Nokea
A nurse is teaching a patient with weak dorsiflexion how to prevent foot drop. Which instruction should the nurse include?
- A. Maintain the supine position with supination on the feet.
- B. Ask the family to bring in high-top sneakers to maintain foot dorsiflexion.
- C. Encourage hyperextension of the feet with adapdive devices or splints.
- D. Use pillows to keep the feet in the abducted position.
Correct Answer: B
Rationale: To prevent foot drop, the nurse should support the feet in dorsiflexion using a footboard and/or high-top sneakers for further support. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions do not prevent foot drop.
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The trochanter roll is used for what purpose?
- A. To support the hips and legs to prevent external rotation
- B. To prevent DVT
- C. To allow for foot rotation
- D. To increase sacral pressure
Correct Answer: A
Rationale: The trochanter roll is used to support the hips and legs to prevent external rotation. SCDs and antiembolism stockings are used to prevent DVT. Fowler's position allows for foot rotation and increases sacral pressure.
A nurse working in a long-term care facility uses proper principles of ergonomics when moving and transferring patients to avoid back injury. Which action should be the focus of these preventive measures?
- A. Carefully assessing the patient care environment
- B. Using two nurses to lift a patient who cannot assist
- C. Wearing a back belt to perform routine duties
- D. Properly documenting the patient lift
Correct Answer: A
Rationale: Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and mobility should be documented but are not the primary focus of interventions related to injury prevention.
Which position promotes maximal lung expansion during episodes of dyspnea?
- A. High-Fowler's
- B. Ambulation
- C. Distraction
- D. Holding the breath
Correct Answer: A
Rationale: High-Fowler's position promotes maximal lung expansion and is the position of choice during episodes of dyspnea. Encouraging ambulation during distress will increase dyspnea. Distracting the patient is not addressing the underlying cause of dyspnea, which is activity. Holding the breath increases demands on the heart.
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.
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.