Question 1

A nurse is ambulating an unsteady patient from the bed to a chair in the patient's home. To do so safely, the nurse applies a gait belt and:

Accepted Answer

A)  slides his hand from the bottom under the gait belt at the middle of the patient's back. 
B)  grasps the gait belt from the top at the middle of the patient's back, pulling it tight against the patient's abdomen. 
C)  has one person on each side grasp the belt from the top. 
D)  secures a regular man's belt snugly around the patient's waist to use if the patient starts to fall. 
A)  slides his hand from the bottom under the gait belt at the middle of the patient's back. 
B)  grasps the gait belt from the top at the middle of the patient's back, pulling it tight against the patient's abdomen. 
C)  has one person on each side grasp the belt from the top. 
D)  secures a regular man's belt snugly around the patient's waist to use if the patient starts to fall. A

Question 2

A patient who has had spinal surgery is not permitted to bend at the waist or to sit in a chair. To position the patient correctly in bed, the nurse:

Accepted Answer

A)  places her in low- or semi-Fowler's position only. 
B)  uses logrolling to accomplish position changes from side to side. 
C)  moves the top half of her body first, then the middle, and finally her legs. 
D)  keeps her in a prone position to keep pressure off her back. 
A)  places her in low- or semi-Fowler's position only. 
B)  uses logrolling to accomplish position changes from side to side. 
C)  moves the top half of her body first, then the middle, and finally her legs. 
D)  keeps her in a prone position to keep pressure off her back. B

Question 3

There are two main factors in the development of pressure ulcers. One is pressure and the other is _________________.

Accepted Answer

shearing force
Shearing is the applied force that causes a downward and forward pressure on the tissues beneath the skin. Examples include pulling sheets or clothing from underneath the patient and the force applied when a patient pushes down on the bed with her heels while trying to move up in bed.

Question 4

A patient who is weak from inactivity following a car accident benefits most if the nurse provides for:

Accepted Answer

A)  passive range-of-motion (ROM) exercises to all joints four times a day. 
B)  active ROM exercises to arms and legs several times a day. 
C)  active ROM exercises with weights twice a day with 20 repetitions each. 
D)  passive ROM exercises to the point of resistance or pain and then slightly beyond. 
A)  passive range-of-motion (ROM) exercises to all joints four times a day. 
B)  active ROM exercises to arms and legs several times a day. 
C)  active ROM exercises with weights twice a day with 20 repetitions each. 
D)  passive ROM exercises to the point of resistance or pain and then slightly beyond.

Question 5

A nurse is instructing one of the facility's unlicensed assistive personnel (UAPs) regarding body mechanics for moving and lifting. The nurse recognizes that further instruction is warranted when the UAP states, "I will:

Accepted Answer

A)  lift using my back muscles." 
B)  obtain help whenever possible." 
C)  ask the patient to help if able." 
D)  use a wide base of support." 
A)  lift using my back muscles." 
B)  obtain help whenever possible." 
C)  ask the patient to help if able." 
D)  use a wide base of support."

Question 6

The nurse uses professional knowledge about body mechanics to prevent the most common occupational disorder in nurses, which is:

Accepted Answer

A)  carpal tunnel syndrome from use of computer keyboards in nursing documentation. 
B)  shoulder and elbow injuries from moving patients. 
C)  knee injuries from standing for long periods. 
D)  back injuries from lifting and twisting. 
A)  carpal tunnel syndrome from use of computer keyboards in nursing documentation. 
B)  shoulder and elbow injuries from moving patients. 
C)  knee injuries from standing for long periods. 
D)  back injuries from lifting and twisting.

Question 7

While the nurse is assisting a patient to ambulate, the patient suddenly says, "I'm dizzy. I can't stand up." As the patient begins to fall, the nurse should:

Accepted Answer

A)  tell the patient, "Look up, take some deep breaths, and stand up straight. You can do it." 
B)  call for another nurse or aide to get a wheelchair to return the patient to her room via wheelchair. 
C)  step behind the patient, grasp her around the waist or chest, and slide her down his leg gently to the floor. 
D)  look for the nearest chair and assist the patient to it. 
A)  tell the patient, "Look up, take some deep breaths, and stand up straight. You can do it." 
B)  call for another nurse or aide to get a wheelchair to return the patient to her room via wheelchair. 
C)  step behind the patient, grasp her around the waist or chest, and slide her down his leg gently to the floor. 
D)  look for the nearest chair and assist the patient to it.

