Deck 16: Moving and Positioning Patients

Question 1

A nurse knows that when skin slides over another surface in the opposite direction, it can cause abrasions and open skin areas, which is known as

A) Shearing.
B) Peristalsis.
C) Atelectasis.
D) Deep vein thrombosis (DVT).

Answer 1

Shearing.

Question 2

When proper flexion of the ankle is lost and permanent plantar flexion of the foot develops, the condition is known as

A) Footdrop.
B) Contractures.
C) Osteoporosis.
D) Thromboembolism.

Answer 2

Footdrop.

Question 3

A nurse encourages a patient to take full, deep breaths to keep the alveoli open. The nurse teaches the patient that this is done to prevent

A) Shearing.
B) Peristalsis.
C) Atelectasis.
D) Deep vein thrombosis (DVT).

Answer 3

Atelectasis.

Question 4

While supervising a student who is manually transferring a patient from a bed to a chair, a nurse intervenes when the student transfers the patient while

A) Twisting at the torso.
B) Standing close to the patient.
C) Using proper body mechanics.
D) Maintaining a wide base of support.

Question 5

A nurse educator teaches a student nurse that prevention of venous thrombosis includes

A) Limiting movement of the extremities.
B) Applying bilateral ankle restraints.
C) Performing passive range-of-motion exercises.
D) Discouraging the patient from wearing sequential compression devices.

Question 6

When educating a student nurse about how to correctly logroll a patient, a nursing instructor recognizes that additional teaching is necessary when the student nurse states:

A) "I will count to three before the move occurs."
B) "I will ask two people to help me logroll a patient."
C) "I will stand at the patient's feet and control the turn."
D) "I will ensure that staff members turn the patient as one unit."

Question 7

A nursing instructor is educating a student nurse about methods to prevent orthostatic hypotension. The nursing instructor recognizes that further teaching is needed when the student states:

A) "I will encourage the patient to remain flat in bed."
B) "I will change the patient's position in bed frequently."
C) "I will encourage dorsal and plantar flexion of the feet."
D) "I will perform passive range-of-motion exercises if the patient can't move."

Question 8

A nurse is caring for a patient who has been on prolonged bedrest and is now experiencing shortening and tightening of the muscles due to disuse. The nurse identifies this condition as

A) Footdrop.
B) Contractures.
C) Osteoporosis.
D) Thromboembolism.

Question 9

A nurse recognizes that the most preventable cause of death during hospitalization is

A) An embolism.
B) Hospital-acquired pneumonia.
C) Skin breakdown because of not turning patients.
D) A urinary tract infection leading to urosepsis.

Question 10

While a nurse assists a patient from a lying position to a sitting position, the patient suddenly becomes dizzy, pale, clammy, and nauseated. The nurse recognizes these symptoms are most likely related to

A) Thromboembolism.
B) Orthostatic hypotension.
C) Orthostatic hypertension.
D) Symptomatic bradycardia.

Question 11

A nurse knows that the major effect of immobility on the gastrointestinal system is the lack of natural movement of the intestines, which is known as

A) Shearing.
B) Peristalsis.
C) Atelectasis.
D) Deep vein thrombosis (DVT).

Question 12

While supervising a certified nursing student who is positioning a patient in bed, a nurse intervenes when observing the student

A) Locking the wheels on the bed.
B) Elevating the bed to a comfortable working height.
C) Changing a patient's position at least every 2 hours.
D) Allowing a patient's arm to dangle over the side of the bed.

Question 13

A patient begins to fall during ambulation. The nurse should

A) Hold the patient upright.
B) Keep his or her back bent while lowering the patient.
C) Keep his or her knees straight while lowering the patient.
D) Allow the patient to slide down his or her leg to the floor.

Question 14

While supervising a student nurse who is caring for a patient on bedrest, a nurse intervenes when observing the student

A) Using mild soaps for cleansing the skin.
B) Repositioning in bed at 2-hour intervals.
C) Offering the patient high-protein snacks.
D) Massaging directly on reddened bony prominences.

Question 15

A nurse recognizes that a condition that occurs because of a loss of bone minerals, which leads to an increased risk for skeletal fractures, is known as

A) Footdrop.
B) Contractures.
C) Osteoporosis.
D) Thromboembolism.

Question 16

A nurse educates a patient about how to avoid developing osteoporosis. The nurse recognizes that additional teaching is needed when the patient states:

A) "I will consume dairy products."
B) "I will remain in bed when I have a cold."
C) "I will exercise several times a week."
D) "I will take a daily calcium supplement."

Question 17

When caring for a patient who is confined to bed, a nurse recognizes that the patient is at increased risk for the formation of a blood clot, which is known as

A) Footdrop.
B) Contractures.
C) Osteoporosis.
D) Thromboembolism.

Question 18

While lying in bed, a patient has a blood pressure of 142/86 mm Hg and a heart rate of 76 beats/min. When a nurse helps the patient to sit up and dangle at the side of the bed, the patient becomes dizzy. The nurse rechecks the patient's vital signs and finds that the patient's blood pressure is now 112/54 mm Hg, and the patient's heart rate is now 98 beats/min. The next action to take would be to

A) Recheck the patient's vital signs.
B) Assist the patient to a Fowler position.
C) Assist the patient to a standing position.
D) Assist the patient to a lithotomy position.

Question 19

While caring for a patient who has a spinal cord injury, a nurse obtains assistance to logroll the patient. The nurse intervenes when observing the assistant prepare for the logroll by standing at the patient's

A) Feet.
B) Head.
C) Waist.
D) Thighs.

