Module 6 Flashcards
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed?
When assisting the client from the bed into a wheelchair, the nurse would take position near the client’s hip, with legs shoulder width apart and one foot near the head of the bed. This ensures that the nurse’s center of gravity is placed near the client’s greatest weight to assist the client to a sitting position safely.
The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response?
“To preserve the client’s functional ability to grasp and pick up objects.”
What do trochanter rolls do?
Trochanter rolls prevent the legs from rotating outward.
What do foot boards do in regard to pt positioning?
Foot boards prevent foot drop
What is the purpose of side rails?
Side rails help a weak client turn independently and protect the client from falling out of bed.
What is a benefit of regular exercise over time?
Regular physical activity over time results in cardiovascular conditioning and therefore decreased heart rate. Regular exercise increases circulating fibrinolysin that serves to break up small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity.
Using proper body mechanics, which motions would the nurse make to move an object?
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
The nurse adjusts a client’s bed to a comfortable working height in order to turn the client. What would be the nurse’s next action?
When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.
A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client?
When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client’s weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.
The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?
When I lift and carry a heavy box of supplies I will keep it at arm’s length from my body.
The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway?
Upright
Fowler
Semi-Fowler
The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?
trapeze bar
The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?
Acts to prevent injury to the client and/or nurse
The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?
transfer belt
A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Which assistive device would the nurse include in the plan of care?
trochanter rolls
A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client?
moving the bedroom to the ground floor
removing clutter from the floor
placing nightlights in the bathroom and hallways
A client asks what trochanter rolls are used for when providing client care. What is the appropriate nursing response?
“To prevent your legs from rotating outward.”
Which type of mobility aid would be most appropriate for a client who has poor balance?
a cane with four prongs on the end (quad cane)
Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client’s weight?
Shift their weight back and forth, from back leg to front leg.
The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure?
When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.
The nurse is caring for a client with hemorrhoids. To facilitate a rectal examination, into which position will the nurse place the client?
Sims’
The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?
the 24-month-old child who is unable to walk unassisted
Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer?
If the client is in pain, administer the prescribed analgesic sufficiently in advance of the transfer to allow the client to participate in the move comfortably. Clients should be encouraged to assist in their own transfers. During any client-transferring task, if any caregiver is required to lift more than 35 lb (16 kg) of a client’s weight, then the client should be considered to be fully dependent and assistive devices should be used for the transfer. Handling aids should be used whenever possible to help reduce the risk of injury to the nurse and client.
The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?
pull the shoulder blade forward and out from under the client
When logrolling a client, the nurse should use supportive devices in turning the client in order to:
maintain the natural alignment of the client’s body.
Explanation:
Logrolling is a technique used for turning clients who have had surgery or an injury involving the back or spine. It maintains spinal alignment, thus preventing injury. It is not performed for the purpose of maximizing the client’s participation or preventing blood stasis.
When moving a client up in bed with the assistance of another caregiver, the nurse should:
have the client fold the arms across the chest.
The nurse is caring for a client with incontinence who has been neglected in supine position at home for more than a week. Which priority nursing diagnosis will the nurse select?
risk for impaired skin integrity
The nurse has been educating the client about how to use a walker safely. The nurse knows that the education has been effective when the client:
steps into the walker when walking.
A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?
The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.
Explanation:
During any client-transferring task, if the lift is more than 35 lb (16 kg) of a client’s weight, consider the client to be fully dependent and use assistive devices for the transfer. The nurse would encourage the client to help with the transfer if the client is able and can safely assist. Pain medication would not be indicated after the transfer unless a pain assessment indicated this action. The nurse would not grab and hold the client by the arms. This action could cause injury to the client.
A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?
Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.
Explanation:
Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. The nurse should avoid twisting the client’s head, spine, shoulders, knees, or hips while logrolling. A chair is not used with logrolling.