Question 8

A frail older patient is able to stand but not to ambulate. She has an order to be up in a wheelchair as desired during the day. A safe and appropriate way to assist her up to a chair is to:

Accepted Answer

A)  use a mechanical lift to transfer her from the bed to a chair. 
B)  assist her to stand and pivot to a chair at right angles to the bed, using a transfer belt. 
C)  have another staff member help lift her out of bed to the chair on the count of three. 
D)  place a chair close to the bed and use a roller board to slide her into it. 
A)  use a mechanical lift to transfer her from the bed to a chair. 
B)  assist her to stand and pivot to a chair at right angles to the bed, using a transfer belt. 
C)  have another staff member help lift her out of bed to the chair on the count of three. 
D)  place a chair close to the bed and use a roller board to slide her into it.

Question 9

The patient for whom passive range-of-motion exercises would be most beneficial would be the:

Accepted Answer

A)  66-year-old patient with loss of mobility related to a recent cerebrovascular accident (CV
A) . 
B)  72-year-old patient with chronic dementia who alternately sits in his wheelchair and wanders around the unit. 
C)  80-year-old patient with chronic lung disease who can breathe only when he is sitting in a tripod position. 
D)  94-year-old patient with increasing fatigue and weight loss who needs assistance to ambulate. 
A)  66-year-old patient with loss of mobility related to a recent cerebrovascular accident (CV
A) . 
B)  72-year-old patient with chronic dementia who alternately sits in his wheelchair and wanders around the unit. 
C)  80-year-old patient with chronic lung disease who can breathe only when he is sitting in a tripod position. 
D)  94-year-old patient with increasing fatigue and weight loss who needs assistance to ambulate.

Question 10

As the nurse is helping an 85-year-old man to stand and ambulate, he complains that he feels that he has lost all of his strength in the last several years and cannot do the things he could do when he was 80. The nurse's most informative response would be:

Accepted Answer

A)  "An increase in testosterone will build your muscle bulk back to where it was when you were younger." 
B)  "As we age our muscle cells are lost and replaced by fat, which leads to loss of strength." 
C)  "Inactivity makes our muscles 'lazy' and they just won't do the work they used to do." 
D)  "Additional vitamins will build your strength back up in a few months." 
A)  "An increase in testosterone will build your muscle bulk back to where it was when you were younger." 
B)  "As we age our muscle cells are lost and replaced by fat, which leads to loss of strength." 
C)  "Inactivity makes our muscles 'lazy' and they just won't do the work they used to do." 
D)  "Additional vitamins will build your strength back up in a few months."

Question 11

To place a patient in the Sims' or lateral-lying position, the nurse would initially:

Accepted Answer

A)  raise the head of the bed to a 45- or 60-degree angle. 
B)  raise the bed to a waist-high working level. 
C)  bring the patient to the edge of the bed so that she will be centered when turned on her side. 
D)  place a pillow behind the patient's back to support her and prevent her from rolling onto her back. 
A)  raise the head of the bed to a 45- or 60-degree angle. 
B)  raise the bed to a waist-high working level. 
C)  bring the patient to the edge of the bed so that she will be centered when turned on her side. 
D)  place a pillow behind the patient's back to support her and prevent her from rolling onto her back.

Question 12

A patient in the skilled nursing facility has left-sided paralysis from a stroke several years before, as well as generalized weakness. The nurse should ensure that which of the following devices is in place to prevent flexion contractures?

Accepted Answer

A)  A trochanter roll to keep her legs from turning outward 
B)  A rolled washcloth in the palm of her left hand or a hand splint 
C)  A protective vest to keep her sitting upright in the chair 
D)  A trapeze to permit her to change her position in bed more easily 
A)  A trochanter roll to keep her legs from turning outward 
B)  A rolled washcloth in the palm of her left hand or a hand splint 
C)  A protective vest to keep her sitting upright in the chair 
D)  A trapeze to permit her to change her position in bed more easily

Question 13

When the post-stroke patient complains to the nurse, "I don't see why you are wasting your time doing the passive range-of-motion exercises on my legs," the nurse's most informative response would be based on the knowledge that the exercises:

Accepted Answer

A)  guarantee the prevention of pressure ulcers. 
B)  are part of the basic care given to all patients. 
C)  prevent contractures of the hips. 
D)  maintain the muscle mass of the limb prior to the stroke. 
A)  guarantee the prevention of pressure ulcers. 
B)  are part of the basic care given to all patients. 
C)  prevent contractures of the hips. 
D)  maintain the muscle mass of the limb prior to the stroke.

