Download Week 3 Pre Class Activity 1. You are to get a patient with right

WEEK 3 PRE CLASS ACTIVITY
1. You are to get a patient with right-sided weakness up in a chair. On what side of the bed will you place
the chair?
a) On the patient’s left side
b) On the patient’s weak side
c) Either side, because you are assisting the patient
d) On whichever side the patient prefers
Correct answer: a
Rationale: To facilitate balance and movement, the chair or wheelchair should be positioned so that the
move will be toward the patient's stronger side.
2. Two nurses are assisting a patient to move up in bed, and the patient is unable to assist. Which of the
following actions is inappropriate?
a) Remove the pillow, lower the head of the bed to the lowest position that the patient can
tolerate, and lower the side rails. Keep the bed at a working height.
b) Place the pillow at the head of the bed. Roll the patient from side to side and place a lift sheet
under the patient that extends from the patient’s waist to the patient’s knees.
c) With one nurse on each side of the patient, grasp the lift sheet firmly with hands near the
patient’s upper arms and hips, and then fanfold the sheet close to the patient. Flex knees with
the patient’s body facing the direction of the move.
d) Instruct the patient to rest the arms on the body and lift the head on the count of three. Lift
the patient toward the head of the bed on the count of three. Repeat the move, if necessary.
Correct answer: b
Rationale: The lift sheet should extend from the patient’s shoulders to the thighs in order to support the
patient’s weight and reduce friction during the move.
3. Which of the following patients would require repositioning?
a) A patient in correct body alignment who was turned 2 hours ago
b) A patient who has been sitting in a chair for 10 minutes watching television
c) A patient with paraplegia who has been sitting in a chair for 30 minutes but states that she is
comfortable
d) A patient who was repositioned for comfort 30 minutes ago after being moved up in bed
Correct answer: a, c
Rationale: In general, patients should be repositioned as needed and at least every 2 hours if they are in
bed and every 20 to 30 minutes if they are sitting in a chair to prevent the development of pressure
ulcers. A patient with paraplegia would not be able to feel discomfort from pressure.
4. Which of the following patients should be allowed to lie back down?
a) A patient who was just transferred to a chair and states that she was more comfortable in
bed. Physician’s orders are to be up in the chair twice daily
b) A patient whose blood pressure was 120/80 prior to transfer, and is now 112/78
c) A patient who complains of feeling dizzy and slightly nauseous when dangling on the bedside
d) A patient whose blood pressure was 110/70 prior to transfer and is now 125/80
Correct answer: c
Rationale: A drop in blood pressure of approximately 20 mm Hg in systolic pressure or 10 mm Hg in
diastolic pressure with symptoms of dizziness, pallor, or fainting indicates orthostatic hypotension. This
patient's blood pressure changed within a normal range.
5. A nursing instructor asks you what may cause orthostatic hypotension. You correctly reply (Select all
that apply):
a) Prolonged bed rest
b) Hypokalemia
c) Low body weight
d) Antihypertensives
e) Room temperature
Correct answer: a, b, d
Rationale: Orthostatic hypotension may be related to bed rest, hypovolemia, hypokalemia, and certain
medications such as sedatives, hypnotics, analgesics, antihypertensives, antiemetics, antihistamines,
diuretics, and antianxiety agents. Body weight and room temperature are unrelated to the occurrence of
orthostatic hypotension.
APPLYING ELASTIC STOCKINGS QUIZ
MULTIPLE CHOICE
1. When initially preparing to apply elastic stockings, the nurse must first:
1. Measure the patient’s legs.
2. Select the appropriate size stockings.
3. Determine the patient’s sensitivity to talcum powder.
4. Place the patient in a comfortable sitting position in the bed.
ANS: 1
1
2
3
4
Feedback
This option is the first action to be performed because it is vital that the stockings fit
properly to ensure the optimum therapy outcome.
Although appropriate, this is not the initial action because the selection of the
appropriate stocking depends on another available option.
Although appropriate, this is not the correct option because other available options
have priority in this situation.
Although appropriate, this is not the correct option because other available options
have priority in this situation.
2. Which of the following statements made by the nurse will be most effective in instructing ancillary staff
in the most effective means of minimizing patient discomfort when applying elastic stockings?
1. “Please be sure that you smooth out any wrinkles in the stockings.”
