Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder – Test Bank

Skills in Clinical Nursing 8th Edition by Audrey J. Berman- Shirlee Snyder – Test Bank

Exam
Name___________________________________
MULTIPLE CHOICE.

Choose the one alternative that best completes the statement or answers the question.

1) A person maintains balance as long as the line of gravity passes through the: 1)

A) Base of support. B) Center of gravity. C) Center of gravity and base of support. D) Moving body part. Answer: C Explanation: A) Balance is a state of equilibrium in which opposing forces counteract each other, requiring the line of gravity to pass through the center of gravity and the base of support. Balance is the result of proper body alignment. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Implementation B) Balance is a state of equilibrium in which opposing forces counteract each other, requiring the line of gravity to pass through the center of gravity and the base of support. Balance is the result of proper body alignment. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Implementation C) Balance is a state of equilibrium in which opposing forces counteract each other, requiring the line of gravity to pass through the center of gravity and the base of support. Balance is the result of proper body alignment. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Implementation D) Balance is a state of equilibrium in which opposing forces counteract each other, requiring the line of gravity to pass through the center of gravity and the base of support. Balance is the result of proper body alignment. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Implementation Objective: Learning Outcome 10-1: Define the key terms used in body mechanics and the skills of positioning clients.
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2) The center of gravity of a well-aligned standing adult is located: 2) A) Slightly anterior of the upper lumbar spine. B) Slightly posterior of the ileac crest. C) Slightly anterior of the waist. D) Slightly anterior of the upper sacrum. Answer: D Explanation: A) The center of gravity on a well-aligned standing adult is located slightly anterior of the upper sacrum. Center of gravity changes with pregnancy, when carrying something, or when the adult moves. The other answer options are incorrect. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Assessment B) The center of gravity on a well-aligned standing adult is located slightly anterior of the upper sacrum. Center of gravity changes with pregnancy, when carrying something, or when the adult moves. The other answer options are incorrect. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Assessment C) The center of gravity on a well-aligned standing adult is located slightly anterior of the upper sacrum. Center of gravity changes with pregnancy, when carrying something, or when the adult moves. The other answer options are incorrect. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Assessment D) The center of gravity on a well-aligned standing adult is located slightly anterior of the upper sacrum. Center of gravity changes with pregnancy, when carrying something, or when the adult moves. The other answer options are incorrect. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Assessment Objective: Learning Outcome 10-1: Define the key terms used in body mechanics and the skills of positioning clients.
3) The nurse is preparing to lift a client up in bed. Prior to beginning, the nurse should do which of the following to maintain safety? Select all that apply.
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A) Plan the move. B) Face the head of the bed. C) Raise the bed to waist level. D) Stand close to the bed with the legs close together. E) Straighten the knees. Answer: A, B, C Explanation: A) Planning the move before beginning helps to foresee any potential problems and arrange for adequate assistance with moving the client. By facing the bed, the nurse will move the client in the same direction the nurse is facing to avoid twisting or straining. The bed should always be brought to waist level when the client is performing care, to avoid back strain. The nurse should stand close to the bed with legs spread to create a broad base of support in order to avoid back injury. The knees should be bent, not straight. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation
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B) Planning the move before beginning helps to foresee any potential problems and arrange for adequate assistance with moving the client. By facing the bed, the nurse will move the client in the same direction the nurse is facing to avoid twisting or straining. The bed should always be brought to waist level when the client is performing care, to avoid back strain. The nurse should stand close to the bed with legs spread to create a broad base of support in order to avoid back injury. The knees should be bent, not straight. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation C) Planning the move before beginning helps to foresee any potential problems and arrange for adequate assistance with moving the client. By facing the bed, the nurse will move the client in the same direction the nurse is facing to avoid twisting or straining. The bed should always be brought to waist level when the client is performing care, to avoid back strain. The nurse should stand close to the bed with legs spread to create a broad base of support in order to avoid back injury. The knees should be bent, not straight. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation D) Planning the move before beginning helps to foresee any potential problems and arrange for adequate assistance with moving the client. By facing the bed, the nurse will move the client in the same direction the nurse is facing to avoid twisting or straining. The bed should always be brought to waist level when the client is performing care, to avoid back strain. The nurse should stand close to the bed with legs spread to create a broad base of support in order to avoid back injury. The knees should be bent, not straight. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation E) Planning the move before beginning helps to foresee any potential problems and arrange for adequate assistance with moving the client. By facing the bed, the nurse will move the client in the same direction the nurse is facing to avoid twisting or straining. The bed should always be brought to waist level when the client is performing care, to avoid back strain. The nurse should stand close to the bed with legs spread to create a broad base of support in order to avoid back injury. The knees should be bent, not straight. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Objective: Learning Outcome 10-2: Identify essential guidelines for safe and efficient body movements.
