Nokea
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.
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You are caring for a patient on the first day after surgery. You have orders to get her up in the chair for 30 minutes twice a day. Her BP is 110/64 and P 86 while lying down. After you assist her to dangle, her BP is 102/60 and P 102. What will you do?
- A. Return her to lying position and monitor vitals
- B. Proceed to transfer her to the chair
- C. Administer IV fluids immediately
- D. Notify the physician
Correct Answer: A
Rationale: A drop in BP and increased pulse suggest orthostatic hypotension; returning her to bed and monitoring is safest.
Which position will you use for a patient in severe respiratory distress?
- A. Lithotomy
- B. Dorsal recumbent
- C. Orthopneic
- D. Semi-Fowler's
Correct Answer: C
Rationale: The orthopneic position maximizes chest expansion, aiding breathing in severe respiratory distress.
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.
Describe a patient who is most at risk for skin breakdown as a result of immobility and being confined to a wheelchair.
- A. A young patient with no comorbidities
- B. An elderly patient with diabetes and poor nutrition
- C. A patient with frequent repositioning
- D. A patient with good skin integrity
Correct Answer: B
Rationale: Elderly patients with diabetes and poor nutrition are at high risk due to impaired healing and circulation.
How will you be able to tell if this patient has pain or discomfort during range-of-motion exercises?
- A. Verbal complaints of pain
- B. Facial grimacing or wincing
- C. Increased heart rate or blood pressure
- D. Refusal to continue exercises
Correct Answer: B
Rationale: Nonverbal cues like grimacing indicate pain in a patient with impaired speech.