Nokea
If a patient is able to bear partial weight but not full weight, which type of assistive device would you select to transfer him from the bed to the wheelchair?
- A. Slide board
- B. Transfer belt
- C. Mechanical lift
- D. Cane
Correct Answer: B
Rationale: A transfer belt supports partial weight-bearing patients during safe transfers.
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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.
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.
To perform perineal care, you will place the patient in which position?
- A. Dorsal recumbent
- B. Trendelenburg
- C. Reverse Trendelenburg
- D. Sims'
Correct Answer: A
Rationale: The dorsal recumbent position provides optimal access for perineal care while maintaining patient comfort.
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.
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.