Nokea
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.
You may also like to solve these questions
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 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 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.