Nokea
What is the purpose of assisting a patient to dangle?
- A. To increase blood flow to the feet and lower legs
- B. To determine if the patient can tolerate changing positions
- C. To allow time to assist the patient to put on a robe and slippers
- D. To evaluate circulation to all extremities
Correct Answer: B
Rationale: Dangling assesses tolerance to position changes, preventing orthostatic hypotension or dizziness.
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How can you be certain that the wheels of a stretcher are locked before transferring a patient?
- A. Press the foot lock and announce loudly that the wheels are locked.
- B. Physically attempt to move the stretcher, even if you have locked the wheels.
- C. Bend down on one knee to ensure that the red lever is up and the green one is down.
- D. Assign one person to hold the stretcher in place while the patient is transferred.
Correct Answer: B
Rationale: Physically attempting to move the stretcher confirms that the wheels are locked, ensuring safety during patient transfer.
When you care for your assigned patient with paralysis of both legs, you are concerned about skin breakdown. Which nursing interventions would you use?
- A. Reposition him every 4 hours while he is in bed.
- B. Inspect bony prominences for redness every 2 hours. If found, massage around the area but not on it.
- C. Dry skin thoroughly but gently after cleansing it with mild soap.
- D. Pat bony prominences with fluffy towels to relieve pressure points.
- E. Provide adequate nutrition so that the tissue can repair itself.
Correct Answer: B,C,E
Rationale: Repositioning every 2 hours (not 4) prevents pressure ulcers; inspecting bony prominences and providing nutrition support skin integrity. Massaging red areas can worsen damage, and patting with towels doesn't relieve pressure effectively.
A newly admitted patient with a diagnosis of right-sided weakness resulting from cerebrovascular attack puts on her light and asks for assistance to the bathroom. You have not yet assessed this patient's transfer abilities. What will you do?
- A. Ask the certified nursing assistant (CNA) assigned to the patient to carefully assist her to the bedside commode.
- B. Tell the CNA that the patient has right-sided weakness but can transfer with minimal assistance.
- C. Ask the CNA to accompany you and together transfer the patient to the bedside commode.
- D. Ask the CNA to assist the patient with a bed pan until you have time to get an order for a lift for her.
Correct Answer: C
Rationale: Assessing transfer abilities with assistance ensures safety, as the patient's capabilities are unknown.
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.
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.