Module 3

Question 1

To which other member of a multidisciplinary team would the nurse delegate the task of moving an immobile patient to maintain skin integrity?

Answer 1

unlicensed assistive personnel

Question 2

In which area would the nurse place a pillow for a patient in the supine position?

Answer 2

under the calves

Question 3

Which device would be most appropriate for a patient who has had surgery on a fractured femur and needs help repositioning in bed?

Answer 3

trapeze bar

Question 4

Which ambulation aid would the nurse suggest for a patient who has a history of falls, is displaying generalized weakness, and requires some assistance with ambulation?

Answer 4

walker

Question 5

Which exercise benefit would the nurse likely emphasize to a patient who has limited mobility to help facilitate normal movement?

Answer 5

promotes muscle strength

Question 6

In which position would the nurse place the patient to perform coughing and deep breathing?

Answer 6

fowlers

Question 7

Which action would the nurse take when using a mechanical lift for a patient who is experiencing limited mobility?

Answer 7

obtains two unlicensed assistive personnel to help

Question 8

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills?

Answer 8

notify the health care provider that the patient may have pneumonia

Question 9

Which action would the nurse take for an immobile patient who is coughing up thick secretions and has chills?

Answer 9

increase patients dietary fiber and fluid intake

Question 10

Which interventions would the nurse select for a patient who is on bed rest?

Answer 10

have patient shift weight every 15 minutes while awake
reduce hallway light at night
apply pressure-relief ankle-food orthotic boot

Question 11

Which actions would the nurse take for a patient who is immobile?

Answer 11

suggest drinking at least 200ml during a 24-hour period
encourage passive range of motion exercises
place high-top tennis shoes on feet

Question 12

Which instructions about respiratory and range-of-motion measures would the nurse share with a patient who has limited mobility?

Answer 12

uses incentive spirometer 5 to 12 times every 1 to 2 hours
deep breathe 10 times every hour
cough two to three times every 2
move each joint three to five times during a range of motion exercises

Question 13

Which actions by the nurse caring for patients with mobility problems would require correction by the charge nurse?

Answer 13

places a gait belt on a patient with osteoporosis to assist with ambulation
allows the patients elbows to be bent at a 45 degree angle when using a cane
tell the patient with a four-point crutch gait to move one crutch forward simultaneously with the opposite leg

Question 14

When providing care to patients, which safety and body mechanic aspects would the nurse consider to prevent injury to him- or herself and the patient?

Answer 14

leave top side rails up
bend at the knees
carry weight close to body
use mechanical lift equipment

Question 15

Which safety measures would the nurse implement for a patient who is a fall risk?

Answer 15

use low bed
frequently orient the patient
place floor mats beside bed

Question 16

Which evaluative cues indicate the patient with a Risk for Deep Vein Thrombosis is deteriorating?

Answer 16

experiences a pulmonary embolus
has dusky toes
has coagulation laboratory results that indicate the patient is clotting too fast

Question 17

Which cues alert the nurse that the patient with Paralysis is declining?

Answer 17

develops disuse osteoporosis
does not participate in physical therapy

Question 18

Which cues prompt the nurse to determine the patient with impaired mobility who needs a one-person assist is improving?

Answer 18

needs no assistance to transfer
ambulates unassisted down the corridor and back
ambulates with no slips on the floor

Question 19

Which actions would the nurse take if the patient falls while ambulating in the hall?

Answer 19

call for help
assess the patiens physical and nuerologic status
notify charge nurse and primary health care provider
complete occurence repro

Question 20

he nurse would inform unlicensed assistive personnel to turn the patient how often (in hours) to maintain skin integrity? Record your answer as a whole number. __ hour(s)

Answer 20

2

Question 21

Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity?

Answer 21

bone
tendon
muscle

Question 22

Which hypothesis would the nurse develop for an immobile patient who has intact skin?

Answer 22

risk for impaired skin integrity

Question 23

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity?

Answer 23

low prealbumin levels
immobility
stage 2 pressure injury

Question 24

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound?

Answer 24

repositioning the patient
reporting any changes in patients skin integrity or condition
applying non-sterile dressing for chronic wounds with an established treatment plan

Question 25

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days?

Answer 25

therapies consist with guidelines for treatment of wounds
recommendations from collaborating health professionals, such as a wound, ostomy, and continence nurse (WOCN)
agreement of the patient with the treatment plan
capability of the patient to purchase supplies for home care as required

Question 26

For which patient hypotheses would the nurse select turning and positioning as a solution?

Answer 26

impaired skin integrity
risk for pressure ulcer/injury
impaired tissue integrity
risk for impaired tissue integrity

Question 27

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident?

Answer 27

patients wound would exhibit granulation tissue in the wound by 1 week

Question 28

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound?

Answer 28

patient will eat a high-protien diet every meal
patient will help with transfers within 24 hours

Question 29

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum?

Answer 29

wound, ostomy, and continence nurse
social worker
nutritionist

Question 29

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat?

Answer 29

exhibit signs of healing as evidenced by the presence of granulation tissue in the would within 1 week