Nokea
How will you provide stability as you assist a patient to stand before you begin ambulation?
- A. Place a gait belt around the patient's shoulders.
- B. Place your feet in front of the patient's feet and your knees against the patient's knees.
- C. Have the patient use a walker to stand but not while he or she ambulates.
- D. Place a rolled blanket in front of the patient's feet to prevent slipping.
Correct Answer: B
Rationale: Positioning feet and knees against the patient's provides stability and prevents falls during standing.
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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.
Which position will you use for a patient in severe respiratory distress?
- A. Lithotomy
- B. Dorsal recumbent
- C. Orthopneic
- D. Semi-Fowler's
Correct Answer: C
Rationale: The orthopneic position maximizes chest expansion, aiding breathing in severe respiratory distress.
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.
You are caring for a patient on the first day after surgery. You have orders to get her up in the chair for 30 minutes twice a day. Her BP is 110/64 and P 86 while lying down. After you assist her to dangle, her BP is 102/60 and P 102. What will you do?
- A. Return her to lying position and monitor vitals
- B. Proceed to transfer her to the chair
- C. Administer IV fluids immediately
- D. Notify the physician
Correct Answer: A
Rationale: A drop in BP and increased pulse suggest orthostatic hypotension; returning her to bed and monitoring is safest.
You and an unlicensed assistive personnel (UAP) are preparing to turn an immobile patient from her back to her right side. Which of the following actions will you take first?
- A. Place a pillow between her knees and ankles.
- B. Cross the patient's left leg over her right leg.
- C. Move the patient to the left side of the bed.
- D. Externally rotate the patient's right shoulder.
Correct Answer: C
Rationale: Moving the patient to the left side of the bed first provides space for safe turning to the right side.