Chapter 44 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 44

Question 1

Type: MCMA

The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the clients legs when turning?

Standard Text: Select all that apply.

1. Stabilizes the spine

2. Prevents hip contractures

3. Supports the upper leg

4. Keeps the legs parallel and aligned

5. Prevents adduction of the upper leg

Correct Answer: 3, 4, 5

Rationale 1: A pillow between the legs when logrolling does not stabilize the spine.

Rationale 2: A pillow between the legs when logrolling does not prevent hip contractures.

Rationale 3: A pillow between the clients legs when logrolling supports the upper leg when the client is turned.

Rationale 4: A pillow between the clients legs when logrolling keeps the legs parallel and aligned.

Rationale 5: A pillow between the clients legs when logrolling prevents adduction of the upper leg.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: c. Logrolling a client.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1042

Question 2

Type: MCSA

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?

1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy.

2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day.

3. Healthy pregnant women should exercise at least 30 minutes on most if not all days.

4. The pregnant womans exercise should actually increase above normal recommended levels to prevent water weight gain.

Correct Answer: 3

Rationale 1: Pregnant clients should be encouraged to exercise, regardless if exercise was a part of life prior to being pregnant.

Rationale 2: Exercise should be done 30 minutes on most days.

Rationale 3: The current recommendation of the American College of Obstetricians and Gynecologists is for healthy pregnant women to get as much exercise as the general population (30 minutes on most if not all days). This is a change from the previous recommendation that pregnant women can exercise.

Rationale 4: There is no indication that the pregnant woman needs more exercise than the general population.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Compare the effects of exercise and immobility on body systems.

MNL Learning Outcome: 4.3.2. Recognize factors that affect movement and immobility.

Page Number: 1017

Question 3

Type: MCSA

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

1. Institute an exercise plan that includes weight-bearing activities.

2. Increase the amount of calcium in the clients diet.

3. Protect the clients bones with strict bed rest.

4. Provide the client with assisted range-of-motion exercising twice daily.

Correct Answer: 1

Rationale 1: Osteoporosis is a demineralization of the bone in which calcium leaves the bone matrix. One causative factor is lack of weight-bearing activity. Weight bearing helps to move calcium back into the bones, thereby strengthening them. A standard intervention for those attempting to prevent or reverse osteoporosis is beginning an exercise plan that includes weight-bearing activities.

Rationale 2: Additional calcium in the diet after osteoporosis has begun is not thought to be effective.

Rationale 3: Strict bed rest may well make the osteoporosis worse because there is no weight-bearing activity.

Rationale 4: Assisted range-of-motion exercises are not weight-bearing activities and do not help delay or reverse osteoporosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Differentiate isotonic, isometric, isokinetic, aerobic, and anaerobic exercise.

MNL Learning Outcome: 4.3.2. Recognize factors that affect movement and immobility.

Page Number: 1020

Question 4

Type: MCSA

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

1. Frequent position changes to reverse the contractures

2. Exercises to strengthen flexor muscles

3. Range-of-motion exercises to prevent worsening of contractures

4. Weight-bearing activities to stimulate joint relaxation

Correct Answer: 3

Rationale 1: Frequent position changes will not reverse contractures.

Rationale 2: The contracture occurs because the flexor muscles are stronger than the extensor muscles. This imbalance in strength pulls the inactive joint into a flexed position, and a permanent shortening of the muscle occurs.

Rationale 3: Once contractures occur they are irreversible except by surgical intervention. The best nursing intervention is to keep the contractures from getting tighter (or worse) by providing range-of-motion exercises.

Rationale 4: Weight-bearing activities will not reverse contractures.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility.

MNL Learning Outcome: 4.3.2. Recognize factors that affect movement and immobility.

Page Number: 1051

Question 5

Type: MCSA

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

1. Decrease in blood pressure when moving from supine to standing

2. Decrease in heart rate when moving from supine to sitting

3. Pale color in the legs when lying in bed

4. Complaints of dizziness when first sitting up

Correct Answer: 1

Rationale 1: Orthostatic hypotension occurs when the normal vasoconstriction reflex in the legs is dormant and the clients central blood pressure drops when moving from supine to sitting or to standing.

Rationale 2: Orthostatic hypotension is a drop in blood pressure not a drop in heart rate.

Rationale 3: Paleness of the legs is not significant.

