Week 7 Flashcards by Amelia Humphrey

When preparing to apply graduated compression stockings, why does the nurse assess for skin discoloration?

To identify the potential risk for deep vein thrombosis (DVT)

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Which condition is not associated with venous stasis, part of Virchow’s triad?

Anxiety

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Why might the nurse choose not to apply a pair of prescribed elastic stockings to a patient’s legs?

The patient’s skin is irritated.

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After determining the proper size stocking and assessing the patient’s circulatory status, a nurse delegates the application of elastic stockings to unregulated care providers (UCP). The nurse discovers that the UCP has been using moisturizer on the patient’s legs before applying the stockings. What is the best action by the nurse?

Instruct UCP to use a small amount of cornstarch or powder.

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Why does the nurse remove the patient’s elastic stockings at least once per shift?

To check the skin for irritation or breakdown

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To which patient might the nurse apply a physical restraint?

A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out their shunt

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Why does the nurse instruct an unregulated care provider (UCP) to remove the wrist restraint of a confused patient every 2 hours?

To check the skin integrity and range of motion of the wrist

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What would the nurse instruct an unregulated care provider (UCP) to report when caring for a patient in a wrist restraint?

“Tell me if the skin under the restraint becomes abraded or raw.”

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The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse’s best response when the patient’s wife says, “I don’t like them being tied down in the bed?”

“We will try all other alternatives before using physical restraints.”

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When an unregulated care provider (UCP) enters the room of a patient in a belt restraint, they find the patient’s gown bunched around the patient’s chest and the patient asking for help. What would the UCP do?

Untie the restraint and smooth the patient’s gown.

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While feeding a patient, the nurse puts the fork down on the tray and turns on the suction machine. Why might the nurse perform this action?

The patient is choking.

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What would the nurse instruct an unregulated care provider (UCP) to do to ensure safety when feeding Salisbury steak to a dependent patient?

Cut the steak into small, bite-size pieces.

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When assisting a patient who has self-feeding difficulties, why would the nurse ask the patient to try to self-feed?

To determine what kind of assistance the patient needs with feeding

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While feeding a patient recovering from a stroke, an unregulated care provider (UCP) becomes distracted and does not watch the patient swallow a bite of food. What would the UCP do to ensure that the patient safely swallowed the food?

Check the patient’s mouth for pocketing.

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Why would the nurse want to determine if the patient is passing flatus before giving a meal?

To determine whether the GI tract is functioning

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When preparing to move a patient in bed, what will the nurse do first?

Assess the patient’s ability to help with moving.

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When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety?

Flex the hips and knees.

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A patient who weighs 95.3 kg (210 lbs) needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers?

At least three

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In which position will the nurse place the patient to move them up in bed?

Supine with the head of the bed flat

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A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient?

Roll the patient from side to side, and place the device under the drawsheet.

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A patient with male genitalia on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure their safety before helping them to a standing position?

Determine the patient’s risk for orthostatic hypotension.

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The nurse is delegating to an unregulated care provider (UCP) the task of assisting with a urinal. The nurse specifies to the UCP that the urinal is to be used in bed, not in a standing position, for which patient?

Patient with complete left-sided paralysis caused by a stroke

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Why would the nurse assess a patient’s abdomen before helping with the use of a urinal?

To assess for bladder distention

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The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response?

“I respect your preference. Please remember to recap the urinal, hang it on your side rail, and use your call light to let me know you’re finished.”

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Which action promotes infection control when assisting a patient with a urinal?

Applying gloves before emptying and cleaning the patient’s urinal

The nurse is helping a patient with hemiparesis take a few steps. A gait belt has been applied. The patient is using a cane. Where should the nurse stand in relation to the patient?

On the patient’s weak side

The nurse is preparing to initiate ambulation with a patient who is recovering from a stroke. What information will help the nurse determine how far to walk?

Ask the patient how far they would like to go.

The nurse has applied a gait belt to a patient who is postoperative in order to facilitate ambulation. Within a few feet of the bed, the patient begins to complain of dizziness and leans heavily on the nurse. What would be the nurse’s initial response?

