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A nurse instructs an unlicensed assistive personnel about moving older adult patients in bed. When should the nurse intervene when observing the unlicensed assistive personnel perform a return demonstration?
- A. The unlicensed assistive personnel is using simple language.
- B. The unlicensed assistive personnel is avoiding jerky movements.
- C. The unlicensed assistive personnel is avoiding sudden movements.
- D. The unlicensed assistive personnel is pulling the patient across bed linens.
Correct Answer: D
Rationale: The skin of older adults is more fragile and susceptible to injury. When moving or transferring older adults, it is essential to avoid pulling them across bed linens because this may cause shearing or tearing of the skin. The nurse should explain each step in simple language and avoid jerky, sudden movements.
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To maintain a wide base of support the nurse should stand with the feet separated by the distance of ____ width apart.
Correct Answer: shoulder
Rationale: Actions to promote proper body mechanics include positioning feet shoulder width apart to create a wide base of support.
The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient?
- A. Pupils
- B. Pain
- C. Sensation
- D. Color
- E. Skin temperature
Correct Answer: B,C,D,E
Rationale: One of the responsibilities of the nurse is to frequently monitor the patient's neurovascular function, or circulation, movement, and sensation (CMS) assessment. The LPN/LVN checks for skin color, temperature, movement, sensation, pulses, capillary refill, and pain. Pupil assessment is part of a neurologic assessment.
What should the nurse do to protect his or her back when lifting or moving a patient?
- A. Lowering the height of the bed
- B. Holding the back straight with locked knees
- C. Bending knees and hips
- D. Getting the patient to the side of the bed
Correct Answer: C
Rationale: The nurse's back can be well protected when he or she bends knees and hips.
The nurse is educating a patient on ways to regain the ability to perform ADLs and maintain normal physiologic activities. What will the nurse relay as a requirement?
- A. Strength
- B. Wellness
- C. Alertness
- D. Mobility
Correct Answer: D
Rationale: The purpose of mobility is completing ADLs and maintaining physiologic activities.
Continuous ____ motion machines flex and extend joints to mobilize them passively without the strain of active exercises.
Correct Answer: passive
Rationale: Continuous passive motion (CPM) machines flex and extend joints to mobilize them passively without the strain of active exercises. It is imperative that the CPM machine be set according to the health care provider's orders for the degree and the speed of flexion and extension for each individual patient to prevent damage to the joint or surgical site.