Rationale 4: The blood pressure drops, the heart rate increases, and the client may complain of dizziness or may faint upon arising.

Global Rationale: Page Reference:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility.

MNL Learning Outcome: 4.3.2. Recognize factors that affect movement and immobility.

Page Number: 1054

Question 6

Type: MCSA

The clients chief complaint is, I just cant get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired. Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance:

1. Level 1.

2. Level 2.

3. Level 3.

4. Level 4.

Correct Answer: 3

Rationale 1: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 1 indicates normal activity with slightly more shortness of breath.

Rationale 2: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 2 indicates ability to walk about one level city block without difficulty or to climb one flight of stairs without stopping.

Rationale 3: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 3 (this clients level) indicates ability to walk no more than 50 feet on level ground without stopping and inability to climb one flight of stairs without stopping.

Rationale 4: The NANDA diagnosis Activity Intolerance is further individualized to the clients level of intolerance. Level 4 indicates dyspnea and fatigue at rest.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1030

Question 7

Type: MCSA

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?

1. Include what mobility is impaired.

2. Use Level 1, 2, 3, or 4 to describe immobility.

3. Describe what happens when the client attempts mobility.

4. Add strength assessment data.

Correct Answer: 1

Rationale 1: In order to make this broad nursing diagnosis more specific to the client, the nurse should include what mobility is impaired. For example, if the client cannot transfer from bed to chair, a more specific nursing diagnosis is Impaired Transfer Mobility.

Rationale 2: There are NANDA levels of activity intolerance, but not of immobility.

Rationale 3: Describing what happens when the client attempts mobility might be used in the as manifested by section of the nursing diagnosis, but not in the problem statement section.

Rationale 4: Strength assessment data might be used in the as manifested by section of the nursing diagnosis, but not in the problem statement section.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Develop nursing diagnoses and outcomes related to activity, exercise, and mobility problems.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1030

Question 8

Type: MCSA

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?

1. Nurses must wear back belts when lifting clients.

2. All nursing personnel must attend annual body mechanics education.

3. In order to prevent injury, nurses must strive to become physically fit.

4. No solo lifting of clients is permitted in the facility.

Correct Answer: 4

Rationale 1: Wearing a back belt does not prevent injury.

Rationale 2: Body mechanics training does not prevent injuries.

Rationale 3: Physical fitness does not prevent back injury.

Rationale 4: The only option that has any influence on frequency of back injury is a practice prohibiting solo lifting.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients.

MNL Learning Outcome: 4.3.1. Recognize aspects of normal movement and associated physiology.

Page Number: 1033

Question 9

Type: MCSA

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?

1. Place the feet together to provide a strong base of support.

2. Flex the knees to lower the center of gravity.

3. Face the box, pick it up, and rotate the upper body toward the table.

4. Hold the box as close to the body as possible.

Correct Answer: 4

Rationale 1: Placing the feet together makes the body more unstable and more likely to fall.

Rationale 2: In order to pick up this box as safely as possible, the nurse should flex the knees to lower the center of gravity.

Rationale 3: After picking up the weight, the body should not be rotated, but should be turned to face the table.

Rationale 4: In order to pick up this box as safely as possible, the nurse should hold the box as close to the body as possible.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients.

MNL Learning Outcome: 4.3.1. Recognize aspects of normal movement and associated physiology.

Page Number: 1033

Question 10

Type: MCSA

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

1. High Fowlers position with two pillows behind the head

2. Orthopneic position across the overbed table

3. Prone position with knees flexed and arms extended

4. Sims position with both legs flexed

Correct Answer: 2

Rationale 1: The high Fowlers position should not be used with more than one pillow or with overly large pillows.

Rationale 2: The orthopneic position across the overbed table facilitates respiration by allowing maximum chest expansion.

Rationale 3: The prone position places the client on the abdomen and makes chest expansion difficult.

Rationale 4: The Sims position is a side-lying position and does not support full chest expansion as much as the orthopneic position.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility.

MNL Learning Outcome: 4.3.2. Recognize factors that affect movement and immobility.

Page Number: 1037

Question 11

Type: MCSA

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

1. Give the client a washcloth to wash the face.

2. Move the wash basin farther toward the foot of the bed so the client must reach for it.

3. Have the client brush the hair and teeth.

4. Move each of the clients hand and arm joints through passive range of motion.

Correct Answer: 3

Rationale 1: This activity does not utilize all of the major joints in the hands and arms.