Slowly lower the patient to the floor.

The nurse is preparing to delegate the ambulation of a patient with the use of a gait belt to an unregulated care providers (UCP). Which statement made by the UCP requires the nurse to follow up?

“I will use the under-axillae technique to help the patient up to a standing position.”

The nurse is ambulating a patient with a gait belt when the patient says they feel sick to their stomach. What would the nurse do?

Return the patient to the bed or chair (whichever is closer).

When preparing to move a patient in bed, what will the nurse do first?

Assess the patient’s ability to help with moving.

When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety?

Flex the hips and knees.

A patient who weighs 95.3 kg (210 lbs) needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers?

At least three

In which position will the nurse place the patient to move them up in bed?

Supine with the head of the bed flat

A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient?

Roll the patient from side to side, and place the device under the drawsheet.

When positioning a hemiplegic patient in the supported Fowler’s position, what is the primary reason a trochanter roll is placed alongside the patient’s legs?

To reduce the risk of contracture

To which position would the nurse assist the patient who is experiencing difficulty with breathing?

Fowler’s position

When repositioning a patient, what can the nurse do to prevent the patient’s hips from rolling outward?

Place sandbags along the legs.

The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto their side?

Place a pillow on the abdomen.

The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned?

To roll the patient as a unit

An otherwise strong, healthy patient with a lower leg cast is learning to ambulate with axillary crutches. Which gait is most appropriate?

Three point gait

Where do the patient’s feet stop when performing the swing-through crutch gait?

Past the crutch tips

The nurse is teaching a patient who has crutches how to sit down in a chair. In which hand should the patient hold both crutches?

The hand on the injured side

In general, forearm crutches are used by patients with which types of conditions?

General weakness or paraplegia

A patient requires only minimal assistance with ambulation. Which assistive device would be most appropriate?

A cane

Before applying a brace to a patient’s back, what will the nurse do first?

Review the patient’s medical record and prescriptions for positioning restrictions.

What will the nurse do first before applying an immobilization device over a dressing?

Change the dressing.

When applying an immobilization device, the nurse will place the bed in which position?

An appropriate height for the patient’s position during immobilization device application

When applying a immobilization device the nurse ensures that wraps are applied

distal to proximal.

What will the nurse do next after applying an immobilization device to a patient?

Provide an opportunity for a return demonstration.

Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?

Use appropriate personal protective equipment.

The wound bed of a patient’s pressure injury is red. What does this finding indicate to the nurse?

Granulation tissue

Which measurements would the nurse use to calculate the surface area of a patient’s pressure injury?

Length and width

How would the nurse safely apply an enzyme debridement ointment?

Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.

Which action can the nurse delegate to an unregulated care provider (UCP) to help prevent the development of pressure injuries in an older adult patient?

Reposition the patient and use specific positions individualized for the patient.

The nurse has one bed alarm available and can use it for any of the following patients, all of whom have dementia. Having an alarm is most important for which patient?

A patient who was returned to the unit last week by staff in an adjacent assisted living facility

When caring for a patient with Alzheimer’s disease, why does the nurse cover the external urinary collection catheter?

To reduce the patient’s access to the device

Which nursing action is most therapeutic in response to a cognitively impaired patient who demands to know when their child is coming to visit?

Marking the date of the visit on the patient’s wall calendar

The nurse wants to offer some diversional activity to a patient with dementia. The patient’s family has told the nurse that they are a bit of a loner who enjoyed a 40-year career as an aircraft mechanic. The patient seems frustrated and bored. What is the best activity for the nurse to offer the patient?

A jigsaw puzzle of an appropriate level of difficulty

Which statement made by an unregulated care provider (UCP) assigned to care for a patient with dementia requires the nurse to follow up?

“They don’t understand much of what anyone says to them today, so I didn’t put in their hearing aids.”

The nurse who is preparing to make an unoccupied bed should do what to ensure their personal safety?

Place the bed at a comfortable working height.

The nurse is preparing to change the soiled linen of a patient’s unoccupied bed. Which precaution minimizes the risk of transmitting microorganisms?