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4) Two nurses are preparing to transfer a client from the stretcher to the bed. Which of the following is a safe and efficient action?
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A) The nurse pulling the client onto the bed enlarges the base of support by moving the feet apart laterally. B) The nurse pushing the object moves one foot forward. C) The nurse pushing faces the head of the bed. D) The nurse pulling faces the foot of the bed. Answer: B Explanation: A) The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the client is to be moved. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation B) The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the client is to be moved. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation C) The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the client is to be moved. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation D) The nurse who is pushing the client from the stretcher to the bed would put one foot forward to provide leverage. This nurse faces the direction the client is to be moved and widens the base of support in the direction the client is to be moved. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Objective: Learning Outcome 10-2: Identify essential guidelines for safe and efficient body movements.
5) Which of the following describes the limits of body mechanics regarding the nurse and client’s safety?
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A) The nurse who uses good body mechanics cannot injure his back. B) The nurse who lifts weights can safely lift more weight. C) The nurse who lifts a client with a mechanical assistive device reduces the risk of self-injury. D) The nurse will not cause self-injury if he lifts the dependent client independently as long as correct technique is used. Answer: C Explanation: A) Use of a mechanical assistive device reduces the work performed by the nurse, and the risk of injury is also reduced. While using good body mechanics can reduce the risk of injury, it does not prevent the risk entirely. The nurse who lifts weights is still capable of injuring himself if correct technique isn’t followed. Lifting an inanimate object is very different from lifting a client. It is recommended that a nurse lift no more than 51 pounds independently, so lifting a dependent client can result in injury to both the nurse and the client if adequate assistance is not obtained. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation 4
B) Use of a mechanical assistive device reduces the work performed by the nurse, and the risk of injury is also reduced. While using good body mechanics can reduce the risk of injury, it does not prevent the risk entirely. The nurse who lifts weights is still capable of injuring himself if correct technique isn’t followed. Lifting an inanimate object is very different from lifting a client. It is recommended that a nurse lift no more than 51 pounds independently, so lifting a dependent client can result in injury to both the nurse and the client if adequate assistance is not obtained. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation C) Use of a mechanical assistive device reduces the work performed by the nurse, and the risk of injury is also reduced. While using good body mechanics can reduce the risk of injury, it does not prevent the risk entirely. The nurse who lifts weights is still capable of injuring himself if correct technique isn’t followed. Lifting an inanimate object is very different from lifting a client. It is recommended that a nurse lift no more than 51 pounds independently, so lifting a dependent client can result in injury to both the nurse and the client if adequate assistance is not obtained. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation D) Use of a mechanical assistive device reduces the work performed by the nurse, and the risk of injury is also reduced. While using good body mechanics can reduce the risk of injury, it does not prevent the risk entirely. The nurse who lifts weights is still capable of injuring himself if correct technique isn’t followed. Lifting an inanimate object is very different from lifting a client. It is recommended that a nurse lift no more than 51 pounds independently, so lifting a dependent client can result in injury to both the nurse and the client if adequate assistance is not obtained. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Objective: Learning Outcome 10-3: Describe the limits of body mechanics regarding nurse and client safety.
6) The nurse may delegate which of the following to the unlicensed assistive personnel (UAP)? Select all that apply.
