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Which factors will the nurse assess when implementing a position change
schedule for an older adult? SATA
A. Ability of the patient to change positions
B. Condition of the patient's skin with each position change
C. Presence of abnormal breath sounds
D. Type of injury the patient sustained
E. Age of the patient
F. Frailty in older adults - ANSWERS-A. Ability of the patient to change positions
B. Condition of the patient's skin with each position change
D. Type of injury the patient sustained
E. Age of the patient
F. Frailty in older adults
The patient is at risk for impaired skin integrity. For which action performed by
the unlicensed assistive personnel (UAP) must the nurse intervene?
A. UAP assists the patient to turn in bed every 2 hours
B. UAP carefully cleans and dries skin after incontinence episode
C. UAP rubs and massages a reddened area on the patient's hip
D. UAP uses pillows to support the patient when turned on his side - ANSWERS-C.
UAP rubs and massages a reddened area on the patient's hip
,Which statement by a nursing student providing care for a patient with impaired
skin integrity on a pressure-relieving mattress requires intervention by the clinical
instructor?
A. "The purpose of this mattress is to reduce pressure on the patient's skin"
B. "Because my patient is on a pressure relieving mattress, I will only turn her
every 6 hours"
C. "I will do a careful skin assessment while giving my patient her morning bath"
D. "With assistance, I will get my patient up in the chair as ordered by the health
care provider" - ANSWERS-B. "Because my patient is on a pressure relieving
mattress, I will only turn her every 6 hours"
For which priority common gastrointestinal problem should the nurse create a
plan to prevent for a rehab patient?
A. Constipation
B. Diarrhea
C. Emaciation
D. Electrolyte imbalance - ANSWERS-A. Constipation
A patient with decreased cardiac output is entering a rehabilitation program.
What will the nurse expect to find during the assessment of this patient?
A. Fatigue and need for rest periods
B. Ability to ambulate without angina
C. Feeling rested upon awakening from sleep
D. Ability to move from sitting to standing position easily - ANSWERS-A. Fatigue
and need for rest periods
, A patient with paraplegia is entering a rehabilitation program. What does the
nurse focus on first in assessing this patient?
A. Family and cultural background
B. Baseline hemoglobin and hematocrit measurements
C. Habits of bowel elimination before illness
D. Manual dexterity, muscle control, and mobility - ANSWERS-D. Manual
dexterity, muscle control, and mobility
A patient with a neurogenic bladder is to be taught how to perform intermittent
self-catheterization. Before beginning the teaching-learning sessions, what will
the nurse assess in this patient first?
A. Motor function of both upper extremities
B. Type of neurogenic bladder the patient has
C. Client's gender
D. Age of the client - ANSWERS-A. Motor function of both upper extremities
To maintain the skin integrity of a patient in a rehabilitation unit, what does the
nurse assess? SATA
A. Sensation of the skin
B. Placement of clear dressings over reddened areas
C. Ability to move extremities
D. Presence or absence of exudate and odor
E. Ability to change position as needed
F. Photographs taken of patient skin on admission - ANSWERS-A. Sensation of the
skin
C. Ability to move extremities