A nurse is assisting a postoperative patient with conditioning exercises to prepare for
ambulation. Which instructions from the nurse are appropriate for this patient? Select
all that apply.
A. Do full-body pushups in bed six to eight times daily.
B. Breathe in and out smoothly during quadriceps drills.
C. Place the bed in the lowest position or use a footstool for dangling.
D. Dangle on the side of the bed for 30 to 60 minutes.
E. Allow the nurse to bathe the patient completely to prevent fatigue.
F. Perform quadriceps two to three times per hour, four to six times a day.
Give this one a try later!
, b, c, f. Breathing in and out smoothly during quadriceps drills maximizes
lung inflation. The patient should perform quadriceps two to three times
per hour, four to six times a day, or as ordered. The patient should never
hold their breath during exercise drills because this places a strain on the
heart. Pushups are usually done three or four times a day and involve only
the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should
place the bed in the lowest position or use a footstool for dangling. The
nurse should also encourage the patient to be as independent as possible
to prepare for return to normal ambulation and ADLs.
A patient who injured the spine in a motorcycle accident is receiving rehabilitation
services in a short-term rehabilitation center. The nurse caring for the patient correctly
tells the aide not to place the patient in which position?
A. Side-lying
B. Fowler's
C. Sims'
D. Prone
Give this one a try later!
d. The prone position is contraindicated in patients who have spinal
problems because the pull of gravity on the trunk when the patient lies
prone produces a marked lordosis or forward curvature of the lumbar
spine.
A nurse interviews a patient who was abused by her partner and is staying at a shelter
with her three children. She tells the nurse, "I'm so worried that my husband will find
me and try to make me go back home." Which data would the nurse most
appropriately document?
A. "Patient displays moderate anxiety related to her situation."
B. "Patient manifests panic related to feelings of impending doom."
C. "Patient describes severe anxiety related to her situation."
D. "Patient expresses fear of her husband."
,Give this one a try later!
d. Fear is a feeling of dread in response to a known threat. Anxiety, on the
other hand, is a vague, uneasy feeling of discomfort or dread from an often
unknown source. Panic causes a person to lose control and experience
dread and terror, which can lead to exhaustion and death; that is not the
case in this situation.
A patient reports abdominal pain that is difficult to localize. The nurse documents this
as which type of pain?
A. Cutaneous
B. Visceral
C. Superficial
D. Somatic
Give this one a try later!
b. The patient's pain would be categorized as visceral pain, which is poorly
localized and can originate in body organs in the abdomen. Cutaneous
pain (superficial pain) usually involves the skin or subcutaneous tissue. A
paper cut that produces sharp pain with a burning sensation is an example
of cutaneous pain. Deep somatic pain is diffuse or scattered and originates
in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure
on a bone or damage to tissue that occurs with a sprain causes deep
somatic pain.
What consideration should the nurse keep in mind regarding the use of side rails for a
patient who is confused?
A. They prevent confused patients from wandering.
B. A history of a previous fall from a bed with raised side rails is insignificant.
C. Alternative measures are ineffective to prevent wandering.
D. A person of small stature is at increased risk for injury from entrapment.
Give this one a try later!
, d. Studies of restraint-related deaths have shown that people of small
stature are more likely to slip through or between the side rails. The desire
to prevent a patient from wandering is not sufficient reason for the use of
side rails. Creative use of alternative measures indicates respect for the
patient's dignity and may in fact prevent more serious fall-related injuries. A
history of falls from a bed with raised side rails carries a significant risk for a
future serious incident
A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick
injury when administering the patient's medications. What would be the first action of
the nurse following the exposure?
A. Report the incident to the appropriate person and file an incident report
B. Wash the exposed area with warm water and soap
C. Consent to PEP at appropriate time
D. Set up counseling sessions regarding safe practice to protect self
Give this one a try later!
b. When a needlestick injury occurs, the nurse should wash the exposed
area immediately with warm water and soap, report the incident to the
appropriate person and complete an incident injury report, consent to and
await the results of blood tests, consent to PEP, and attend counseling
sessions regarding safe practice to protect self and others.
A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain
of childbirth. Which stress reduction activities would be most effective? Select all that
apply.
A. Progressive muscle relaxation
B. Meditation
C. Anticipatory socialization
D. Biofeedback
E. Rhythmic breathing
F. Guided imagery
ambulation. Which instructions from the nurse are appropriate for this patient? Select
all that apply.
