Nokea
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.
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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.
A nurse is instructing a patient recovering from a stroke on proper use of a cane. What information will the nurse include in the teaching plan?
- A. Support weight on the stronger leg and cane and advance weaker foot forward.
- B. Hold the cane in the same hand of the leg with the most severe deficit.
- C. Stand with as much weight distributed on the cane as possible.
- D. Avoid using the cane to rise from a sitting position, as this is unsafe.
Correct Answer: A
Rationale: The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.
A nurse working in a long-term care facility uses proper principles of ergonomics when moving and transferring patients to avoid back injury. Which action should be the focus of these preventive measures?
- A. Carefully assessing the patient care environment
- B. Using two nurses to lift a patient who cannot assist
- C. Wearing a back belt to perform routine duties
- D. Properly documenting the patient lift
Correct Answer: A
Rationale: Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and mobility should be documented but are not the primary focus of interventions related to injury prevention.
Which of the following are appropriate instructions for quadricep-setting exercises?
- A. Breathe in and out smoothly during exercises
- B. Perform exercises two to three times per hour
- C. Perform exercises four to six times a day
- D. Hold breath during exercise drills
- E. Perform pushups three or four times a day
- F. Dangle for 30 to 60 minutes
- G. Use a footstool for dangling
Correct Answer: B,C,F
Rationale: Breathing in and out smoothly during quadricep-setting exercises maximizes lung inflation. The patient should perform quadricep-setting exercises two to three times per hour, four to six times a day, or as ordered. The patient should never hold their breath during exercise drills because this places a strain on the heart. Pushups are usually done three or four times a day and involve only the upper body. Dangling for a few minutes is done to adjust to the upright position; dangling for 30 to 60 minutes is impractical for the nurse to supervise and may prove unsafe. The nurse should place the bed in the lowest position or use a footstool for dangling.
By what age is head control usually achieved in infants?
- A. 5 months
- B. 6 to 9 months
- C. 15 months
- D. 2 years
Correct Answer: A
Rationale: By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.