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A) Determining the number of staff needed for safe transfer B) Assessing the client’s ability to assist with transfers C) Use of a hydraulic lift when moving a client D) Determining appropriate positions for the client E) Encouraging the client to participate as much as possible in repositioning Answer: C, E Explanation: A) The nurse can safely delegate use of a hydraulic lift to the UAP as long as the nurse assesses the UAP’s competence to use the equipment. The UAP should be instructed always to encourage client participation in the provision of care in order to foster autonomy for the client. Determining the number of staff needed to safely transfer a client, assessing the client’s ability to assist, and determining the best position for the client are the nurse’s responsibility because they take advanced education, and should not be delegated to the UAP. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning 5
B) The nurse can safely delegate use of a hydraulic lift to the UAP as long as the nurse assesses the UAP’s competence to use the equipment. The UAP should be instructed always to encourage client participation in the provision of care in order to foster autonomy for the client. Determining the number of staff needed to safely transfer a client, assessing the client’s ability to assist, and determining the best position for the client are the nurse’s responsibility because they take advanced education, and should not be delegated to the UAP. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning C) The nurse can safely delegate use of a hydraulic lift to the UAP as long as the nurse assesses the UAP’s competence to use the equipment. The UAP should be instructed always to encourage client participation in the provision of care in order to foster autonomy for the client. Determining the number of staff needed to safely transfer a client, assessing the client’s ability to assist, and determining the best position for the client are the nurse’s responsibility because they take advanced education, and should not be delegated to the UAP. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning D) The nurse can safely delegate use of a hydraulic lift to the UAP as long as the nurse assesses the UAP’s competence to use the equipment. The UAP should be instructed always to encourage client participation in the provision of care in order to foster autonomy for the client. Determining the number of staff needed to safely transfer a client, assessing the client’s ability to assist, and determining the best position for the client are the nurse’s responsibility because they take advanced education, and should not be delegated to the UAP. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning E) The nurse can safely delegate use of a hydraulic lift to the UAP as long as the nurse assesses the UAP’s competence to use the equipment. The UAP should be instructed always to encourage client participation in the provision of care in order to foster autonomy for the client. Determining the number of staff needed to safely transfer a client, assessing the client’s ability to assist, and determining the best position for the client are the nurse’s responsibility because they take advanced education, and should not be delegated to the UAP. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Planning Objective: Learning Outcome 10-4: Recognize when it is appropriate to delegate positioning of clients to unlicensed assistive personnel.
7) The nurse would do which of the following to support the unresponsive client in the dorsal recumbent position? Select all that apply.
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A) Place several pillows under the client’s head. B) Place a pillow under the lower legs from knee to ankle. C) Place trochanter rolls laterally against the femur. D) Always place a rolled towel or small pillow under the lumbar curvature. E) Elevate the upper arms on pillows. Answer: B, C
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Explanation: A) Usually, only one pillow of adequate thickness would be placed under the client’s head and shoulders to prevent hyperextension of the neck. Placing a pillow under the lower leg prevents hyperextension of the knees, keeps the heels off the bed, and reduces lumbar lordosis. Placing pillows against the femur prevents external rotation of the hips. A pillow should be placed under the lumbar curvature only if a space is found between the lumbar area and the bed. The nurse would elevate the forearms and hands, not the upper arms, on pillows if the client is unconscious or has paralysis of the upper extremities. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation B) Usually, only one pillow of adequate thickness would be placed under the client’s head and shoulders to prevent hyperextension of the neck. Placing a pillow under the lower leg prevents hyperextension of the knees, keeps the heels off the bed, and reduces lumbar lordosis. Placing pillows against the femur prevents external rotation of the hips. A pillow should be placed under the lumbar curvature only if a space is found between the lumbar area and the bed. The nurse would elevate the forearms and hands, not the upper arms, on pillows if the client is unconscious or has paralysis of the upper extremities. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation C) Usually, only one pillow of adequate thickness would be placed under the client’s head and shoulders to prevent hyperextension of the neck. Placing a pillow under the lower leg prevents hyperextension of the knees, keeps the heels off the bed, and reduces lumbar lordosis. Placing pillows against the femur prevents external rotation of the hips. A pillow should be placed under the lumbar curvature only if a space is found between the lumbar area and the bed. The nurse would elevate the forearms and hands, not the upper arms, on pillows if the client is unconscious or has paralysis of the upper extremities. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation D) Usually, only one pillow of adequate thickness would be placed under the client’s head and shoulders to prevent hyperextension of the neck. Placing a pillow under the lower leg prevents hyperextension of the knees, keeps the heels off the bed, and reduces lumbar lordosis. Placing pillows against the femur prevents external rotation of the hips. A pillow should be placed under the lumbar curvature only if a space is found between the lumbar area and the bed. The nurse would elevate the forearms and hands, not the upper arms, on pillows if the client is unconscious or has paralysis of the upper extremities. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation
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E) Usually, only one pillow of adequate thickness would be placed under the client’s head and shoulders to prevent hyperextension of the neck. Placing a pillow under the lower leg prevents hyperextension of the knees, keeps the heels off the bed, and reduces lumbar lordosis. Placing pillows against the femur prevents external rotation of the hips. A pillow should be placed under the lumbar curvature only if a space is found between the lumbar area and the bed. The nurse would elevate the forearms and hands, not the upper arms, on pillows if the client is unconscious or has paralysis of the upper extremities. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Objective: Learning Outcome 10-5: Verbalize the steps used to: A. Support the client’s position in bed. B. Move a client up in bed. C. Turn a client to the lateral or prone position in bed. D. Logroll a client. E. Assist the client to sit on the side of the bed. F. Transfer between bed and chair. G. Transfer between bed and stretcher. H. Operate a hydraulic lift.
