Nokea
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.
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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.
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.
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.
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.
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.