Chapter 28 EAQ Flashcards
Following surgery, a pt has become bedridden and has developed a thrombus in the left leg. The nurse instructs the pt, caregiver, and staff members to avoid massaging the affected area. What is the most likely reason for this instruction?/
A. Massaging the area may be painful for the pt
B. Massaging the area may dislodge the thrombus
C. Massaging the area may cause skin breakdown
D. Massaging the area may promote ulcer formation
B. Massaging the area may dislodge the thrombus
The nurse puts elastic stocking on a pt following a major abdominal surgery. Why are elastic stocking used after a surgical procedure?
A. To prevent varicose veins
B. To prevent muscular atrophy
C. To ensure joint mobility and prevent contracture
D. To promote venous return to the heart
D. To promote venous return to the heart
A pt had a left-sided CVA 3 days ago and is receiving 5000 units of heparin SubQ every 12 hrs to prevent thrombophlebitis. The pt is receiving enteral feedings through a small-bore NG tube because of dysphasia. Which symptom requires the nurse to call the healthcare provider immediately?
A. Pale yellow urine
B. Unilateral neglect
C. Slight movement noted on the right side
D. Coffee ground-like aspirate from the feeding tube
D. Coffee ground-like aspirate from the feeding tube
Healthcare professionals have an increased of musculoskeletal injuries, because of their occupation involves lifting and transferring pts. How can the nurse reduce the risk of musculoskeletal injuries when lifting any person or object?
A. Keep the object away from the body
B. Bend at the hips and not at the knees
C. Relax the abdominal muscles
D. Keep trunk erect and bend at the knees
D. Keep the truck erect and bend at the knees
Which indicates that additional assistance is needed to transfer a pt from the bed to the stretcher?
A. The pt is 5’6 and weighs 120 lbs
B. The pt speaks and understands English
C. The pt received an injection of morphine 30 mins ago for pain
D. The nurse feels comfortable handling a pt of the size and with this level of cooperation
C. The pt received an injection of morphine 30 mins ago for pain
An older adult who was in a car accident and fractures the femur has been immobilized for 5 days. Which nursing dx is related to pt safety when the nurse assists this pt put of bed for the first time?
A. Chronic pain
B. Impaired skin condition
C. Risk for ineffective cerebral tissue blood flow
D. Risk for inability to tolerate activity
D. Risk for inability to tolerate activity
The nurse reviews discharge instruction with a pt who has osteoporosis. Which statement by the pt indicates that the pt understands the instructions?
A. I will avoid intake of leafy green vegetables
B. I will avoid exercises, because they may cause bone fracture
C. I will reduce consumption of food contains calcium
D. I will stop smoking as soon as possible
D. I will stop smoking as soon as possible
A pt has her call bell on and looks frightened when the nurse enters the room. The pt has been on bed rest for 33 days following a fractured femur. She says, its hurts when I try to breath. What should the nurse do first?
A. Call the healthcare provider to report this change in condition
B. Give the pt a paper bag to breath in to decrease anxiety
C. Assess vital signs, perform a respiratory assessment, and be prepared to start oxygen
D. Explain that this is normal after such a trauma and administer the ordered pain medication
C. Assess vital signs, perform a respiratory assessment, and be prepared to start oxygen
While assessing a pt for joint mobility, the nurse notices that they pt is unable to dorsiflex the foot. Which condition does the nurse suspect in the pt?
A. Scoliosis
B. Torticolis
C. Joint contracture
D. Disuse osteoporosis
C. Joint contracture
Which assessment finding may indicate orthostatic hypotension associated with prolonged immobility?
A. Pallor
B. Pain upon breathing
C. Decreased heart rate
D. Increased cardiac output
A. Pallor
Which movement is assessed in the frontal plane when the nurse is observing the mobility of the joint?
A. Rotation
B. Extension
C. Abduction
D. Supination
C. Abduction
A pt is being transferred from bed to stretcher. Which precautions should the nurse take to ensure safety during transfer? (Select all that apply)
A. Release the breaks of the bed to allow movement
B. Raise the bed to the level of the stretcher
C. Cross the pts areas on chest while transferring
D. Involve multiple caregivers for safe transfer
E. Unlock the stretchers wheels once it is in place along the bedside
B. Raise the bed to the level of the stretcher
C. Cross the pts areas on chest while transferring
D. Involve multiple caregivers for safe transfer
A pt with left-sided weakness asks the nurse, Why are you walking on my left side? I can hold on to you better with my right hand. What would the best therapeutic response?
A. Walking on your left side lets me use my right hand to hold on to your arm. In case you start to fall, I can still hold you
B. Would you like me to walk on your right side so you fell more secure?
C. Either side is appropriate, but I prefer the left side. If you like, I can have another nurse walk with you who will will hold you on the right side
D. By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint
D. By walking on your left side I can support you and help keep you from injury if you should start to fall. By holding your waist I would protect your shoulder if you should start to fall or faint
While logrolling a pt, the nurse crosses the pts arms on the chest. What is the reason for the nurses action?
A. Prevent injury to arm
B. Maintain alignment of the body
C. Prevent tension on spinal column
D. Prepare for turning onto one side
A. Prevent injury to arm
A pt is being transferred from bed to stretcher. Which precautions should the nurse take to ensure safety during transfer? (Select all that apply)
A. Release the breaks of the bed to allow movement
B. Raise the bed to the level of the stretcher
C. Cross the pts areas on chest while transferring
D. Involve multiple caregivers for safe transfer
E. Unlock the stretchers wheels once it is in place along the bedside
B. Raise the bed to the level of the stretcher
C. Cross the pts areas on chest while transferring
D. Involve multiple caregivers for safe transfer
