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When you assist a patient to a left lateral position, where will you place the additional pillows?
- A. Under the knees
- B. Between the knees and ankles and at the back
- C. At the right lateral thigh
- D. At the soles of the feet and at the back
Correct Answer: B
Rationale: Pillows between knees and ankles and at the back maintain alignment and comfort in the left lateral position.
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A patient you are caring for has been on bedrest for 4 days and is having difficulty with gas and constipation. What nursing interventions will you use to help prevent further gastrointestinal complications?
- A. Encourage fluid intake of 6 ounces every 4 hours to prevent further constipation.
- B. Help the patient choose well-balanced meals, keeping in mind the patient's food preferences.
- C. Assess bowel sounds and the frequency of bowel movements, and document.
- D. Serve preferred liquids with a straw to provide continuous access to fluids.
- E. Encourage fresh fruits and vegetable intake, raw if possible, to add fiber.
Correct Answer: B,C,E
Rationale: Balanced meals, bowel assessments, and high-fiber foods prevent constipation. Fluid intake should be higher than 6 ounces every 4 hours, and a straw doesn't address the core issue.
A patient is returning to your unit from surgery. What assistive device would you place in the room prior to the patient's return?
- A. Slide sheet
- B. Transfer board
- C. Mechanical lift
- D. Gait belt
Correct Answer: C
Rationale: A mechanical lift ensures safe transfers for a post-surgical patient with potential weakness.
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.
What common linen item might you use to manually transfer a weak patient who is unable to help move herself from a bed to a stretcher if no assistive devices are available?
- A. Pillowcase
- B. Draw sheet
- C. Blanket
- D. Towel
Correct Answer: B
Rationale: A draw sheet, placed under the patient, facilitates manual transfers by reducing friction.
When you prepare to turn a patient who has had spinal surgery, you will plan to
- A. Have a total of three health-care staff assist with the turn.
- B. Have the patient assist by using a trapeze bar.
- C. Have each person turn a section of the patient's body at a separate time.
- D. Logroll the patient.
- E. Have one person at the patient's head to direct the turn.
Correct Answer: A,D,E
Rationale: Logrolling with three staff, one directing at the head, ensures spinal alignment and safety post-surgery.