Perform hand hygiene and apply clean gloves.

What would the nurse instruct the unregulated care provider (UCP) to do before making an unoccupied bed if the mattress is soiled?

Wipe off moisture with antiseptic solution, and dry thoroughly.

The nurse is reviewing placement of an unfitted bottom sheet with the unregulated care provider (UCP) assigned to make an unoccupied bed. What should the nurse include in this teaching?

The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress.

When making an unoccupied bed, where would the nurse place a waterproof pad?

Over the bottom sheet

The nurse who is preparing to make an unoccupied bed should do what to ensure their personal safety?

Place the bed at a comfortable working height.

The nurse is preparing to change the soiled linen of a patient’s unoccupied bed. Which precaution minimizes the risk of transmitting microorganisms?

Perform hand hygiene and apply clean gloves.

What would the nurse instruct the unregulated care provider (UCP) to do before making an unoccupied bed if the mattress is soiled?

Wipe off moisture with antiseptic solution, and dry thoroughly.

The nurse is reviewing placement of an unfitted bottom sheet with the unregulated care provider (UCP) assigned to make an unoccupied bed. What should the nurse include in this teaching?

The lower hem of the sheet should lie seam down and even with the bottom edge of the mattress.

When making an unoccupied bed, where would the nurse place a waterproof pad?

Over the bottom sheet

Which instruction would the nurse give when asking an unregulated care provider (UCP) to give a complete bed bath to a patient?

Do not massage any reddened areas on the patient’s skin.

The nurse has washed a patient’s arms. Which area should the nurse wash next?

Hands

A patient is being given a bed bath. The nurse realizes that another washcloth is needed to complete the bath. What is one way in which the nurse can ensure the patient’s safety?

Make sure the call light is within the patient’s reach.

Which patient should not have their fingers soaked during a complete bed bath?

A patient with diabetes mellitus

The nurse is bathing a patient who is unconscious. What should the nurse do to ensure safe care of the patient’s eyes?

Use eye patches or shields taped in place.

The nurse would not offer back massage to which of the following patients?

Patient who has a muscle, bone, or joint injury

A patient with difficulty breathing requests a back massage. In which position would the nurse instruct an unregulated care provider (UCP) to place the patient during the massage?

Side-lying

After performing back massage for a patient experiencing pain, what is the primary reason the nurse asks the patient to rate their current pain level on a scale of 1 to 10?

To evaluate the effectiveness of the massage in relieving pain

The nurse delegates a patient’s back massage to an unregulated care provider (UCP). Which statement by the UCP requires the nurse to follow up?

“The muscles of their lower back twitch when I start to rub it, but they calm down if I keep massaging.”

When preparing to delegate a patient’s back massage to an unregulated care provider (UCP), the nurse would do what first?

Assess the UCP’s understanding of the proper technique for back massage.

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what?

Assessing the patient’s gag reflex

What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided?

To reduce the risk of aspiration

The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient’s mouth?

Upside down, or with the curve facing up

When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line?

To allow the bristles to reach beneath the gum line

What must the nurse avoid when brushing the tongue of an unconscious patient?

Stimulating the gag reflex

Why would the nurse plan to perform foot care for a patient with peripheral vascular disease (PVD), rather than delegate this activity to an unregulated care provider (UCP)?

The patient’s elevated risk of infection makes it unsafe for the UCP to perform the care.

For which patient would the nurse most likely ask for a podiatrist consult for nail care?

A middle-aged patient with type 2 diabetes mellitus who feels tingling in their right foot

Which action would the nurse encourage an older person with foot problems to take at home?

Wear socks made of natural fibers.

In providing foot care, the nurse would soak the feet and hands of which patient?

An 86-year-old patient with generalized weakness

A patient with diabetes remarks during foot care that they have been letting their skin air-dry after bathing at home because the doctor told them to use plenty of moisturizer on their hands and feet. What should the nurse teach the patient?

To towel-dry thoroughly before applying moisturizer

The nurse is delegating to the unregulated care provider (UCP) the perineal care of a patient with female genitalia who is totally dependent and confined to bed. Which statement by the UCP requires the nurse’s follow-up?

