Nokea
Describe a patient who is most at risk for skin breakdown as a result of immobility and being confined to a wheelchair.
- A. A young patient with no comorbidities
- B. An elderly patient with diabetes and poor nutrition
- C. A patient with frequent repositioning
- D. A patient with good skin integrity
Correct Answer: B
Rationale: Elderly patients with diabetes and poor nutrition are at high risk due to impaired healing and circulation.
You may also like to solve these questions
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.
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.
When performing range-of-motion exercises, which action will you take first?
- A. Cover the patient with a bath blanket to preserve dignity and keep the patient warm.
- B. Wash your hands to prevent cross-contamination.
- C. Exercise the patient's neck by moving it from side to side.
- D. Check the patient's chart for any contraindications to full range-of-motion exercises.
Correct Answer: B
Rationale: Hand washing prevents infection, a critical first step before any patient contact.
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.
A patient is returning to your unit from surgery. What assistive device would you place in the room prior to the patient's return?
- A. Slide sheet
- B. Transfer board
- C. Mechanical lift
- D. Gait belt
Correct Answer: C
Rationale: A mechanical lift ensures safe transfers for a post-surgical patient with potential weakness.