Rationale 2: The wash basin should be close to the client to prevent overreaching and possible falls.

Rationale 3: Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face.

Rationale 4: Passive range of motion is a second best choice after normal use of the joints.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Compare and contrast active, passive, and active-assistive range-of-motion (ROM) exercises.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1050

Question 12

Type: MCSA

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

1. Deeply palpate the area for rebound tenderness.

2. Percuss over the area for change in tone.

3. Measure the calf and compare to the opposite calf.

4. Medicate the client for pain and reassess in 30 minutes.

Correct Answer: 3

Rationale 1: Palpating the area is contraindicated because injury to the vein may induce a thrombus.

Rationale 2: Percussing the area is contraindicated because injury to the vein may induce a thrombus.

Rationale 3: The nurse should measure the calf and compare it to the opposite calf. The client may be developing a deep vein thrombosis or thrombophlebitis.

Rationale 4: Medicating the client and reassessing in 30 minutes might allow a worsening of the clients condition.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1029

Question 13

Type: MCSA

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

1. Percuss for flatness over the liver.

2. Palpate for bladder fullness.

3. Use the p.r.n. order to medicate the client with an antacid.

4. Inspect the sacral area for edema.

Correct Answer: 2

Rationale 1: Flatness is the normal percussion sound over the liver.

Rationale 2: The nurse should palpate for bladder fullness that could cause this discomfort.

Rationale 3: The nurse should not medicate the client until assessment is complete.

Rationale 4: Sacral edema may occur with the bed-bound client, but should not be a contributor to abdominal pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1029

Question 14

Type: MCSA

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

1. Place high-topped shoes on the client while in bed.

2. Keep the linens on the end of the bed turned back to expose the feet.

3. Use only the prone and Sims positions for client positioning.

4. Use a device to elevate the linens off the feet.

Correct Answer: 1

Rationale 1: High-topped shoes will place the clients feet in the anatomical position of dorsal flexion.

Rationale 2: Turning the linens back will keep the weight of the linens off of the feet but will not prevent foot drop.

Rationale 3: The prone and Sims positions are implicated in the development of foot drop.

Rationale 4: A device to elevate the linens off of the feet will not prevent foot drop.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1035

Question 15

Type: MCMA

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.

1. Place a turn sheet on the bed.

2. Always use two personnel to move the client.

3. Stand at the head of the bed to pull the client up.

4. Slide the client toward the head of the bed.

5. Encourage the client to assist as possible.

Correct Answer: 1, 2, 5

Rationale 1: Placing a turn sheet on the bed will help overcome inertia and friction during moving.

Rationale 2: Using two personnel will allow a lift and move rather than pulling or sliding the client over linens.

Rationale 3: The personnel should stand on either side of the bed and use the turn sheet to move the client.

Rationale 4: Sliding the client causes friction. The client should be moved using the turn sheet.

Rationale 5: Encouraging the client to assist as much as possible will lighten the workload.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1035

Question 16

Type: MCSA

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

1. Perform hand hygiene.

2. Move the client to the side of the bed.

3. Place the clients arm over the chest.

4. Raise the opposite side rail.

Correct Answer: 1

Rationale 1: Even though the intervention being performed is placing the client on a bedpan, the nurse should first perform hand hygiene. This prevents cross-transmission of infection from one client to another. Performing this hygiene in front of the client also increases the clients perception of the quality of care being provided and the nurses concern about infection control.

Rationale 2: This action is done later in the procedure.

Rationale 3: This action is done later in the procedure.

Rationale 4: This action is done later in the procedure.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1041

Question 17

Type: MCSA

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

1. A client with documented pneumonia

2. The client who has had abdominal surgery

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

4. A client who has a severe headache from hypertensive crisis

Correct Answer: 3

Rationale 1: There is no physiological reason why a client with pneumonia would need to be logrolled.

Rationale 2: There is no physiological reason why a client recovering from abdominal surgery would need to be logrolled.

Rationale 3: The logrolling technique is used in moving any client who may have sustained a spinal injury. Of these clients, the most concern is for the client who fell from a house.

Rationale 4: There is no physiological reason why the client with a headache would need to be logrolled.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Use safe practices when positioning, moving, transferring, and ambulating clients.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1042

Question 18

Type: MCSA

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?

