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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.
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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.
You are concerned about the psychological effects of immobility on the patient you are caring for during your clinical experience. To help prevent psychological complications, you would avoid which of these interventions?
- A. Encourage the patient to stay awake during the day and allow natural light into the room.
- B. Encourage the patient to read, watch TV, solve puzzles, and interact with family and friends.
- C. Encourage the patient to do as much as possible during his personal care.
- D. Encourage the patient to look on the bright side and be glad that he is alive, even though he is paralyzed.
Correct Answer: D
Rationale: Minimizing the patient's condition can dismiss their feelings, potentially worsening psychological health.
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.
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.
How can you be certain that the wheels of a stretcher are locked before transferring a patient?
- A. Press the foot lock and announce loudly that the wheels are locked.
- B. Physically attempt to move the stretcher, even if you have locked the wheels.
- C. Bend down on one knee to ensure that the red lever is up and the green one is down.
- D. Assign one person to hold the stretcher in place while the patient is transferred.
Correct Answer: B
Rationale: Physically attempting to move the stretcher confirms that the wheels are locked, ensuring safety during patient transfer.