8) The nurse is observing two unlicensed assistive personnel (UAPs) moving a client with emphysema up in bed. Which of the following actions would indicate the need for further instruction on the procedure?
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A) One UAP adjusts the bed to a flat position. B) The wheels are locked and the bed is raised to waist level. C) All pillows are removed, with one placed against the head of the bed. D) One UAP stands on either side of the bed. Answer: A Explanation: A) The client with emphysema might not tolerate lying flat in bed, and the nurse would need to instruct the UAPs on the importance of altering their technique based on the needs of the client. The remaining actions are correct procedure. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation B) The client with emphysema might not tolerate lying flat in bed, and the nurse would need to instruct the UAPs on the importance of altering their technique based on the needs of the client. The remaining actions are correct procedure. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation C) The client with emphysema might not tolerate lying flat in bed, and the nurse would need to instruct the UAPs on the importance of altering their technique based on the needs of the client. The remaining actions are correct procedure. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation D) The client with emphysema might not tolerate lying flat in bed, and the nurse would need to instruct the UAPs on the importance of altering their technique based on the needs of the client. The remaining actions are correct procedure. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Evaluation
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Objective: Learning Outcome 10-5: Verbalize the steps used to: A. Support the client’s position in bed. B. Move a client up in bed. C. Turn a client to the lateral or prone position in bed. D. Logroll a client. E. Assist the client to sit on the side of the bed. F. Transfer between bed and chair. G. Transfer between bed and stretcher. H. Operate a hydraulic lift.
9) The nurse is caring for a postoperative client who had a rod placed for scoliosis, and who is required to maintain bedrest. The client is currently supine. What must the nurse do before log rolling the client?
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A) Move the client closer to the side she will turn toward. B) Place a pillow under the client’s head. C) Place one or two pillows between the client’s legs. D) Have the client fold her arms on her chest. Answer: D Explanation: A) Having the client fold her arms on her chest prevents injury to the client and makes logrolling the client smoother and easier for the nurse. The client is moved away from the side she will turn toward, and pillows are not placed until after the client has been positioned. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation B) Having the client fold her arms on her chest prevents injury to the client and makes logrolling the client smoother and easier for the nurse. The client is moved away from the side she will turn toward, and pillows are not placed until after the client has been positioned. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation C) Having the client fold her arms on her chest prevents injury to the client and makes logrolling the client smoother and easier for the nurse. The client is moved away from the side she will turn toward, and pillows are not placed until after the client has been positioned. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation D) Having the client fold her arms on her chest prevents injury to the client and makes logrolling the client smoother and easier for the nurse. The client is moved away from the side she will turn toward, and pillows are not placed until after the client has been positioned. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Objective: Learning Outcome 10-5: Verbalize the steps used to: A. Support the client’s position in bed. B. Move a client up in bed. C. Turn a client to the lateral or prone position in bed. D. Logroll a client. E. Assist the client to sit on the side of the bed. F. Transfer between bed and chair. G. Transfer between bed and stretcher. H. Operate a hydraulic lift. 9
10) The nurse is caring for a client who has been on complete bedrest for the past week. As the nurse assists the client to sit in the chair, the client becomes dizzy when the legs are dangled over the side of the bed. The nurse’s priority action is:
