Nokea
The trochanter roll is used for what purpose?
- A. To support the hips and legs to prevent external rotation
- B. To prevent DVT
- C. To allow for foot rotation
- D. To increase sacral pressure
Correct Answer: A
Rationale: The trochanter roll is used to support the hips and legs to prevent external rotation. SCDs and antiembolism stockings are used to prevent DVT. Fowler's position allows for foot rotation and increases sacral pressure.
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In a nonerect patient, what is a potential consequence of immobility?
- A. Improved blood flow to the kidneys
- B. Urinary stasis favoring bacterial growth
- C. Bone mineralization
- D. Acidic urine
Correct Answer: B
Rationale: In a nonerect patient, the kidneys and ureters are level, limiting or delaying urinary drainage from the kidney pelvis to ureter and bladder. The resulting urinary stasis favors the growth of bacteria that can promote urinary tract infections. Regular exercise, not immobility, improves blood flow to the kidneys. Immobility predisposes the patient to bone demineralization, resulting in increased urinary calcium levels and alkaline urine, contributing to renal calculi and urinary tract infection, respectively.
Which position promotes maximal lung expansion during episodes of dyspnea?
- A. High-Fowler's
- B. Ambulation
- C. Distraction
- D. Holding the breath
Correct Answer: A
Rationale: High-Fowler's position promotes maximal lung expansion and is the position of choice during episodes of dyspnea. Encouraging ambulation during distress will increase dyspnea. Distracting the patient is not addressing the underlying cause of dyspnea, which is activity. Holding the breath increases demands on the heart.
When a patient is being moved or ambulated and starts to fall, the nurse should take which actions in which order?
- A. Place their feet wide apart with one foot in front
- B. Rock their pelvis out toward the side of the patient
- C. Grasp the gait belt
- D. Support the patient by pulling the patient's weight backward against their body
- E. Gently slide the patient down their body toward the floor while protecting the patient's head
- F. Remain with the patient while calling for help
Correct Answer: C,F,A,E,D,B
Rationale: When a patient is being moved or ambulated and starts to fall, the nurse places their feet wide apart with one foot in front, rocks their pelvis out toward the side of the patient, grasps the gait belt, supports the patient by pulling the patient's weight backward against their body, gently slides the patient down their body toward the floor while protecting the patient's head, and remains with the patient while calling for help.
A patient has a fractured left leg, which has been casted. Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient?
- A. Lean on the crutches using the axillae to bear body weight.
- B. Keep elbows close to the sides of the body.
- C. When rising, extend the uninjured leg to prevent weight bearing.
- D. To climb stairs, place weight on affected leg first.
Correct Answer: B
Rationale: The patient should keep the elbows at the sides, prevent pressure on the axillae to avoid damage to nerves and circulation, extend the injured leg when rising to prevent weight bearing, and advance the unaffected leg first when climbing stairs.
Which of the following are appropriate instructions for quadricep-setting exercises?
- A. Breathe in and out smoothly during exercises
- B. Perform exercises two to three times per hour
- C. Perform exercises four to six times a day
- D. Hold breath during exercise drills
- E. Perform pushups three or four times a day
- F. Dangle for 30 to 60 minutes
- G. Use a footstool for dangling
Correct Answer: B,C,F
Rationale: Breathing in and out smoothly during quadricep-setting exercises maximizes lung inflation. The patient should perform quadricep-setting exercises two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for a few minutes is done to adjust to the upright position; dangling for 30 to 60 minutes is impractical for the nurse to supervise and may prove unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling.