Chapter 18: Lifting, Moving, and Positioning Patients My Nursing Test Banks

Chapter 18: Lifting, Moving, and Positioning Patients

Test Bank

MULTIPLE CHOICE

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

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.

ANS: D

Back injuries are the most common injury in health care workers, and in many cases, they are preventable through use of proper body mechanics.

DIF: Cognitive Level: Knowledge REF: p. 259 OBJ: Theory #2

TOP: Body Mechanics KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

2. The nurse assisting a weak patient from a bed to the wheelchair to go to physical therapy would:

a.

seat the patient on the side of the bed with feet touching the floor.

b.

place hands under the patients elbows to assist in rising.

c.

lock knees as the patient is lowered to the chair.

d.

assist the patient to don a robe after being seated in the wheelchair.

ANS: A

After locking the wheels of the wheelchair, seat the patient on the side of the bed with the feet touching the floor.

DIF: Cognitive Level: Application REF: p. 276, Skill 18-4

OBJ: Clinical Practice #1 TOP: Patient Transfers

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment

3. 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:

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.

ANS: B

A patient who can stand can safely be assisted to pivot and transfer with the use of a transfer belt. This benefits the patient (active exercise) and is safe for both the nurse and the patient.

DIF: Cognitive Level: Application REF: p. 276, Skill 18-4

OBJ: Theory #5 TOP: Patient Transfers

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

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

a.

Most of your assigned patients are able to move about a little. Dont 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 doesnt assist at all.

d.

Use your back muscles to liftthat will strengthen them and make it easier for you to lift or move heavy patients.

ANS: C

Getting adequate assistance and using mechanical assistance are important to reduce injury to staff and patients. It also increases the comfort of the move for the patient.

DIF: Cognitive Level: Application REF: p. 260, Box 18-4

OBJ: Theory #3 TOP: Patient Transfers

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

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

a.

66-year-old patient with loss of mobility related to a recent cerebrovascular accident (CVA).

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.

ANS: A

A patient with a recent CVA is unable to independently change position or move the affected side. The patient may regain use of motor functions lost, so it is very important to prevent loss of muscle strength, contractures, and pressure ulcers.

DIF: Cognitive Level: Analysis REF: p. 272, Skill 18-3

OBJ: Theory #2 TOP: Patient Positioning

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

6. 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:

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.

ANS: D

The prone position is an excellent (but underused) position to take pressure off the sacral area. Raising the head and the knees of the patient interferes with venous return from the legs and puts a great deal of pressure on the sacrum. Use of a wheelchair for a semiconscious patient is not effective.

DIF: Cognitive Level: Application REF: p. 264 OBJ: Theory #2

TOP: Patient Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

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

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 patients back to support her and prevent her from rolling onto her back.

ANS: B

A waist-high bed height is a comfortable and safe working height for the nurse and also prevents staff back injuries. The head is not raised in a side-lying position; it is in a Fowlers or semi-Fowlers position.

DIF: Cognitive Level: Application REF: p. 265, Skill 18-1

OBJ: Clinical Practice #1 TOP: Body Mechanics

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

8. To provide correct body alignment for a physically immobile patient in bed in the supine position, the nurse:

a.

uses trochanter rolls between the patients legs to prevent inward rotation.

b.

places a large pillow behind the patients head and neck to hyperflex the neck.

c.

raises the head and knees to maintain as much flexion of the hips and knees as possible.

d.

uses a footboard or places high-top sneakers on the patients feet to maintain dorsiflexion.

ANS: D

The use of high-top sneakers (or a footboard) prevents footdrop and maintains dorsiflexion.

DIF: Cognitive Level: Application REF: p. 264 OBJ: Theory #2

TOP: Patient Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

9. A nurse and an assistant are preparing to get a patient out of bed for the first time after a week of bed rest. They begin by having the patient dangle on the edge of the bed. The nurse should:

a.

allow the patient to dangle for 10 to 15 minutes and then transfer her to a nearby chair.

b.

perform passive range-of-motion exercises on the patients arms and legs while she is dangling to improve circulation.

c.

assess the patients response to the changed position, looking for orthostatic hypotension, nausea, or dizziness before proceeding.

d.

dangle the patient only momentarily and then assist her to ambulate as far as she is able.

ANS: C

A patient who has been immobilized for any length of time may feel dizzy or experience a drop in blood pressure when sitting or standing for the first time. Therefore the nurse must assess the patient carefully to determine whether transfer to a chair, ambulation, or return to bed is indicated.

DIF: Cognitive Level: Analysis REF: p. 276 OBJ: Clinical Practice #2

TOP: Sitting up on Side of Bed KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

10. The nurse caring for a patient with a nursing diagnosis of Injury, risk for, related to right-sided weakness as evidenced by unsteady gait, would accommodate the patient by:

a.

keeping the right arm in a sling to prevent injury.

b.

keeping bed rails up to prevent the patient from attempting to get up unassisted.

c.

placing the wheelchair on the left side of the patient before transfer.

d.

allowing unassisted ambulation with the support of a walker.

ANS: C

Placing the wheelchair on the patients stronger side aids in transfer.

DIF: Cognitive Level: Application REF: p. 276, Skill 18-4

OBJ: Theory #5 TOP: Patient Transfers

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

11. The nurse explains to the unlicensed assistive personnel (UAP) that a shearing force is applied to the patient when:

a.

a lifting sheet is used to move the patient to a stretcher.

b.

the patient is pulled up in bed without being lifted.

c.

the patient is seated in a wheelchair without a pressure cushion.

d.

the patient is left in the supine position.

ANS: B

When a patient is pulled up in bed without being lifted up first, shearing force is applied on the bony prominences and tissues of the back, which predisposes the patient to a pressure ulcer.

DIF: Cognitive Level: Comprehension REF: p. 262 OBJ: Theory #3

TOP: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

12. 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:

a.

places her in low- or semi-Fowlers 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.

ANS: B

Logrolling, or moving the patients body as one unit, is used after back surgery or trauma or when twisting or flexion must be avoided. Logrolling is accomplished using a sheet and at least two persons.

DIF: Cognitive Level: Application REF: p. 268 OBJ: Theory #3

TOP: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

13. 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?

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

ANS: B

A hand splint or rolled cloth in the palm of her hand (along with range-of-motion exercises) will help prevent flexion contractures of her hand. A trochanter roll prevents outward rotation, not flexion.

DIF: Cognitive Level: Application REF: p. 265, Skill 18-1

OBJ: Theory #3 TOP: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

14. When the post-stroke patient complains to the nurse, I dont see why you are wasting your time doing the passive range-of-motion exercises on my legs, the nurses most informative response would be based on the knowledge that the exercises:

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.

ANS: C

Passive range-of-motion (ROM) exercises, although not part of care given to all patients, does prevent contractures in persons who are bedfast. ROM does not guarantee the prevention of pressure ulcers but helps in the improved circulation of the limbs.

DIF: Cognitive Level: Application REF: p. 272, Skill 18-3

OBJ: Clinical Practice #3 TOP: Effects of ROM

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

15. While the nurse is assisting a patient to ambulate, the patient suddenly says, Im dizzy. I cant stand up. As the patient begins to fall, the nurse should:

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.

ANS: C

A patient who is threatening to fall needs to be lowered to the floor to avoid injury from a fall by allowing the patient to gently slide down the nurses leg to the floor.

DIF: Cognitive Level: Analysis REF: p. 282, Skill 18-6

OBJ: Clinical Practice #6 TOP: Patient Transfers

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

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

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.

ANS: B

Active ROM is best to restore strength in a weak patient who can independently perform activities of daily living but is immobilized because of injury.

DIF: Cognitive Level: Application REF: p. 271 OBJ: Clinical Practice #3

TOP: Active Range of Motion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

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

a.

slides his hand from the bottom under the gait belt at the middle of the patients back.

b.

grasps the gait belt from the top at the middle of the patients back, pulling it tight against the patients abdomen.

c.

has one person on each side grasp the belt from the top.

d.

secures a regular mans belt snugly around the patients waist to use if the patient starts to fall.