“I’ll be sure to use hot, soapy water, since they have been incontinent.”

The nurse is preparing to provide perineal care for a patient with female genitalia who is on bed rest. Which patient position should the nurse use for this care?

Dorsal recumbent

As the nurse is preparing to provide perineal care to a patient with female genitalia with limited mobility, the patient says, “I can do that myself.” Which action would be the priority?

Assess the patient’s ability to perform proper perineal care.

How can the nurse promote infection control while providing perineal care for a patient with female genitalia who has a catheter?

By cleansing the patient’s labia from the pubic area toward the rectum

The nurse is delegating the care of a patient with female genitalia to the unregulated care provider (UCP). Which instruction would the nurse give to ensure the UCP’s safety while performing this care?

Wear clean gloves.

Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an older patient with male genitalia who has a catheter?

Wear clean gloves during care.

The nurse observes the unregulated care provider (UCP) providing perineal care to a patient with male genitalia. Which observation of care requires the nurse’s follow-up?

Reserving the cleansing of the tip of the penis as the final step in perineal care

A patient with male genitalia receiving perineal care tells the nurse “It has started to hurt a little down there.” What is the nurse’s best response?

“When did you start experiencing the pain?”

The nurse has delegated the perineal care of a patient with male genitalia to the unregulated care provider (UCP). Which statement made by the UCP requires the nurse’s follow-up?

“I will be sure to use hot, soapy water to be sure they are clean.”

What is the primary reason for performing perineal care on a patient with male genitalia with incontinence?

To reduce the risk of skin breakdown in the patient’s genital and perineal area

The nurse has delegated to unregulated care provider (UCP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the UCP requires the nurse’s follow-up?

“If I can get someone to help, I’ll walk them to the bathroom.”

A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient’s safety?

Obtain help to place the patient on the bedpan.

A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient’s safety?

Raise the side rails on the bed before leaving the room.

The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan?

Elevate the head of the bed to between 30 and 60 degrees.

After assisting with a bedpan, the nurse notes that the patient’s stool is streaked with bright-red blood. What should the nurse do first?

Ask if the patient has a history of hemorrhoids.

Which patient is at least risk for dysphagia? A 22-year-old patient with a traumatic brain injury (TBI) sustained during combat Incorrect A 40-year-old patient undergoing stroke rehabilitation who had been smoking and taking oral contraceptives A 76-year-old patient with dementia A 55-year-old patient with pancreatic cancer who is receiving palliative care

A 55-year-old patient with pancreatic cancer who is receiving palliative care

What would the nurse instruct the unregulated care provider (UCP) to report while feeding any patient on aspiration precautions?

Coughing

What is the most effective way of preventing aspiration?

Put any at-risk patient on NPO status until a dysphagia evaluation can be conducted by a speech and language pathologist (SLP).

Which food item would not be given to a patient on a dysphagia diet?

Chicken noodle soup

Why would the nurse provide special instructions to the unregulated care provider (UCP) before feeding a patient with dysphagia?

To reduce the risk of aspirating food or fluids

The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer? Four

One

The nurse is preparing to move a patient from the bed to a stretcher. Which of the following will the nurse do first?

Make sure the bed brakes are locked.

In turning a patient to place a slide board, where do the assistants stand?

At the side of the bed to which the patient will be turned

The nurse and assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move?

Hold the slide board.

After moving a patient from the bed to a stretcher, the nurse raises the head of the stretcher. What will the nurse do next?

Raise the head of the stretcher if doing so is not contraindicated.

When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first?

Assess the patient’s physiological capacity to transfer.

Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt?

“When I count to three, please rock yourself into a standing position.

A patient lying supine in bed is being transferred to a chair using a transfer belt. Which action would the nurse perform just before moving the patient to the side of the bed?

Explain the procedure to the patient.

The nurse is preparing to transfer a patient from the bed to a wheelchair using a transfer belt. Which of the following statements pertaining to transfer belt application is correct?

The transfer belt has not been placed over an incision.

A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair?

Make sure their head is erect and vertebrae are in straight alignment.