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What implementation might the nurse use to improve safety during a transfer?
- A. Weighing the patient first
- B. Using a transfer belt
- C. Putting shoes on the patient
- D. Supporting a flaccid arm
Correct Answer: B
Rationale: As a general rule, the nurse should use a transfer belt.
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The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient?
- A. The need for additional calcium
- B. The need for additional protein
- C. The need for some type of exercise
- D. The need for a special protective bed
Correct Answer: C
Rationale: The immobilized patient must receive some type of exercise to prevent atrophy and contractures.
The nurse instructs an unlicensed assistive personnel to use large muscle groups when lifting. What is the rationale for this instruction?
- A. Workers' compensation claims will be prevented.
- B. Big muscles work more effectively.
- C. It guarantees no muscle strain.
- D. It distributes workload more evenly.
Correct Answer: D
Rationale: Proper body mechanics provide for even distribution of workload.
What should the nurse do to reduce the effort of moving a heavy object?
- A. Bring the feet close together and flex the knees.
- B. Keep the back straight and bend at the waist.
- C. Widen the base of support in the direction of movement.
- D. Broaden the base of support and twist toward the direction of movement.
Correct Answer: C
Rationale: The base of support should be broadened in the direction of movement.
A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult?
- A. The skin of older adults is more fragile and susceptible to injury.
- B. Always support older adults under the soft tissue when moving them in bed.
- C. Weakness and hypertension are common signs and symptoms noted in an older adult on bed rest.
- D. Aging tends to result in loss of flexibility and joint mobility.
- E. Older adults sometimes become fearful when hydraulic lifts are used for transfers.
Correct Answer: A,D,E
Rationale: The skin of older adults is more fragile and susceptible to injury. Aging tends to result in the loss of flexibility and joint mobility and older adults sometimes do become fearful with use of hydraulic lifts. Older adults should be supported under the joints when moving in bed. Weakness and hypotension are common signs and symptoms noted in an older adult on bed rest.
The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient?
- A. Pupils
- B. Pain
- C. Sensation
- D. Color
- E. Skin temperature
Correct Answer: B,C,D,E
Rationale: One of the responsibilities of the nurse is to frequently monitor the patient's neurovascular function, or circulation, movement, and sensation (CMS) assessment. The LPN/LVN checks for skin color, temperature, movement, sensation, pulses, capillary refill, and pain. Pupil assessment is part of a neurologic assessment.