Question 14

An emaciated semiconscious bed-bound patient does not remain in a side-lying position and repeatedly turns onto her back, where she is developing a pressure area over her sacrum. The nurse should add to the nursing care plan to:

Accepted Answer

A)  raise the knees to keep the patient from sliding down. 
B)  position the patient on her side and use protective wrist and vest devices to keep her from turning onto her back. 
C)  assist the patient to sit in a wheelchair for short periods before returning her to bed. 
D)  place the patient on her stomach (prone position) using a small pillow below her diaphragm. 
A)  raise the knees to keep the patient from sliding down. 
B)  position the patient on her side and use protective wrist and vest devices to keep her from turning onto her back. 
C)  assist the patient to sit in a wheelchair for short periods before returning her to bed. 
D)  place the patient on her stomach (prone position) using a small pillow below her diaphragm.

Question 15

The primary function of a joint is to provide ______________ to the skeleton.

Accepted Answer

movement
Ligaments a

Question 16

A physician orders the nurse to place a patient in Fowler's position. The nurse should elevate the head of the patient's bed _____ degrees.

Accepted Answer

A)  60 to 90 
B)  30 to 60 
C)  15 to 30 
D)  10 to 15 
A)  60 to 90 
B)  30 to 60 
C)  15 to 30 
D)  10 to 15

Question 17

Complications from incorrect alignment and positioning include which of the following? (Select all that apply.)

Accepted Answer

A)  Pressure ulcers 
B)  Osteoporosis 
C)  Contractures 
D)  Increased blood pressure 
E)  Fluid in the lungs
F) Elevated temperature 
A)  Pressure ulcers 
B)  Osteoporosis 
C)  Contractures 
D)  Increased blood pressure 
E)  Fluid in the lungs
F) Elevated temperature

Question 18

A 70-year-old immobile patient, who has right-sided weakness caused by a recent stroke, weighs approximately 250 pounds and needs to be moved up in bed. Which of the following actions should the nurse take? (Select all that apply.)

Accepted Answer

A)  Summon at least one other person to assist. 
B)  Obtain a mechanical lift. 
C)  Perform the move by himself, because it should not be too difficult. 
D)  Obtain a lift sheet. 
E)  Put the bed in semi-Fowler's position.
F) Place the patient flat on her back. 
A)  Summon at least one other person to assist. 
B)  Obtain a mechanical lift. 
C)  Perform the move by himself, because it should not be too difficult. 
D)  Obtain a lift sheet. 
E)  Put the bed in semi-Fowler's position.
F) Place the patient flat on her back.

Question 19

An example of the principles of good body mechanics applied to patient care occurs when the nurse:

Accepted Answer

A)  keeps his feet fixed, spread one in front of the other, and turns his upper body to move the patient up in bed with a rocking movement. 
B)  assists another nurse in pushing a patient from one side of the bed to the other. 
C)  bends at the waist to pick up and empty or move the urinary drainage bag attached to the lower end of the side rail. 
D)  works at arm's distance from the patient when lifting or transferring the patient. 
A)  keeps his feet fixed, spread one in front of the other, and turns his upper body to move the patient up in bed with a rocking movement. 
B)  assists another nurse in pushing a patient from one side of the bed to the other. 
C)  bends at the waist to pick up and empty or move the urinary drainage bag attached to the lower end of the side rail. 
D)  works at arm's distance from the patient when lifting or transferring the patient.

Question 20

The charge nurse on the night shift of a skilled nursing facility is orienting a new aide to the unit. The LPN's most accurate information relative to moving patients is:

Accepted Answer

A)  "Most of your assigned patients are able to move about a little. Don't wake them to change their positions in bed if they are sleeping." 
B)  "When you get Mrs. S up to the toilet, be sure to keep your feet together and your knees locked, or she will pull you over." 
C)  "Get one other aide to help and use the mechanical lift when you get Mr. A out of bed in the morning. He is heavy and doesn't assist at all." 
D)  "Use your back muscles to lift-that will strengthen them and make it easier for you to lift or move heavy patients." 
A)  "Most of your assigned patients are able to move about a little. Don't wake them to change their positions in bed if they are sleeping." 
B)  "When you get Mrs. S up to the toilet, be sure to keep your feet together and your knees locked, or she will pull you over." 
C)  "Get one other aide to help and use the mechanical lift when you get Mr. A out of bed in the morning. He is heavy and doesn't assist at all." 
D)  "Use your back muscles to lift-that will strengthen them and make it easier for you to lift or move heavy patients."