2. “It’s easier to put them on if you turn them inside out up to the heels.”
3. “She isn’t allergic, so apply a little powder to the legs and feet before you start.”
4. “There is a clean pair of stockings in her bedside stand; her family brought them.”
ANS: 3
1
2
3
4
Feedback
Although appropriate, this option is not as directed at patient comfort as other
available options.
Although appropriate, this option is not as directed at patient comfort as other
available options.
This option is correct because it will minimize the friction on the skin as the stocking
are applied.
Although appropriate, this option is not as directed at patient comfort as other
available options.
3. Which of the following instructions provided by the nurse to ancillary staff assigned the responsibility of
bathing a patient who has been prescribed elastic stockings is most likely to ensure the continued skin
integrity of the patient's legs?
1. “Please let me know when the stockings are off so I can look at her legs.”
2. “Be sure to tell me if you see any redness, dryness, or cracking on her legs.”
3. “Turning the feet of the stockings inside out will make putting them on easier.”
4. “Remember to apply a little powder to her legs before reapplying the stockings.”
ANS: 1
1
2
3
4
Feedback
This option will best ensure continued skin integrity because it facilitates the nurse’s
regular assessment of the patient’s legs.
Although appropriate, this option is not the best because it identifies skin damage
after it occurs.
Although appropriate, this option is more directed at ease of application.
Although appropriate and specific to skin integrity, this is not the most effective of the
available options.
4. Which of the following statements made by ancillary staff assigned to apply the elastic stockings of an
elderly patient shows the best understanding of the importance of communicating the patient's
reactions to the intervention with the nurse?
1. "She doesn’t like the fact that she has to wear the stockings."
2. "She tells me that her legs are itching and there is a slight red rash."
3. "I asked her family to bring in a clean pair of stocking she has at home."
4. "Please explain to the patient why I can’t remove the stockings all the time."
ANS: 2
1
2
3
4
Feedback
Although this statement shows an understanding of the importance of communication,
another option addresses more important patient issues.
This statement shows the best understanding of the importance of communication
because it deals with the patient’s physical reaction to the stockings—possibly a
reaction to the elastic in the stockings.
Although this statement shows an understanding of the importance of communication,
another option addresses more important patient issues.
Although this statement shows an understanding of the importance of communication,
another option addresses more important patient issues.
5. The nurse can best determine the effect of elastic stockings on the patient's peripheral vascular
circulation by assessing:
1. For pain or numbness in the legs when the stockings are on.
2. Pedal pulses before, during, and after application of the stockings.
3. The skin color of the legs immediately after removing the stockings.
4. The skin temperature of the legs frequently while the stockings are on.
ANS: 2
1
2
3
4
Feedback
Although not inappropriate, this option is not the best method of determining the
effect that the elastic stockings have on the patient’s peripheral vascular circulation.
This action is most effective in determining the effect that the elastic stockings have on
the patient’s peripheral vascular circulation because it directly assesses the indicator of
blood flow—the pulse.
Although not inappropriate, this option is not the best method of determining the
effect that the elastic stockings have on the patient’s peripheral vascular circulation.
Although not inappropriate, this option is not the best method of determining the
effect that the elastic stockings have on the patient’s peripheral vascular circulation.
ASSISTING WITH MOVING AND POSITIONING A PATIENT IN BED
MULTIPLE CHOICE
1. When preparing to move or position a patient, the nurse should first:
a. Assemble adequate help to facilitate the change.
b. Assess the patient’s ability to assist with the change.
c. Determine the effect of the patient’s weight on the change.
d. Decide upon the most effective method to facilitate the change.
ANS:
A
B
C
D
B
Feedback
Although this intervention is appropriate and will help ensure patient and staff safety,
the amount of help needed cannot be determined before other assessment data are
collected.
This is the initial intervention because the remaining preparatory interventions all
depend on knowing the patient’s ability to participate in the position change.
Although this intervention is appropriate and will help ensure patient and staff safety,
the effect of the patient’s weight on the transfer will be affected by other assessment
data collected.
Although this intervention is appropriate and will help ensure patient and staff safety,
the selection of the most effective positioning method depends on other assessment
data.
