Deck 44: Rest

Question 1

When planning care,the nurse should identify which client as needing logrolling for position changes?

A)A client with documented pneumonia
B)The client who has had abdominal surgery
C)The client who fell from a house,sustaining a fractured tibia
D)A client who has a severe headache from hypertensive crisis

Answer 1

The client who fell from a house,sustaining a fractured tibia

Question 2

The nurse is planning care for a client who has limited bed mobility.What instruction should be given to the assistive personnel who will be caring for this client?
Standard Text: Select all that apply.

A)Place a turn sheet on the bed.
B)Always use two personnel to move the client.
C)Stand at the head of the bed to pull the client up.
D)Slide the client toward the head of the bed.
E)Encourage the client to assist as possible.

Answer 2

Place a turn sheet on the bed.
Always use two personnel to move the client.
Encourage the client to assist as possible.

Question 3

The bed-bound client complains of pain and burning in the right calf area.What action should be taken by the nurse?

A)Deeply palpate the area for rebound tenderness.
B)Percuss over the area for change in tone.
C)Measure the calf and compare to the opposite calf.
D)Medicate the client for pain and reassess in 30 minutes.

Answer 3

Measure the calf and compare to the opposite calf.

Question 4

The nurse is assisting in logrolling a client recovering from spinal surgery.Why should the nurse place a pillow between the client's legs when turning?
Standard Text: Select all that apply.

A)Stabilizes the spine
B)Prevents hip contractures
C)Supports the upper leg
D)Keeps the legs parallel and aligned
E)Prevents adduction of the upper leg

Question 5

What is the priority action of the nurse prior to transferring a client from bed to wheelchair?

A)Place the bed in its lowest position.
B)Place the wheelchair parallel to the bed.
C)Lock the brakes on the bed.
D)Place a transfer belt on the client.

Question 6

The postoperative client is ambulating for the first time since surgery.The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions.Which staff member should ambulate this client?

A)The UAP
B)A licensed practical (vocational)nurse
C)A registered nurse
D)It makes no difference

Question 7

During a prenatal visit,the nurse is instructing a newly pregnant client in regard to exercise.What advice is best for the nurse to give this client?

A)Pregnant clients can exercise if exercise was a part of their life prior to pregnancy.
B)Due to the stress of a growing fetus,exercise should be limited to no more than 10 minutes per day.
C)Healthy pregnant women should exercise at least 30 minutes on most if not all days.
D)The pregnant woman's exercise should actually increase above normal recommended levels to prevent water weight gain.

Question 8

The nurse has documented that the client has orthostatic hypotension.Which assessment finding would support this assessment?

A)Decrease in blood pressure when moving from supine to standing
B)Decrease in heart rate when moving from supine to sitting
C)Pale color in the legs when lying in bed
D)Complaints of dizziness when first sitting up

Question 9

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client.In order to make this problem statement more individual,the nurse should take which action?

A)Include what mobility is impaired.
B)Use Level 1,2,3,or 4 to describe immobility.
C)Describe what happens when the client attempts mobility.
D)Add strength assessment data.

Question 10

The nurse is working on a hospital committee focused on preventing back injury in nurses.Which recommendation by this committee is most likely to result in a decrease in back injuries if followed?

A)Nurses must wear back belts when lifting clients.
B)All nursing personnel must attend annual body mechanics education.
C)In order to prevent injury,nurses must strive to become physically fit.
D)No solo lifting of clients is permitted in the facility.

Question 11

While assisting the client with a bath,the nurse encourages full range of motion in all the client's joints.Which activity would best support range of motion in the hand and arm?

A)Give the client a washcloth to wash the face.
B)Move the wash basin farther toward the foot of the bed so the client must reach for it.
C)Have the client brush the hair and teeth.
D)Move each of the client's hand and arm joints through passive range of motion.

Question 12

The newly admitted client has contractures of both lower extremities.What nursing intervention should be included in this client's plan of care?

A)Frequent position changes to reverse the contractures
B)Exercises to strengthen flexor muscles
C)Range-of-motion exercises to prevent worsening of contractures
D)Weight-bearing activities to stimulate joint relaxation

Question 13

The nurse is caring for a client diagnosed with early osteoporosis.Which intervention is most applicable for this client?

A)Institute an exercise plan that includes weight-bearing activities.
B)Increase the amount of calcium in the client's diet.
C)Protect the client's bones with strict bed rest.
D)Provide the client with assisted range-of-motion exercising twice daily.

Question 14

The nurse is preparing to transfer a client from the bed to a stretcher.The correct position for the bed to be placed is parallel to the stretcher and

A)slightly higher.
B)slightly lower.
C)at the same height.
D)at least 2 inches lower.

Question 15

The nurse is caring for a client experiencing dyspnea.In which position should the nurse place this client?

A)High Fowler's position with two pillows behind the head
B)Orthopneic position across the overbed table
C)Prone position with knees flexed and arms extended
D)Sims position with both legs flexed

Question 16

The nurse is assisting the client to dangle on the bedside.After raising the head of the bed,in which position should the nurse face?

A)Toward the nearest corner of the head of the bed
B)Toward the side of the bed
C)Toward the far corner of the foot of the bed
D)Directly toward the client

Question 17

The nurse is preparing to assist a client to a lateral position to position a bedpan.What action should the nurse take first?

A)Perform hand hygiene.
B)Move the client to the side of the bed.
C)Place the client's arm over the chest.
D)Raise the opposite side rail.

Question 18

The client who is bed-bound complains of abdominal pain.Bowel sounds are present.What action should be taken by the nurse?

A)Percuss for flatness over the liver.
B)Palpate for bladder fullness.
C)Use the p.r.n.order to medicate the client with an antacid.
D)Inspect the sacral area for edema.

Question 19

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table.Which technique should the nurse use to protect the back?

A)Place the feet together to provide a strong base of support.
B)Flex the knees to lower the center of gravity.
C)Face the box,pick it up,and rotate the upper body toward the table.
D)Hold the box as close to the body as possible.

Question 20

The client who is unconscious is developing foot drop.What nursing action is indicated?

A)Place high-topped shoes on the client while in bed.
B)Keep the linens on the end of the bed turned back to expose the feet.
C)Use only the prone and Sims positions for client positioning.
D)Use a device to elevate the linens off the feet.

Question 21

The client has a history of postural hypotension.Which activities should the nurse advise this client as likely to cause postural hypotension?
Standard Text: Select all that apply.

A)Hot baths
B)Heavy meals
C)Use of a rocking chair
D)Moving in bed
E)Bending down to the floor

Question 22

The nurse is teaching a client on the use of a cane.What should the nurse include in this teaching?
Standard Text: Select all that apply.

A)Hold the cane on the weaker side of the body.
B)Move the cane forward while the body weight is between both legs.
C)The length of the cane should permit the elbow to be fully extended.
D)Move the weaker leg forward while the weight is between the cane and the stronger leg.
E)Move the stronger leg forward while the weight is between the cane and the weaker leg.

Question 23

The nurse is providing range-of-motion exercising to the client's elbow when the client complains of pain.What action should the nurse take?

A)Stop immediately and report the pain to the client's physician.
B)Discontinue the treatment and document the results in the medical record.
C)Reduce the movement of the joint just until the point of slight resistance.
D)Continue to exercise the joint as before to loosen the stiffness.

Question 24

The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby.The client complains of light-headedness and begins to faint.What is the nurse's most important action?

A)Ensure the client's modesty as she falls.
B)Be certain the client does not hit the head on anything.
C)Call for immediate assistance.
D)Check the vital signs and for excessive vaginal bleeding.