Nokea
A patient you are caring for has been on bedrest for 4 days and is having difficulty with gas and constipation. What nursing interventions will you use to help prevent further gastrointestinal complications?
- A. Encourage fluid intake of 6 ounces every 4 hours to prevent further constipation.
- B. Help the patient choose well-balanced meals, keeping in mind the patient's food preferences.
- C. Assess bowel sounds and the frequency of bowel movements, and document.
- D. Serve preferred liquids with a straw to provide continuous access to fluids.
- E. Encourage fresh fruits and vegetable intake, raw if possible, to add fiber.
Correct Answer: B,C,E
Rationale: Balanced meals, bowel assessments, and high-fiber foods prevent constipation. Fluid intake should be higher than 6 ounces every 4 hours, and a straw doesn't address the core issue.
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A newly admitted patient with a diagnosis of right-sided weakness resulting from cerebrovascular attack puts on her light and asks for assistance to the bathroom. You have not yet assessed this patient's transfer abilities. What will you do?
- A. Ask the certified nursing assistant (CNA) assigned to the patient to carefully assist her to the bedside commode.
- B. Tell the CNA that the patient has right-sided weakness but can transfer with minimal assistance.
- C. Ask the CNA to accompany you and together transfer the patient to the bedside commode.
- D. Ask the CNA to assist the patient with a bed pan until you have time to get an order for a lift for her.
Correct Answer: C
Rationale: Assessing transfer abilities with assistance ensures safety, as the patient's capabilities are unknown.
Slide sheets are different from draw sheets because they are
- A. Placed beneath the patient.
- B. Used to move the patient up in the bed.
- C. Made of thin webbed nylon.
- D. Used to turn the patient from back to side.
Correct Answer: C
Rationale: Slide sheets are made of low-friction nylon, unlike draw sheets, to facilitate patient movement.
What is the purpose of assisting a patient to dangle?
- A. To increase blood flow to the feet and lower legs
- B. To determine if the patient can tolerate changing positions
- C. To allow time to assist the patient to put on a robe and slippers
- D. To evaluate circulation to all extremities
Correct Answer: B
Rationale: Dangling assesses tolerance to position changes, preventing orthostatic hypotension or dizziness.
Which assistive device will you use to assist a patient with mild right-sided weakness as he moves from the bed to the wheelchair?
- A. Transfer belt
- B. Slide sheet
- C. Slide board
- D. Transfer board
Correct Answer: A
Rationale: A transfer belt provides support and safety for a patient with mild weakness during transfers.
Give the rationale for each intervention that you chose.
- A. Turn, cough, and deep breathe every 2 hours prevents respiratory complications like pneumonia.
- B. Passive ROM to the right side and active ROM to the left maintains joint mobility and prevents contractures.
- C. Avoiding right-side positioning is not needed unless specified by the provider.
- D. Encourage fluid intake prevents dehydration and supports overall health.
- E. Making decisions for the patient disregards autonomy and communication efforts.
- F. Assist to dangle assesses tolerance to position changes, preventing falls or hypotension.
Correct Answer: A,B,D,F
Rationale: These rationales explain why the chosen interventions are appropriate for the patient's condition.