would do what first? - ✔✔Assess the patient's physiological
capacity to transfer.
✔✔which instruction would the nurse give a patient who is able to assist with transfer
from a bed to a wheelchair using a transfer belt? - ✔✔Please push down onto the
mattress with both hands and stand when I count to 3