Nokea
You and an unlicensed assistive personnel (UAP) are preparing to turn an immobile patient from her back to her right side. Which of the following actions will you take first?
- A. Place a pillow between her knees and ankles.
- B. Cross the patient's left leg over her right leg.
- C. Move the patient to the left side of the bed.
- D. Externally rotate the patient's right shoulder.
Correct Answer: C
Rationale: Moving the patient to the left side of the bed first provides space for safe turning to the right side.
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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 is the purpose of assisting a patient to dangle?
- A. To increase blood flow to the feet and lower legs
- B. To determine if the patient can tolerate changing positions
- C. To allow time to assist the patient to put on a robe and slippers
- D. To evaluate circulation to all extremities
Correct Answer: B
Rationale: Dangling assesses tolerance to position changes, preventing orthostatic hypotension or dizziness.
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.
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.