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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.
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A newly admitted patient with a diagnosis of right-sided weakness resulting from cerebrovascular attack puts on her light and asks for assistance to the bathroom. You have not yet assessed this patient's transfer abilities. What will you do?
- A. Ask the certified nursing assistant (CNA) assigned to the patient to carefully assist her to the bedside commode.
- B. Tell the CNA that the patient has right-sided weakness but can transfer with minimal assistance.
- C. Ask the CNA to accompany you and together transfer the patient to the bedside commode.
- D. Ask the CNA to assist the patient with a bed pan until you have time to get an order for a lift for her.
Correct Answer: C
Rationale: Assessing transfer abilities with assistance ensures safety, as the patient's capabilities are unknown.
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.
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.
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.
Slide sheets are different from draw sheets because they are
- A. Placed beneath the patient.
- B. Used to move the patient up in the bed.
- C. Made of thin webbed nylon.
- D. Used to turn the patient from back to side.
Correct Answer: C
Rationale: Slide sheets are made of low-friction nylon, unlike draw sheets, to facilitate patient movement.