Nokea
When a patient reports fatigue during range-of-motion exercises, the nurse should take which actions?
- A. Stop the activity
- B. Reevaluate the plan of care
- C. Assess the patient for further symptoms indicating the activity is not tolerated
- D. Reschedule exercises for times when the patient is more rested
- E. Space out exercises at different times of the day
- F. Continue the exercises regardless of fatigue
Correct Answer: A,C,F
Rationale: When a patient reports fatigue during range-of-motion exercises, the nurse should stop the activity, reevaluate the plan of care, and assess the patient for further symptoms indicating the activity is not tolerated. The exercises can be rescheduled for times of the day when the patient is feeling more rested, or spaced out at different times of the day. Continuing exercises despite fatigue could exacerbate the patient's condition and is not appropriate.
You may also like to solve these questions
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.
A nurse is using the Katz Index of Independence in Activities of Daily Living (ADLs) to assess the mobility of a hospitalized patient. During the patient interview, the nurse documents the following patient data: 'Patient bathes self completely but needs help with dressing. Patient toilets independently and is continent. Patient needs help moving from bed to chair. Patient follows directions and can feed self.' Based on this data, which score would the patient receive on the Katz index?
- A. 2
- B. 4
- C. 5
- D. 6
Correct Answer: B
Rationale: The total score for this patient is 4. On the Katz Index of Independence in ADLs, one point is awarded for independence in each of the following activities: bathing, dressing, toileting, transferring, continence, and feeding. The patient is independent in bathing (1 point), toileting (1 point), continence (1 point), and feeding (1 point), but requires help with dressing and transferring, so no points are awarded for those activities. Thus, the total score is 4.
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.
Teaching points for exercising for a patient with COPD include which of the following?
- A. Avoiding sudden position changes that may cause dizziness
- B. Avoiding extreme temperatures
- C. Remaining adequately hydrated
- D. Respecting fatigue as a sign of activity intolerance
- E. Not pushing to the point of exhaustion
- F. Consuming a high-protein, high-calcium, and vitamin D-enriched diet
Correct Answer: A,D
Rationale: Teaching points for exercising for a patient with COPD include avoiding sudden position changes that may cause dizziness and avoiding extreme temperatures. The nurse should also instruct the patient to remain adequately hydrated, respect fatigue as a sign of activity intolerance and not push to the point of exhaustion, and avoid exercise if weak or ill. Older adults should consume a high-protein, high-calcium, and vitamin D-enriched diet.
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.