EVALUATION VERIFIED A+
◉ A nurse is ambulating a client with a gait belt. The client catches
her foot on the bed frame and begins to fall. How should the nurse
best prevent or minimize damage from this fall?
A.The nurse should place his or her feet close together with one foot
in front of the other.
B.The nurse should rock his or her pelvis out of the opposite side of
the client.
C.The nurse should grasp the gait belt and pull the client's body
backward away from his or her body.
D.The nurse should gently slide the client down his or her body to
the floor. Answer: d
◉ The nurse is assisting a client with limited mobility to turn in bed.
After successfully turning the client to the side, where would the
nurse place an additional pillow?
A.In front of the client's head
B.Supporting the client's back
C.In front of the client's abdomen
d. Under the client's feet Answer: b
,◉ A nurse is planning care for a client who is on bed rest. Which of
the following interventions should the nurse plan to implement?
Select all that apply.
A.Encourage the client to perform antiembolic exercises every 1-2
hours
B.Restrict the client's fluid intake
C.Reposition the client every 4 hours
D.Instruct the client to cough and deep breathe every 1-2 hours
Advise the client to use high-fiber diet if possible Answer: a, d, e
◉ 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?
A.Trochanter rolls
B.Foot boards
C.Foot splints
Roller sheets Answer: a
◉ •What are two things that we need to take into consideration
regarding personal hygiene? Answer: 1.Respect individual
preferences
2.Provide only the care the patients cannot (or should not)
,◉ •What are some techniques of performing a bed bath? Answer:
•When assisting in hygiene activities, nurse should use this time to
inspect skin and skin integrity
◉ •What type of soap do we recommend to be used on the skin?
Answer: MILD SOAP
◉ •What are other skin products may we consider using? Answer:
Chlorhexidine gluconate
emollient
◉ •What are techniques for perineal care? Answer: •For females -
wipe from FRONT to BACK
•For males uncircumcised - pull foreskin back, clean skin
underneath, and replace foreskin to natural position
◉ •What are techniques for eye care? Answer: •Eye care involves
removing drainage and crusts from eyes or if client is
sedated/unconscious, will provide eye drops to prevent drying
•If client uses contacts or glasses, be sure to clean and provide for
client
◉ •What are techniques for ear care? Answer: •warm washcloth,
wiping outside of ear
, •Nothing should go inside a client's ear
◉ Describe how to make an occupied bed vs unoccupied bed:
OCCUPIED BED
•Safety first!!!
-Put side rails up on the side you are ____ standing on; pt will usually
hold onto this for help
-Adjust bed height to ___________ height
-HOB ______________ unless contraindicated
•You'll take off ____ of the dirty sheets, rolling ____________ pt, making
the bed with clean fitted sheet on the side you're standing on
•You'll then roll the patient gently over the pile of sheets, taking off
the _________ and then finish making the bed with the rest of the clean
sheets. Answer: not
working
lowered
half, underneath
dirty
◉ A nurse is assisting an older adult with an unsteady gait to a tub
bath. Which action is recommended in this procedure?
A. Add bath oil to the water to prevent dry skin
B. Allow the patient to lock the door to guarantee privacy