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A nurse is getting a patient with right hemiparesis out of bed to the chair. What will the nurse say to the patient?
- A. Stand on the weaker leg and pivot toward the chair.
- B. I will call the lift team to carry you to the chair.
- C. The chair is by your non-affected leg for smoother movement.
- D. Avoid putting your hospital socks on, as that will restrict your feet moving.
Correct Answer: C
Rationale: When transferring a patient, the chair is placed on the unaffected or stronger side, rather than the weaker or affected side. Lifting and carrying a patient unless absolutely necessary poses an unnecessary risk for injury to patient and staff. Patients should wear proper shoes, sturdy slippers, or hospital-issued socks with grips to prevent sliding and/or falling.
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A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient?
- A. Lean on the crutches using the axillae to bear body weight.
- B. Keep elbows close to the sides of the body.
- C. When rising, extend the uninjured leg to prevent weight bearing.
- D. To climb stairs, place weight on affected leg first.
Correct Answer: B
Rationale: The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg when rising to prevent weight bearing, and advance the unaffected leg first when climbing stairs.
In a nonerect patient, what is a potential consequence of immobility?
- A. Improved blood flow to the kidneys
- B. Urinary stasis favoring bacterial growth
- C. Bone mineralization
- D. Acidic urine
Correct Answer: B
Rationale: In a nonerect patient, the kidneys and ureters are level, limiting or delaying urinary drainage from the kidney pelvis to ureter and bladder. The resulting urinary stasis favors the growth of bacteria that can promote urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to bone demineralization, resulting in increased urinary calcium levels and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.
Two nurses are repositioning a patient and pulling the patient up in bed. Which of these steps is most appropriate to prevent injury to the nurses?
- A. Telling the patient to cross their arms and legs
- B. Pulling the patient from underneath the axilla toward the top of the bed
- C. Avoiding using a draw sheet to lift or reposition the patient
- D. Ensuring the bed is at the level of the nurses' hips
- E. Facing the head of the bed and rocking in synchrony
Correct Answer: D
Rationale: The nurses should face the direction the patient will move and rock in synchrony prior to moving the patient in that direction. A lifting or repositioning sheet or device is used to decrease friction and facilitate movement. While the patient can cross their arms, they can also be instructed to press their feet into the mattress to assist movement. The bed should be at the level of the nurses' elbows, not hips, to maintain proper ergonomics and prevent injury.
Which of the following are appropriate instructions for quadricep-setting exercises?
- A. Breathe in and out smoothly during exercises
- B. Perform exercises two to three times per hour
- C. Perform exercises four to six times a day
- D. Hold breath during exercise drills
- E. Perform pushups three or four times a day
- F. Dangle for 30 to 60 minutes
- G. Use a footstool for dangling
Correct Answer: B,C,F
Rationale: Breathing in and out smoothly during quadricep-setting exercises maximizes lung inflation. The patient should perform quadricep-setting exercises two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for a few minutes is done to adjust to the upright position; dangling for 30 to 60 minutes is impractical for the nurse to supervise and may prove unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling.
A nurse is assisting a patient who is 2 days postoperative from a cesarean section dangle in preparation for sitting in a chair. After assisting the patient to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action?
- A. Supporting the patient as she stands, waiting a few moments, then continuing the move to the chair
- B. Calling for assistance and continuing the move with the assistance of another nurse
- C. Lowering the patient back to the side of the bed and pivoting her back into bed
- D. Having the patient sit down on the bed and dangle her feet before moving
Correct Answer: C
Rationale: If a patient becomes faint and their knees buckle when moving from bed to a chair or ambulating, the nurse should stop the activity, as the patient has demonstrated a clear risk for falling. The nurse should lower the patient back to the side of the bed, pivot her back into bed, cover her, and raise the side rails. Assess the patient's vital signs and for the presence of other symptoms. When vital signs are stable, another attempt can be made with the assistance of another staff. Instruct the patient to remain in the sitting position on the side of the bed for several minutes to allow the circulatory system to adjust to a change in position and prevent hypotension related to a sudden change from the supine position.