Exam 18: Lifting, Moving, and Positioning Patients

A nurse is ambulating an unsteady patient from the bed to a chair in the patient's home. To do so safely, the nurse applies a gait belt and:

A patient who has had spinal surgery is not permitted to bend at the waist or to sit in a chair. To position the patient correctly in bed, the nurse:

There are two main factors in the development of pressure ulcers. One is pressure and the other is _________________.

A patient who is weak from inactivity following a car accident benefits most if the nurse provides for:

A nurse is instructing one of the facility's unlicensed assistive personnel (UAPs) regarding body mechanics for moving and lifting. The nurse recognizes that further instruction is warranted when the UAP states, "I will:

The nurse uses professional knowledge about body mechanics to prevent the most common occupational disorder in nurses, which is:

While the nurse is assisting a patient to ambulate, the patient suddenly says, "I'm dizzy. I can't stand up." As the patient begins to fall, the nurse should:

A frail older patient is able to stand but not to ambulate. She has an order to be up in a wheelchair as desired during the day. A safe and appropriate way to assist her up to a chair is to:

The patient for whom passive range-of-motion exercises would be most beneficial would be the:

As the nurse is helping an 85-year-old man to stand and ambulate, he complains that he feels that he has lost all of his strength in the last several years and cannot do the things he could do when he was 80. The nurse's most informative response would be:

To place a patient in the Sims' or lateral-lying position, the nurse would initially:

A patient in the skilled nursing facility has left-sided paralysis from a stroke several years before, as well as generalized weakness. The nurse should ensure that which of the following devices is in place to prevent flexion contractures?

When the post-stroke patient complains to the nurse, "I don't see why you are wasting your time doing the passive range-of-motion exercises on my legs," the nurse's most informative response would be based on the knowledge that the exercises:

An emaciated semiconscious bed-bound patient does not remain in a side-lying position and repeatedly turns onto her back, where she is developing a pressure area over her sacrum. The nurse should add to the nursing care plan to:

The primary function of a joint is to provide ______________ to the skeleton.

A physician orders the nurse to place a patient in Fowler's position. The nurse should elevate the head of the patient's bed _____ degrees.

Complications from incorrect alignment and positioning include which of the following? (Select all that apply.)

A 70-year-old immobile patient, who has right-sided weakness caused by a recent stroke, weighs approximately 250 pounds and needs to be moved up in bed. Which of the following actions should the nurse take? (Select all that apply.)

An example of the principles of good body mechanics applied to patient care occurs when the nurse:

The charge nurse on the night shift of a skilled nursing facility is orienting a new aide to the unit. The LPN's most accurate information relative to moving patients is:

Nursing and the Health Care System

Concepts of Health, Illness, Stress, and Health Promotion

Legal and Ethical Aspects of Nursing

Nursing Process and Critical Thinking

Assessment, Nursing Diagnosis, and Planning

Implementation and Evaluation

Documentation of Nursing Care

Communication and the Nurse-Patient Relationship

Patient Teaching for Health Promotion

Delegation, Leadership, and Management

Growth and Development: Infancy Through Adolescence

Adulthood and the Family

Promoting Healthy Adaptation to Aging

Cultural and Spiritual Aspects of Patient Care

Loss, Grief, the Dying Patient, and Palliative Care

Infection Prevention and Control: Protective Mechanisms and Asepsis

Infection Prevention and Control in the Hospital and Home

Assisting with Hygiene, Personal Care, Skin Care, and the Prevention of Pressure Ulcers

Patient Environment and Safety

Measuring Vital Signs

Assessing Health Status

Admitting, Transferring, and Discharging Patients

Diagnostic Tests and Specimen Collection

Fluid, Electrolyte, and Acid–Base Balance

Concepts of Basic Nutrition and Cultural Considerations

Diet Therapy and Assisted Feeding

Assisting with Respiration and Oxygen Delivery

Promoting Urinary Elimination

Promoting Bowel Elimination

Pain, Comfort, and Sleep

Complementary and Alternative Therapies

Pharmacology and Preparation for Drug Administration

Administering Oral, Topical, and Inhalant Medications

Administering Intradermal, Subcutaneous, and Intramuscular Injections

Administering Intravenous Solutions and Medications

Care of the Surgical Patient

Providing Wound Care and Treating Pressure Ulcers

Promoting Musculoskeletal Function

Common Physical Care Problems of the Elderly

Common Psychosocial Care Problems of the Elderly

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