2. It has been determined that a patient is capable of assisting with her own repositioning toward the head
of the bed. Which of the following statements made by the nurse will be most effective in instructing
the patient on how to best facilitate the move?
a. “When I count to 3, please push off with your feet.”
b. “Please help by folding your arms across your chest.”
c. “Please bend your knees so your feet are flat on the bed.”
d. “Please let me know how I can best help you with this move.”
ANS:
A
B
C
D
C
Feedback
Although this is an appropriate instruction, it fails to provide the patient with
instructions regarding how to safely accomplish the action.
This would be appropriate only if the patient were incapable of assisting with the
move.
The move will be most effectively accomplished if the patient is instructed to assume a
supine position with her knees flexed and the soles of her feet on the bed to facilitate
pushing off to help in moving upward toward the head of the bed.
Although the patient’s input regarding the move is important, the nurse should
provide proper instructions to the patient and any staff assisting with the move.
3. A comatose patient who weighs 201 pounds requires repositioning in the bed. Which of the following
actions is most likely to ensure that the patient and staff will be safe during the move?
a. Accomplish the move in two or three small moves instead of one big move.
b. Place a repositioning aid (such as a lift sheet) from his shoulders to his thighs.
c. Enlist the help of two assistants since the patient weighs more than 200 pounds.
d. Assume a wide stance with the foot closest to the head of the bed behind the other.
ANS:
A
B
C
D
B
Feedback
Although this may be appropriate, this option is not the best because it does not
directly affect a safe patient move.
Placing a repositioning aide will provide the most effective means of safely transferring
the patient by reducing friction injuries to the patient and minimizing physical strain on
the staff.
Although this is appropriate, this intervention by itself does not fully protect the
patient and staff.
Although this is appropriate, this intervention by itself does not fully protect the
patient and staff.
4. Which of the following statements made by ancillary staff assigned to position an immobile patient
reflects the best understanding of the importance of appropriately communicating with the nurse
regarding this intervention?
a. “I’ll let you know if I need your help with her positioning.”
b. “Do you think she will be ready to be positioned before lunch?”
c. “I noticed a small reddened area on her left hip when I turned her.”
d. “Do you think I should use the mechanical lift when moving her?”
ANS:
A
B
C
D
C
Feedback
Although this statement does reflect an understanding of the importance of
communication, it does not deal with the most important aspect of this patient’s care
or condition.
Although this statement does reflect an understanding of the importance of
communication, it does not deal with the most important aspect of this patient’s care
or condition.
This statement best reflects an understanding of the importance of communicating
with the nurse because it deals with the patient’s immediate condition regarding
possible skin breakdown.
Although this statement does reflect an understanding of the importance of
communication, it does not deal with the most important aspect of this patient’s care
or condition.
5. Which of the following patients should not be assigned to ancillary staff for repositioning in bed?
a. A 66-year-old patient who is 2 days postcholecystectomy.
b. A 47-year-old patient in the terminal stage of lung cancer.
c. A 16-year-old patient with a concussion resulting from a bicycle accident.
d. A 76-year-old patient who has a Foley catheter and an intravenous fluid line.
ANS:
A
B
C
D
C
Feedback
This patient’s positioning may be delegated to ancillary staff because the patient’s
condition does not involve spinal cord or neurologic trauma.
This patient’s positioning may be delegated to ancillary staff because the patient’s
condition does not involve spinal cord or neurologic trauma.
This patient’s positioning should not be delegated to ancillary staff because the
patient’s condition involves spinal cord or neurologic trauma.
This patient’s positioning may be delegated to ancillary staff because the patient’s
condition does not involve spinal cord or neurologic trauma.
TRANSFERRING FROM A BED TO A STRETCHER QUIZ
MULTIPLE CHOICE
1. The nurse is preparing to transfer a patient from her bed to a stretcher for transport to radiology for
testing. The nurse realizes that a primary concern regarding patient safety is to:
1. Assess the patient’s ability to actively participate in the actual transfer.
2. Minimize the risk of falls or other injury during the transfer procedure.
3. Assure the patient that the transfer will cause her as little pain as possible.
4. Reassure the patient that she will be safely transported to the radiology department.
ANS: 2
1
2
3
4
Feedback
While assessing the patient’s ability to help in the transfer should be considered for
determining the number of staff members required to accomplish the transfer safely, it
is not the primary safety issue.
Patient safety is the primary safety issue regarding this transfer and so has priority
over all other options stated.