Question 20

A nurse delegates the task of assisting patients with ambulation to a student nurse. The nurse intervenes when observing the student

A) Instructing the patient to move from supine to standing positions in stages.
B) Assisting the patient to a dangling position with his or her feet firmly on the floor.
C) Holding the transfer belt loosely near the patient's body while ambulating.
D) Raising the head of the bed and assisting the patient with sitting on the side of the bed.

Question 21

A nurse needs to transfer a female patient who is only partially capable of bearing her own weight into a wheelchair for transport to an x-ray. The nurse determines that the correct device for transferring this patient is a

A) Slide sheet.
B) Transfer belt.
C) Slide board.
D) Lift.

Question 22

A nurse encourages patients to ambulate because complications from immobility include which of the following?

A) Blood clots
B) Pneumonia
C) Frequent loose stools
D) Depression
E) Urinary retention

Question 23

Nursing measures to prevent integumentary complications include which of the following?

A) Maintaining adequate nutrition
B) Using mild soaps for cleansing the skin
C) Repositioning in bed at 4-hour intervals
D) Vigorously drying the skin after bathing
E) Inspecting bony prominences at least every 2 hours

Question 24

Nursing measures to prevent urinary complications include which of the following?

A) Monitoring urinary output
B) Having the patient void at least every 8 hours
C) Assisting the patient to urinate while in a sitting position
D) Assisting the patient to urinate while in a reclined position
E) Ensuring that the patient consumes at least 8 ounces of fluid every 2 hours

Question 25

Nursing measures to prevent gastrointestinal complications include which of the following?

A) Ambulating the patient once per day
B) Teaching the patient to consume a low-fiber diet
C) Giving a laxative or stool softener as needed
D) Repositioning the patient on bedrest at 4-hour intervals
E) Having the patient drink at least 8 ounces of fluid every 2 hours

Question 26

A nurse is preparing a patient for an enema. The correct body position for this type of procedure would be

A) Dorsal recumbent.
B) Semi-Fowler.
C) Lithotomy.
D) Left Sims.

Question 27

A patient lies in a special type of bed frame that allows the entire bed to turn from side to side. The mattress is low air-loss and the bed can be programmed to turn by degrees at set intervals. The nurse explains to the patient that this is a type of specialty bed called a

A) Specialized mattress.
B) Mattress overlay.
C) Combination bed.
D) Continuous lateral-rotation bed.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

Question 28

A nurse needs to prevent the external rotation of a patient's legs. The nurse identifies that the correct positioning device would be

A) Stirrups.
B) A blanket roll.
C) A trochanter roll.
D) A foot board.

Question 29

A nurse is preparing a female patient for a vaginal examination. The correct body position for this patient would be

A) Lithotomy.
B) Lateral.
C) High Fowler.
D) Reverse Trendelenburg.

Question 30

An instructor explains to students the Handle With Care campaign that was instituted by the American Nurses Association (ANA). A student demonstrates understanding by saying:

A) "The purpose of the Handle With Care campaign is to build an industry-wide program in health care to prevent musculoskeletal injuries."
B) "The Handle With Care campaign provides guidelines for disciplinary action for those who lift and move patients incorrectly."
C) "The Handle With Care bill was passed by the House of Representatives and requires safe patient handling programs in all health-care facilities."
D) "The Handle With Care campaign instituted a 'no lifting' program that prevents nursing staff from lifting patients under any circumstance."

Question 31

A nurse implements nursing measures to prevent neurological complications. The nurse knows the importance of which of the following?

A) Performing neurological checks as ordered
B) Keeping the room curtains closed
C) Assessing the patient's level of consciousness
D) Using a footboard or high-topped tennis shoes
E) Keeping a calendar and clock where the patient can see them

Question 32

A nurse needs to position a patient in severe respiratory distress in a manner that allows the chest to expand to maximum capacity for moving air in and out of the lungs. The correct body position for this patient would be

A) Right Sims.
B) Orthopneic.
C) Trendelenburg.
D) Supine.

Question 33

Nursing measures to prevent psychological complications in immobile patients include which of the following?

A) Making all decisions about a patient's care
B) Distracting a patient by turning on his or her television
C) Encouraging a patient to stay awake most of the day
D) Talking to a patient about photographs of his or her children
E) Closing blinds to decrease natural lighting in a patient's room

Question 34

A patient lies in a bed frame lined with a pocketed air mattress. Each pocket is filled with air and can be inflated or slightly deflated to prevent pressure on any one area. A nurse explains to the patient that this type of specialty mattress that can be customized for the needs of each patient is called a

A) Continuous lateral-rotation bed.
B) Low air-loss bed.
C) Mattress overlay.
D) Air-fluidized bed.

Question 35

Nursing interventions to prevent atelectasis and pneumonia include which of the following?

A) Elevating the head of the bed 45 degrees
B) Keeping the patient lying in a prone position
C) Turning from side to side at least every 2 hours
D) Assisting with turning, coughing, and deep breathing once per shift
E) Assisting with the use of an incentive spirometer, taking 10 to 20 breaths per hour

Question 36

Nursing interventions to prevent musculoskeletal complications include which of the following?

A) Maintaining proper body alignment
B) Maintaining a slump-shouldered position
C) Keeping the head, trunk, and hips positioned in a straight line
D) Maintaining the arms in alignment with the shoulders and trunk
E) Preventing the legs from rotating in the hip sockets either medially or laterally