Nokea
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.
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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.
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.
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.
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.
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.