Nokea
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.
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By what age is head control usually achieved in infants?
- A. 5 months
- B. 6 to 9 months
- C. 15 months
- D. 2 years
Correct Answer: A
Rationale: By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.
When a patient is being moved or ambulated and starts to fall, the nurse should take which actions in which order?
- A. Place their feet wide apart with one foot in front
- B. Rock their pelvis out toward the side of the patient
- C. Grasp the gait belt
- D. Support the patient by pulling the patient's weight backward against their body
- E. Gently slide the patient down their body toward the floor while protecting the patient's head
- F. Remain with the patient while calling for help
Correct Answer: C,F,A,E,D,B
Rationale: When a patient is being moved or ambulated and starts to fall, the nurse places their feet wide apart with one foot in front, rocks their pelvis out toward the side of the patient, grasps the gait belt, supports the patient by pulling the patient's weight backward against their body, gently slides the patient down their body toward the floor while protecting the patient's head, and remains with the patient while calling for help.
A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient tells the AP not to place the patient in which position?
- A. Side-lying
- B. Fowler's
- C. Sims'
- D. Prone
Correct Answer: D
Rationale: While placing the patient in the prone position for 30 minutes two or three times daily helps prevent knee and hip flexion contractures, it is contraindicated in patients who have spinal problems. The pull of gravity on the trunk when the patient lies prone produces a marked lordosis or forward curvature of the lumbar spine.
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.
When a patient reports fatigue during range-of-motion exercises, the nurse should take which actions?
- A. Stop the activity
- B. Reevaluate the plan of care
- C. Assess the patient for further symptoms indicating the activity is not tolerated
- D. Reschedule exercises for times when the patient is more rested
- E. Space out exercises at different times of the day
- F. Continue the exercises regardless of fatigue
Correct Answer: A,C,F
Rationale: When a patient reports fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the plan of care, and assess the patient for further symptoms indicating the activity is not tolerated. The exercises can be rescheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day. Continuing exercises despite fatigue could exacerbate the patient's condition and is not appropriate.