While making the transfer with as little discomfort as possible for the patient is
important, it is not a safety-related issue.
While it is appropriate to assure the patient that her safety is being considered while
transferring her, this is not a safety issue but rather a patient education issue.
2. The nurse realizes that precautions should be taken in order to minimize the risk of injury to those
involved in the transfer. Which of the following apply?
1. Medicate the uncooperative patient before attempting the transfer.
2. Encourage the patient to help with the transfer as much as possible.
3. Have enough available staff members to assist with the patient transfer.
4. Transfer the patient when he or she is most willing to cooperate with staff.
ANS: 3
1
2
3
4
Feedback
Although an uncooperative patient’s behavior may contribute to the increased risk of
injury, it is not appropriate to medicate the patient solely for the purpose of facilitating
the transfer.
Although it is appropriate for some patients to assist with the transfer, it is not
appropriate to encourage all patients because this may result in injury to the patient or
personnel.
Using sufficient personnel to safely transfer the patient will minimize the risk of injury
to the patient and, particularly, to the personnel.
Although it is certainly helpful to have the patient's cooperation, it may not always be
practical to wait for that to happen.
3. The assistive personnel may be delegated the task of transferring a patient from bed to a stretcher.
Which of the following patients' transfers should the nurse delegate to assistive personnel?
1. 92-year-old hospice patient who is being transferred to a skilled nursing unit
2. 35-year-old patient who has been on bedrest for 15 days as a result of a neck injury
3. 26-year-old patient who experienced a closed-head injury resulting from a fall 3 days ago
4. 63-year-old patient who will be transferred for the first time since knee replacement
surgery
ANS: 1
1
2
3
4
Feedback
The 92-year-old hospice patient is stable and his transfer may be delegated
The transfer of the patient with a neck injury should not be delegated to assistive
personnel.
The transfer of the patient with a head injury should not be delegated to assistive
personnel.
The transfer of the patient with the knee replacement should not be delegated
because this will be the first time the patient has been transferred since having major
surgery.
4. The nurse is preparing to delegate the transfer of a patient from bed to a stretcher for transport to the
physical therapy (PT) department to assistive personnel. Which of the following statements by the
assistive personnel requires follow-up by the nurse?
1. "I’ll use gloves for the transfer if the bed sheets have been soiled."
2. "She said her daughter was going to PT with her. I’ll see if she’s here."
3. "I noticed some red areas on her back, so I’ll be extra careful to position her on her side."
4. "The PT department is chilly; I’ll be sure to send an extra blanket with the patient."
ANS: 1
1
2
3
4
Feedback
This statement requires follow-up since standard precautions require the use of
treatment gloves whenever there is the risk of contact with body fluids, blood,
secretions, or excretions. Used linens may carry microorganisms not visible to the
naked eye.
This statement requires no follow-up since seeing if the daughter is present is an
appropriate gesture.
This statement requires no follow-up since positioning the patient off of the reddened
areas on her back would be an appropriate action.
This statement requires no follow-up since sending an extra blanket to provide the
patient with comfort during the stay in PT would be an appropriate action.
5. When preparing to delegate the transfer of a patient from bed to stretcher to assistive personnel, the
nurse must first:
1. Observe the assistive personnel while making the transfer.
2. Determine the most appropriate time for the assistive personnel to transfer the patient.
3. Assess the assistive personnel’s understanding of the proper technique for this task.
4. Inform the assistive personnel of any restrictions the patient may have regarding the
transfer.
ANS: 3
1
2
3
4
Feedback
It is not necessary to observe the assistive personnel unless there is reason to believe
there is need for reinforcement of proper technique.
While it is appropriate to determine the patient’s preference, it is not the nurse’s first
concern.
When delegating a task to assistive personnel, it is a primary nursing responsibility to
determine the personnel’s ability to perform the task appropriately.
While it is the nurse’s responsibility to inform the assistive personnel of any situations
that will affect the performance of this intervention, such information can be shared
with the personnel after the decision has been made to delegate the task based on the
personnel’s ability to appropriately transfer the patient.