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A) Return the client to bed in the Trendelenburg position. B) Call for help. C) Measure the client’s blood pressure. D) Have the client sit on the edge of the bed for several minutes, and encourage a few deep, slow breathes. Answer: D Explanation: A) It is not unusual for the client who has been on bedrest to experience orthostatic hypotension when he first sits up. The nurse should stay with the client, hold onto him in case he faints, and have the client sit on the edge of the bed taking slow, deep breaths until the symptoms abate. There is no need to place the client in Trendelenburg position or to call for help. It is better that the nurse hold on to the client until the symptoms resolve rather than leave the client to obtain blood pressure equipment. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation B) It is not unusual for the client who has been on bedrest to experience orthostatic hypotension when he first sits up. The nurse should stay with the client, hold onto him in case he faints, and have the client sit on the edge of the bed taking slow, deep breaths until the symptoms abate. There is no need to place the client in Trendelenburg position or to call for help. It is better that the nurse hold on to the client until the symptoms resolve rather than leave the client to obtain blood pressure equipment. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation C) It is not unusual for the client who has been on bedrest to experience orthostatic hypotension when he first sits up. The nurse should stay with the client, hold onto him in case he faints, and have the client sit on the edge of the bed taking slow, deep breaths until the symptoms abate. There is no need to place the client in Trendelenburg position or to call for help. It is better that the nurse hold on to the client until the symptoms resolve rather than leave the client to obtain blood pressure equipment. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation D) It is not unusual for the client who has been on bedrest to experience orthostatic hypotension when he first sits up. The nurse should stay with the client, hold onto him in case he faints, and have the client sit on the edge of the bed taking slow, deep breaths until the symptoms abate. There is no need to place the client in Trendelenburg position or to call for help. It is better that the nurse hold on to the client until the symptoms resolve rather than leave the client to obtain blood pressure equipment. Cognitive Level: Analysis Client Need: Physiological Integrity Nursing Process: Implementation
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Objective: Learning Outcome 10-5: Verbalize the steps used to: A. Support the client’s position in bed. B. Move a client up in bed. C. Turn a client to the lateral or prone position in bed. D. Logroll a client. E. Assist the client to sit on the side of the bed. F. Transfer between bed and chair. G. Transfer between bed and stretcher. H. Operate a hydraulic lift.
11) The nurse is transferring the client who is able to provide minimal assistance from the bed to the wheelchair. The safest way to position the bed and chair is:
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A) Raise the bed height to waist height. B) Place the wheelchair on the client’s strong side. C) Place the wheelchair with the feet pointing toward the side of the bed. D) Lock the wheels of the wheelchair and lower the footplate. Answer: B Explanation: A) The wheelchair should be placed close to the bed on the client’s strong side with the wheels locked and the footrests lifted, not lowered, so they are out of the way. The wheelchair should face the client parallel to the bed. The bed should be placed in the low position so the client’s feet are flat on the floor to prevent injury. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation B) The wheelchair should be placed close to the bed on the client’s strong side with the wheels locked and the footrests lifted, not lowered, so they are out of the way. The wheelchair should face the client parallel to the bed. The bed should be placed in the low position so the client’s feet are flat on the floor to prevent injury. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation C) The wheelchair should be placed close to the bed on the client’s strong side with the wheels locked and the footrests lifted, not lowered, so they are out of the way. The wheelchair should face the client parallel to the bed. The bed should be placed in the low position so the client’s feet are flat on the floor to prevent injury. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation D) The wheelchair should be placed close to the bed on the client’s strong side with the wheels locked and the footrests lifted, not lowered, so they are out of the way. The wheelchair should face the client parallel to the bed. The bed should be placed in the low position so the client’s feet are flat on the floor to prevent injury. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Objective: Learning Outcome 10-5: Verbalize the steps used to: A. Support the client’s position in bed. B. Move a client up in bed. C. Turn a client to the lateral or prone position in bed. D. Logroll a client. E. Assist the client to sit on the side of the bed. F. Transfer between bed and chair. G. Transfer between bed and stretcher. H. Operate a hydraulic lift.