ANS: A

The nurse puts his hand from the bottom at the rear, so he can pull up if the patient starts to fall and not lose the grip on the gait belt. The gait belt should be tight enough to secure the patient, but loose enough for the passage of the nurses hand.

DIF: Cognitive Level: Application REF: p. 279

OBJ: Theory #5 | Clinical Practice #6 TOP: Assisted Ambulation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

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

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 arms distance from the patient when lifting or transferring the patient.

ANS: A

Fixing feet and placing one foot in front of the other and facing the direction of the movement will ease the work of moving a patient up in bed. Pulling requires less effort than pushing in this scenario. Twisting should be avoided; nurses should use leg muscles rather than back muscles to pick up objects from the floor. Work should be close to the body to reduce effort and strain.

DIF: Cognitive Level: Application REF: p. 265, Skill 18-1

OBJ: Theory #2 TOP: Body Mechanics

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

19. A nurse is instructing one of the facilitys 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:

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.

ANS: A

Guidelines for moving and lifting include obtaining help whenever possible; asking the patient to help if able; using thigh, arm, or leg muscles rather than back muscles; and using a wide base of support.

DIF: Cognitive Level: Comprehension REF: p. 265, Skill 18-1

OBJ: Theory #2 TOP: Body Mechanics

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

20. A physician orders the nurse to place a patient in Fowlers position. The nurse should elevate the head of the patients bed _____ degrees.

a.

60 to 90

b.

30 to 60

c.

15 to 30

d.

10 to 15

ANS: A

Fowlers position is arranged by elevating the head of the bed 60 to 90 degrees. Semi-Fowlers position is an elevation of 30 to 60 degrees, and low-Fowlers is an elevation of 15 to 30 degrees. Unless contraindicated, the knees can be raised 10 to 15 degrees in these positions.

DIF: Cognitive Level: Comprehension REF: p. 265, Skill 18-1

OBJ: Clinical Practice #1 TOP: Patient Positioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

21. 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 nurses most informative response would be:

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 wont do the work they used to do.

d.

Additional vitamins will build your strength back up in a few months.

ANS: B

Fat replaces muscle cells, which leads to loss of strength and stamina.

DIF: Cognitive Level: Application REF: p. 259 OBJ: Clinical Practice #1

TOP: Patient Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

COMPLETION

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

ANS:

movement

Ligaments and tendons attach to bones at the joints, which allows movement.

DIF: Cognitive Level: Comprehension REF: p. 259 OBJ: Theory #1

TOP: Structure and Function of Musculoskeletal System KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

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

ANS:

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.

DIF: Cognitive Level: Knowledge REF: p. 262 OBJ: Theory #2

TOP: Complications KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

24. The nurse reminds a patient that one of the anatomic parts of a joint that allows the joint to move freely is the fluid-filled ___________.

ANS:

bursa

Bursa are small fluid-filled sacs that provide a cushion at friction points and provide freely movable joints.

DIF: Cognitive Level: Knowledge REF: p. 259 OBJ: Theory #1

TOP: Bursa KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

MULTIPLE RESPONSE

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

a.

Pressure ulcers

b.

Osteoporosis

c.

Contractures

d.

Increased blood pressure

e.

Fluid in the lungs

f.

Elevated temperature

ANS: A, C, E

Constant pressure on the skin, especially on bony prominences, interferes with circulation, causing pressure ulcers. Contractures occur when joints are not positioned frequently, and fluid can accumulate in the lungs with infrequent positioning. Osteoporosis, increased blood pressure, and elevated temperature are not results of improper alignment or positioning.

DIF: Cognitive Level: Comprehension REF: p. 262 OBJ: Theory #2

TOP: Patient Positioning KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: reduction of risk

26. 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.)

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-Fowlers position.

f.

Place the patient flat on her back.

ANS: A, D, F

The patients increased weight and inability to assist requires at least two people to move her up in bed. A lift sheet enables the patient to be moved. Placing the patient on her back decreases gravitational pull, making the move easier. A mechanical lift is used to transfer a patient, not to move her up in bed.

DIF: Cognitive Level: Application REF: p. 269, Skill 18-2

OBJ: Clinical Practice #3 TOP: Patient Moving

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

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