TRANSFERRING FROM A BED TO A WHEELCHAIR WITH A TRANSFER BELT QUIZ
MULTIPLE CHOICE
1. When preparing to safely transfer a patient from a bed to a wheelchair, the nurse should first:
1. Determine the patient’s arm strength.
2. Assess the patient’s weight-bearing ability.
3. Assess the patient’s willingness to cooperate.
4. Decide upon the most appropriate transfer method.
ANS: 3
1
2
3
4
Feedback
Although this intervention is appropriate and will help ensure patient and staff safety,
this is not the initial action because other options have a more generalized effect on
the intervention.
Although this intervention is appropriate and will help ensure patient and staff safety,
this is not the initial action because other options have a more generalized effect on
the intervention.
This intervention is appropriate and will help ensure patient and staff safety and
should be the initial action because the patient’s willingness to be cooperative has a
direct bearing on the safety of the entire process.
Although this intervention is appropriate and will help ensure patient and staff safety,
this is not the initial action because other options have a more generalized effect on
the intervention.
2. It has been determined that a patient is capable and willing to assist with her own transfer from the bed
to the chair. Which of the following statements made by the nurse will be most effective in instructing
the patient on how to best facilitate the move?
1. “When I count to three, please rock yourself into a standing position.”
2. “Please help me by holding onto my waist while I help you stand.”
3. “Please let me know how I can best help you get up off the bed and stand up.”
4. “Please push down onto the mattress with both hands and stand when I count to three.”
ANS: 4
1
2
3
4
Feedback
Although this is an appropriate instruction, it fails to provide the patient with the
complete instructions regarding how to best accomplish the action.
This is not an appropriate instruction to accomplish the action.
Although this is an appropriate instruction, it fails to provide the patient with the
complete instructions regarding how to best accomplish the action.
The move will be most effectively accomplished if the patient is instructed to perform
the actions described because this will best assist the staff in bringing the patient to a
standing position safely.
3. Which of the following actions should have priority to best ensure that the patient will not fall while
being transferred to the chair using a transfer belt?
1. Place skid-resistant shoes or slippers on the patient’s feet.
2. Have the patient sit on the side of the bed with legs dangling for several minutes.
3. Apply the transfer belt snugly over outer clothing while not impairing breathing.
4. Position the chair so that the move will be toward the patient’s stronger side.
ANS: 2
1
2
3
4
Feedback
Although this may be appropriate, this option is not the best because it does not
address a major fall concern.
The risk of falling will be most greatly affected by having the patient dangle in order to
minimize the risk of dizziness.
Although this may be appropriate, this option is not the best because it does not
address a major fall concern.
Although this may be appropriate, this option is not the best because it does not
address a major fall concern.
4. Which of the following statements made by ancillary staff assigned with the transfer of a mobilityimpaired patient reflects the best understanding of the importance of appropriately communicating
with the nurse regarding this intervention?
1. “I’ll let you know if I need your help with her transfer.”
2. “Do you think she will enjoy eating lunch in her chair?”
3. “Has she been complaining of pain or dizziness today?”
4. “She is less able to help with the transfer than she was yesterday.”
ANS: 4
1
2
3
4
Feedback
Although this statement reflects an understanding of the importance of
communication, it does not deal with the most important aspect of this patient’s care
or condition.
Although this statement reflects an understanding of the importance of
communication, it does not deal with the most important aspect of this patient’s care
or condition.
Although this statement reflects an understanding of the importance of
communication, it does not deal with the exchange of information regarding the
current transfer.
This statement best reflects an understanding of the importance of communicating
with the nurse because it deals with the patient’s immediate condition regarding
alterations in the patient’s ability to help with the transfer.
5. Which of the following patient transfers should not be assigned to ancillary staff without supervision by
a registered nurse?
1. 66-year-old patient receiving cancer radiation treatments
2. 47-year-old patient in the terminal stage of renal failure
3. 26-year-old patient who is 8 hours post–caesarian section
4. 76-year-old patient who has an intravenous fluid line in place
ANS: 3
1
2
3
4
Feedback
This patient’s positioning may be delegated to ancillary staff because the patient’s
condition does not involve any prolonged bed rest, extensive surgery, critical illness, or
spinal cord trauma.
This patient’s positioning may be delegated to ancillary staff because the patient’s
condition does not involve any prolonged bed rest, extensive surgery, critical illness, or
spinal cord trauma.
This patient’s positioning should not be delegated to ancillary staff because the
patient’s condition involves extensive surgery.
