Nokea
Describe the actions you will take after you assist Mr. Weldon back to bed.
- A. Assess the skin tear and clean it with saline.
- B. Apply a sterile dressing to the skin tear.
- C. Notify the physician of the incident.
- D. Document the incident and vital signs.
Correct Answer: A,B,C,D
Rationale: These actions address the injury, prevent infection, ensure communication, and meet documentation requirements.
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Why is it important to explain what you will be doing when you assist a patient with position changes?
- A. The patient may be sedated or have an impaired level of consciousness.
- B. The patient may have a preference about who performs repositioning.
- C. The patient will be more cooperative with the position change.
- D. The patient will be less likely to resist during the position change.
- E. The patient can more easily assist with the position change.
Correct Answer: C,D,E
Rationale: Explaining procedures promotes cooperation, reduces resistance, and enables patient assistance, enhancing safety and comfort.
How will you be able to tell if this patient has pain or discomfort during range-of-motion exercises?
- A. Verbal complaints of pain
- B. Facial grimacing or wincing
- C. Increased heart rate or blood pressure
- D. Refusal to continue exercises
Correct Answer: B
Rationale: Nonverbal cues like grimacing indicate pain in a patient with impaired speech.
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.
Which interventions are appropriate for this patient?
- A. Turn, cough, and deep breathe every 2 hours while in bed.
- B. Perform passive range-of-motion (ROM) exercises to his right side and active ROM exercises to his left side bid.
- C. Avoid positioning him on his right side at any time.
- D. Encourage fluid intake every 1 to 2 hours.
- E. Make decisions for the patient because he is difficult to understand.
- F. Assist him to dangle prior to transferring him to the chair.
Correct Answer: A,B,D,F
Rationale: These interventions prevent complications like pneumonia, maintain mobility, promote hydration, and assess position tolerance. Avoiding right-side positioning is unnecessary, and making decisions for the patient disregards autonomy.
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.