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12) The nurse is transporting the toddler to radiology. The nurse would transport this client by: 12) A) Crib. B) Wheelchair. C) Stretcher. D) Carrying the child. Answer: A Explanation: A) A toddler or infant should always be transported in a crib. If the nurse carries the child and something unexpected happened, there would be no way for the nurse to hold the child and provide care. It is far safer to put the child in a crib with high sides to prevent the child from falling out. A wheelchair or stretcher would not be safe to transport a young child because she could fall out and injure herself. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation B) A toddler or infant should always be transported in a crib. If the nurse carries the child and something unexpected happened, there would be no way for the nurse to hold the child and provide care. It is far safer to put the child in a crib with high sides to prevent the child from falling out. A wheelchair or stretcher would not be safe to transport a young child because she could fall out and injure herself. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation C) A toddler or infant should always be transported in a crib. If the nurse carries the child and something unexpected happened, there would be no way for the nurse to hold the child and provide care. It is far safer to put the child in a crib with high sides to prevent the child from falling out. A wheelchair or stretcher would not be safe to transport a young child because she could fall out and injure herself. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation D) A toddler or infant should always be transported in a crib. If the nurse carries the child and something unexpected happened, there would be no way for the nurse to hold the child and provide care. It is far safer to put the child in a crib with high sides to prevent the child from falling out. A wheelchair or stretcher would not be safe to transport a young child because she could fall out and injure herself. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation Objective: Learning Outcome 10-5: Verbalize the steps used to: A. Support the client’s position in bed. B. Move a client up in bed. C. Turn a client to the lateral or prone position in bed. D. Logroll a client. E. Assist the client to sit on the side of the bed. F. Transfer between bed and chair. G. Transfer between bed and stretcher. H. Operate a hydraulic lift.
13) The nurse positions the client on the sling, wheels the lift into position, and connects the sling to the lift. Priority safety measures before lifting the client include: (Select all that apply.)
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A) Lock the wheels of the lift. B) Open the base to the widest position. C) Lower the side rails. D) Check that the hooks are correctly placed and that matching chains are of equal length. E) Face the hooks toward the client. Answer: A, B, C, D 12
Explanation: A) The wheels should be locked to prevent movement, the base widened to prevent tipping, and the side rails lowered to prevent bumping the client into the side rails when lifted. Unequal chains could result in dropping the client, and improperly placed hooks could scratch the client. Hooks should be turned away from the client. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation B) The wheels should be locked to prevent movement, the base widened to prevent tipping, and the side rails lowered to prevent bumping the client into the side rails when lifted. Unequal chains could result in dropping the client, and improperly placed hooks could scratch the client. Hooks should be turned away from the client. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation C) The wheels should be locked to prevent movement, the base widened to prevent tipping, and the side rails lowered to prevent bumping the client into the side rails when lifted. Unequal chains could result in dropping the client, and improperly placed hooks could scratch the client. Hooks should be turned away from the client. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation D) The wheels should be locked to prevent movement, the base widened to prevent tipping, and the side rails lowered to prevent bumping the client into the side rails when lifted. Unequal chains could result in dropping the client, and improperly placed hooks could scratch the client. Hooks should be turned away from the client. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation E) The wheels should be locked to prevent movement, the base widened to prevent tipping, and the side rails lowered to prevent bumping the client into the side rails when lifted. Unequal chains could result in dropping the client, and improperly placed hooks could scratch the client. Hooks should be turned away from the client. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Objective: Learning Outcome 10-5: Verbalize the steps used to: A. Support the client’s position in bed. B. Move a client up in bed. C. Turn a client to the lateral or prone position in bed. D. Logroll a client. E. Assist the client to sit on the side of the bed. F. Transfer between bed and chair. G. Transfer between bed and stretcher. H. Operate a hydraulic lift.
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14) Which of the following assistive devices would be appropriate for the nurse to use when assisting an unconscious client from the bed to the stretcher? Select all that apply.
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A) Transfer belt B) Transfer board C) Hydraulic lift D) Low-friction sheet E) Egg crate mattress Answer: B, C, D Explanation: A) The transfer board can help slide the client from bed to stretcher, while the hydraulic lift will allow the nurse to lift the client onto the stretcher. The lift can be particularly helpful if the client is large in size. A low-friction sheet allows the nurse to slide the client with reduced drag, requiring less energy to make the move. Transfer belts would not be helpful when moving the unconscious client from bed to stretcher. Egg crate mattresses increase drag, and therefore increase the amount of energy required to slide the client. Placing a low-friction sheet over the egg crate can reduce this drag. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation B) The transfer board can help slide the client from bed to stretcher, while the hydraulic lift will allow the nurse to lift the client onto the stretcher. The lift can be particularly helpful if the client is large in size. A low-friction sheet allows the nurse to slide the client with reduced drag, requiring less energy to make the move. Transfer belts would not be helpful when moving the unconscious client from bed to stretcher. Egg crate mattresses increase drag, and therefore increase the amount of energy required to slide the client. Placing a low-friction sheet over the egg crate can reduce this drag. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation C) The transfer board can help slide the client from bed to stretcher, while the hydraulic lift will allow the nurse to lift the client onto the stretcher. The lift can be particularly helpful if the client is large in size. A low-friction sheet allows the nurse to slide the client with reduced drag, requiring less energy to make the move. Transfer belts would not be helpful when moving the unconscious client from bed to stretcher. Egg crate mattresses increase drag, and therefore increase the amount of energy required to slide the client. Placing a low-friction sheet over the egg crate can reduce this drag. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation D) The transfer board can help slide the client from bed to stretcher, while the hydraulic lift will allow the nurse to lift the client onto the stretcher. The lift can be particularly helpful if the client is large in size. A low-friction sheet allows the nurse to slide the client with reduced drag, requiring less energy to make the move. Transfer belts would not be helpful when moving the unconscious client from bed to stretcher. Egg crate mattresses increase drag, and therefore increase the amount of energy required to slide the client. Placing a low-friction sheet over the egg crate can reduce this drag. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation
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E) The transfer board can help slide the client from bed to stretcher, while the hydraulic lift will allow the nurse to lift the client onto the stretcher. The lift can be particularly helpful if the client is large in size. A low-friction sheet allows the nurse to slide the client with reduced drag, requiring less energy to make the move. Transfer belts would not be helpful when moving the unconscious client from bed to stretcher. Egg crate mattresses increase drag, and therefore increase the amount of energy required to slide the client. Placing a low-friction sheet over the egg crate can reduce this drag. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Objective: Learning Outcome 10-6: List indications and contraindications for assistive devices when lifting and transferring clients.
15) The nurse is caring for an unconscious client who has foot drop. Which of the following would be useful in properly aligning the foot?
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A) Pillows B) Footboard C) Trochanter roll D) Foot boot Answer: D Explanation: A) A foot boot provides support to the feet in a natural position and keeps the weight of the covers off the toes. Pillows will not be effective in providing enough support to prevent foot drop. A foot board can be effective for preventing dorsiflexion but will not address foot drop. A trochanter roll prevents external rotation of the leg. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation B) A foot boot provides support to the feet in a natural position and keeps the weight of the covers off the toes. Pillows will not be effective in providing enough support to prevent foot drop. A foot board can be effective for preventing dorsiflexion but will not address foot drop. A trochanter roll prevents external rotation of the leg. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation C) A foot boot provides support to the feet in a natural position and keeps the weight of the covers off the toes. Pillows will not be effective in providing enough support to prevent foot drop. A foot board can be effective for preventing dorsiflexion but will not address foot drop. A trochanter roll prevents external rotation of the leg. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation D) A foot boot provides support to the feet in a natural position and keeps the weight of the covers off the toes. Pillows will not be effective in providing enough support to prevent foot drop. A foot board can be effective for preventing dorsiflexion but will not address foot drop. A trochanter roll prevents external rotation of the leg. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Objective: Learning Outcome 10-7: Demonstrate how to effectively support and maintain proper alignment of clients for the described bed positions included in this chapter.
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16) The nurse is responsible for documenting all of the following related to positioning except: 16) A) Number of personnel required for turning and positioning. B) Client’s ability to assist with positioning. C) Any signs of pressure areas or contractures. D) Instructions provided to unlicensed assistive personnel (UAP). Answer: D Explanation: A) The nurse would not document instructions provided to staff in the client’s medical record. However, the nurse would document the number of personnel required for turning and positioning the client, to provide for continuity of care. The client’s ability to assist with positioning is important documentation to track the client’s progress. Pressure areas or contractures are important information to document. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation B) The nurse would not document instructions provided to staff in the client’s medical record. However, the nurse would document the number of personnel required for turning and positioning the client, to provide for continuity of care. The client’s ability to assist with positioning is important documentation to track the client’s progress. Pressure areas or contractures are important information to document. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation C) The nurse would not document instructions provided to staff in the client’s medical record. However, the nurse would document the number of personnel required for turning and positioning the client, to provide for continuity of care. The client’s ability to assist with positioning is important documentation to track the client’s progress. Pressure areas or contractures are important information to document. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation D) The nurse would not document instructions provided to staff in the client’s medical record. However, the nurse would document the number of personnel required for turning and positioning the client, to provide for continuity of care. The client’s ability to assist with positioning is important documentation to track the client’s progress. Pressure areas or contractures are important information to document. Cognitive Level: Analysis Client Need: Safe, Effective Care Environment Nursing Process: Implementation Objective: Learning Outcome 10-8: Demonstrate appropriate documentation and reporting of positioning skills.
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