This patient’s positioning may be delegated to ancillary staff because the patient’s
condition does not involve any prolonged bed rest, extensive surgery, critical illness, or
spinal cord trauma.
USING A SEQUENTIAL COMPRESSION DEVICE QUIZ
MULTIPLE CHOICE
1. The nurse knows that the primary reason for the application of a sequential compression device (SCD)
on the legs of an immobile patient is to:
1. Stimulate circulation in the deep arterial vascular system.
2. Help prevent the formation of deep vein thrombosis (DVT).
3. Aid in peripheral circulation to minimize the risk of skin breakdown.
4. Assist in passive range of motion exercise of the patient’s lower extremities.
ANS: 2
1
2
3
4
Feedback
Compression devices affect venous, not arterial, blood flow.
The prevention of DVT by venous circulation is a stated SCD application.
SCDs are not directed toward facilitation of peripheral circulation.
SCDs have no role in passive range of motion exercises.
2. The nurse is preparing to apply an SCD to the legs of a postoperative patient. The nurse realizes that
which of the following assessment observations would contraindicate the application of these devices?:
1. Low-grade fever
2. Prescribed anticoagulant
3. Dermatitis on patient’s legs
4. Presence of elastic stockings
ANS: 3
1
2
3
4
Feedback
A low-grade fever is not a contraindication to the use of an SCD. It may be an
indication of a DVT.
Since an anticoagulant is a classification of medications used to control the formation
of DVT, prescription for such a drug would not contraindicate the use of an SCD.
The presence of dermatitis, skin ulcers, or recent skin grafts is a contraindication to the
use of an SCD since its use is likely to result in further altered skin integrity.
Although the removal on any wrinkles on the stockings is required before the
application of the SCD, the presence of the stockings does not contraindicate the use
of this device.
3. The nurse has applied an SCD to a postoperative patient. The most appropriate way for the nurse to
determine proper fit is to:
1.
2.
3.
4.
Ask the patient if the device is causing him any pain.
Be able to slip two fingers between the patient’s leg and the device.
Follow the manufacturer’s instruction for the application of the device.
Ask another nurse to check the patient for proper application of the device.
ANS: 2
1
2
3
4
Feedback
The patient’s complaint of pain may indicate that the device is too tight but does not
indicate whether the device is too loose.
The ability to insert two fingers between the patient’s skin and the device is the
standard method for determining proper fit.
Although the manufacturer’s instructions should be followed to ensure the general
appropriateness of the application, it cannot be the sole indicator of proper fit for a
specific patient.
This is not required unless the nurse is unsure of his or her ability to determine proper
fit.
4. The nurse is preparing to delegate the application of an SCD to assistive personnel. Which of the
following statements by the assistive personnel requires follow-up by the nurse?
1. "I will check the tubing frequently for kinking or bending."
2. "I will remove the SCD before ambulating the patient."
3. "I will tell you if I see any signs of itching, redness, or irritation on the patient’s legs."
4. "I will measure the patient’s legs to determine what size of SCD to apply."
ANS: 4
1
2
3
4
Feedback
Checking the tubing frequently is an appropriate delegated intervention, so this
statement does not require follow-up by the nurse.
Removal of the device before ambulation is an appropriate delegated intervention, so
this statement does not require follow-up by the nurse.
Such observations should be immediately reported, so this statement does not require
follow-up by the nurse.
Measuring the patient’s thighs for the purpose of determining the appropriate size of
device to apply is not a delegated intervention, so this statement does require followup by the nurse.
5. When preparing to delegate the application of an SCD to assistive personnel, the nurse must first:
1. Have the personnel demonstrate the proper application of the SCD.
2. Review the steps for the proper application of the SCD with the personnel.
3. Determine the need for the application of the SCD for this particular patient.
4. Evaluate the personnel’s ability to recognize the early signs of impaired circulation.
ANS: 2
1
2
3
4
Feedback
Demonstration is not required unless there is a question concerning the personnel’s
ability to appropriately apply the device.
Reviewing the steps will give the personnel an opportunity to assure the nurse that he
or she understands and can apply the device appropriately.
Determining the need is a medical responsibility and will be reflected in a physician’s
order to apply the device.
The personnel must be capable of recognizing the early signs of impaired circulation,
but this is not the first concept related to the application of an SCD that the nurse
should evaluate when delegating the task to assistive personnel.