TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 17: Safe Patient Handling Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. A patient’s physical mobility is impaired because of paralysis of both lower extremities.
Which is the best method for the nurse to use to place the patient in semi-Fowler’s position? a. Help the patient push up in bed by bending his or her knees. b. Raise the head of the bed (HOB) to 45 degrees and pull the patient to it. c. Roll the patient to one side using pillows to support his or her back. d. Pull the patient to the (HOB) using a drawsheet and then raise the HOB. ANS: D
With the assistance of another staff member and using a drawsheet, the nurse bends the patient’s knees to reposition the legs, pulls the patient to the HOB, elevates the HOB to 45 degrees, and removes wrinkles from the drawsheet. The patient is unable to push up because of paralysis. Elevating the HOB first increases the force needed to move the patient up in the bed and the risk of injury. Rolling the patient to the side achieves Sims’ or lateral position or assists with logrolling; rolling the patient may be necessary to place the drawsheet under him or her before moving the patient up in bed. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
OBJ: NCLEX: Safe and Effective Care Environment
2. The nurse is caring for a patient after a motor vehicle crash and instructs the patient to avoid
turning independently because the spine is unstable. What explanation of bed mobility does N the nurse provide the patient? a. “We will use a ceiling lift to get you out of bed.” b. “Several staff will logroll you to change position.” c. “You have to remain on your back until your spine is stable.” d. “Physical therapy will get you out of bed in the morning.” ANS: B
The nurse does not allow the patient to turn to the side unassisted because an unstable spine cannot maintain normal alignment since the integrity of one or more vertebrae is disrupted. If the patient moves, he or she risks exacerbating the spinal cord injury by abnormal movements of vertebral bone fragments. To maintain patient safety, the nursing staff turns the patient by logrolling and thereby keeps the head, neck, and spine in straight alignment, thus preventing bone fragments from shifting and potentially increasing the damage. The patient does not need a ceiling lift because he or she will not be getting out of bed until the spine is more stable. Remaining on the back will greatly increase the risk of pressure injury. Physical therapy may be tasked with getting the patient out of bed, but again until the spine is stabilized, the patient will not be getting out of bed. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
OBJ: NCLEX: Safe and Effective Care Environment
3. The nurse and an assistant are moving a dependent patient from the supine to the lateral
position. Which should the nurse implement to begin repositioning? a. Support the upper arm and leg with pillows.
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