A. Do full-body pushups in bed six to eight times daily.
B. Breathe in and out smoothly during quadriceps drills.
C. Place the bed in the lowest position or use a footstool for dangling.
D. Dangle on the side of the bed for 30 to 60 minutes.
E. Allow the nurse to bathe the patient completely to prevent fatigue.
F. Perform quadriceps two to three times per hour, four to six times a day.
Give this one a try later!
, b, c, f. Breathing in and out smoothly during quadriceps drills maximizes
lung inflation. The patient should perform quadriceps two to three times
per hour, four to six times a day, or as ordered. The patient should never
hold their breath during exercise drills because this places a strain on the
heart. Pushups are usually done three or four times a day and involve only
the upper body. Dangling for 30 to 60 minutes is unsafe. The nurse should
place the bed in the lowest position or use a footstool for dangling. The
nurse should also encourage the patient to be as independent as possible
to prepare for return to normal ambulation and ADLs.
A patient who injured the spine in a motorcycle accident is receiving rehabilitation
services in a short-term rehabilitation center. The nurse caring for the patient correctly
tells the aide not to place the patient in which position?
A. Side-lying
B. Fowler's
C. Sims'
D. Prone
Give this one a try later!
d. The prone position is contraindicated in patients who have spinal
problems because the pull of gravity on the trunk when the patient lies
prone produces a marked lordosis or forward curvature of the lumbar
spine.
A nurse interviews a patient who was abused by her partner and is staying at a shelter
with her three children. She tells the nurse, "I'm so worried that my husband will find
me and try to make me go back home." Which data would the nurse most
appropriately document?
A. "Patient displays moderate anxiety related to her situation."
B. "Patient manifests panic related to feelings of impending doom."
C. "Patient describes severe anxiety related to her situation."
D. "Patient expresses fear of her husband."
,Give this one a try later!
d. Fear is a feeling of dread in response to a known threat. Anxiety, on the
other hand, is a vague, uneasy feeling of discomfort or dread from an often
unknown source. Panic causes a person to lose control and experience
dread and terror, which can lead to exhaustion and death; that is not the
case in this situation.
A patient reports abdominal pain that is difficult to localize. The nurse documents this
as which type of pain?
A. Cutaneous
B. Visceral
C. Superficial
D. Somatic
Give this one a try later!
b. The patient's pain would be categorized as visceral pain, which is poorly
localized and can originate in body organs in the abdomen. Cutaneous
pain (superficial pain) usually involves the skin or subcutaneous tissue. A
paper cut that produces sharp pain with a burning sensation is an example
of cutaneous pain. Deep somatic pain is diffuse or scattered and originates
in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure
on a bone or damage to tissue that occurs with a sprain causes deep
somatic pain.
What consideration should the nurse keep in mind regarding the use of side rails for a
patient who is confused?
A. They prevent confused patients from wandering.
B. A history of a previous fall from a bed with raised side rails is insignificant.
C. Alternative measures are ineffective to prevent wandering.
D. A person of small stature is at increased risk for injury from entrapment.
Give this one a try later!
, d. Studies of restraint-related deaths have shown that people of small
stature are more likely to slip through or between the side rails. The desire
to prevent a patient from wandering is not sufficient reason for the use of
side rails. Creative use of alternative measures indicates respect for the
patient's dignity and may in fact prevent more serious fall-related injuries. A
history of falls from a bed with raised side rails carries a significant risk for a
future serious incident
A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick
injury when administering the patient's medications. What would be the first action of
the nurse following the exposure?
A. Report the incident to the appropriate person and file an incident report
B. Wash the exposed area with warm water and soap
C. Consent to PEP at appropriate time
D. Set up counseling sessions regarding safe practice to protect self
Give this one a try later!
b. When a needlestick injury occurs, the nurse should wash the exposed
area immediately with warm water and soap, report the incident to the
appropriate person and complete an incident injury report, consent to and
await the results of blood tests, consent to PEP, and attend counseling
sessions regarding safe practice to protect self and others.
A certified nurse midwife is teaching a pregnant woman techniques to reduce the pain
of childbirth. Which stress reduction activities would be most effective? Select all that
apply.
A. Progressive muscle relaxation
B. Meditation
C. Anticipatory socialization
D. Biofeedback
E. Rhythmic breathing
F. Guided imagery
