Nokea
When performing range-of-motion exercises, which action will you take first?
- A. Cover the patient with a bath blanket to preserve dignity and keep the patient warm.
- B. Wash your hands to prevent cross-contamination.
- C. Exercise the patient's neck by moving it from side to side.
- D. Check the patient's chart for any contraindications to full range-of-motion exercises.
Correct Answer: B
Rationale: Hand washing prevents infection, a critical first step before any patient contact.
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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.
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.
Give the rationale for each intervention that you chose.
- A. Turn, cough, and deep breathe every 2 hours prevents respiratory complications like pneumonia.
- B. Passive ROM to the right side and active ROM to the left maintains joint mobility and prevents contractures.
- C. Avoiding right-side positioning is not needed unless specified by the provider.
- D. Encourage fluid intake prevents dehydration and supports overall health.
- E. Making decisions for the patient disregards autonomy and communication efforts.
- F. Assist to dangle assesses tolerance to position changes, preventing falls or hypotension.
Correct Answer: A,B,D,F
Rationale: These rationales explain why the chosen interventions are appropriate for the patient's condition.
You are concerned about the psychological effects of immobility on the patient you are caring for during your clinical experience. To help prevent psychological complications, you would avoid which of these interventions?
- A. Encourage the patient to stay awake during the day and allow natural light into the room.
- B. Encourage the patient to read, watch TV, solve puzzles, and interact with family and friends.
- C. Encourage the patient to do as much as possible during his personal care.
- D. Encourage the patient to look on the bright side and be glad that he is alive, even though he is paralyzed.
Correct Answer: D
Rationale: Minimizing the patient's condition can dismiss their feelings, potentially worsening psychological health.
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.