1. Toward the nearest corner of the head of the bed

2. Toward the side of the bed

3. Toward the far corner of the foot of the bed

4. Directly toward the client

Correct Answer: 3

Rationale 1: This position could cause the nurses trunk to twist.

Rationale 2: This position could cause the nurses trunk to twist.

Rationale 3: The nurse should face the far corner of the foot of the bed because this is the direction in which movement will occur.

Rationale 4: This position could cause the nurses trunk to twist.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: d. Assisting a client to sit on the side of the bed.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1054

Question 19

Type: MCSA

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

1. Place the bed in its lowest position.

2. Place the wheelchair parallel to the bed.

3. Lock the brakes on the bed.

4. Place a transfer belt on the client.

Correct Answer: 3

Rationale 1: This is not the most important action of the nurse.

Rationale 2: This is not the most important action of the nurse.

Rationale 3: Although all of these activities address important safety issues, the most important is to lock the wheels on the bed. If the wheels are not locked and the bed moves out from under the client, none of the other safety actions will likely prevent a fall or near fall.

Rationale 4: This is not the most important action.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: e. Transferring between bed and chair.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1047

Question 20

Type: MCSA

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

1. slightly higher.

2. slightly lower.

3. at the same height.

4. at least 2 inches lower.

Correct Answer: 1

Rationale 1: When transferring a client from bed to gurney, the bed should be parallel to the stretcher and slightly higher. It is easier for the client to move down a slant to the new surface than to move up to a higher surface or to an even surface.

Rationale 2: It is easier for the client to move down a slant to the new surface than to move up to a higher surface.

Rationale 3: It is easier for the client to move down a slant to the new surface than to move up to an even surface.

Rationale 4: It is easier for the client to move down a slant to the new surface than to move up to a higher surface.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: f. Transferring between bed and stretcher.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1049

Question 21

Type: MCSA

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?

1. The UAP

2. A licensed practical (vocational) nurse

3. A registered nurse

4. It makes no difference

Correct Answer: 3

Rationale 1: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client.

Rationale 2: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client.

Rationale 3: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. The registered nurse must assess and evaluate the clients response to the ambulation. Once the client has successfully ambulated, any nursing staff member can assist. The registered nurse should make assistive personnel aware of potential untoward effects of ambulation and of what to report to the nurse.

Rationale 4: Because this is the first time this client has ambulated, the best choice is for the registered nurse to ambulate the client. Once the client has successfully ambulated, any nursing staff member can assist.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 11. Recognize when it is appropriate to delegate aspects of moving, transferring, and ambulating a client to unlicensed assistive personnel.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1053

Question 22

Type: MCSA

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 nurses most important action?

1. Ensure the clients modesty as she falls.

2. Be certain the client does not hit the head on anything.

3. Call for immediate assistance.

4. Check the vital signs and for excessive vaginal bleeding.

Correct Answer: 2

Rationale 1: This is not the priority for the nurse at this time.

Rationale 2: All of these actions are important, but the priority is ensuring the client does not strike her head on anything when falling. The nurse should ease the client down while supporting her body against the nurse, protecting the head and laying it gently on the floor.

Rationale 3: This is important; however, it does not address that the client is falling.

Rationale 4: This is important to do after the client has been assisted to the floor.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Verbalize the steps used in: g. Assisting a client to ambulate.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1054

Question 23

Type: MCSA

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

1. Stop immediately and report the pain to the clients physician.

2. Discontinue the treatment and document the results in the medical record.

3. Reduce the movement of the joint just until the point of slight resistance.

4. Continue to exercise the joint as before to loosen the stiffness.

Correct Answer: 3

Rationale 1: Stopping the treatment is not justified until an assessment occurs.

Rationale 2: Stopping the exercises is not justified until an assessment occurs.

Rationale 3: Range-of-motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued.

Rationale 4: Continuing at the same level of intensity may cause damage to the joint as well as cause the client pain.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Compare and contrast active, passive, and active-assistive range-of-motion (ROM) exercises.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1050

Question 24

Type: MCMA

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.

1. Hot baths

2. Heavy meals

3. Use of a rocking chair

4. Moving in bed

5. Bending down to the floor

Correct Answer: 1, 2, 5

Rationale 1: Hot baths can cause venous pooling in the lower extremities.

Rationale 2: Heavy meals divert blood to the gastrointestinal organs.

Rationale 3: Use of a rocking chair can be good for the client, as the rocking action exercises the legs.

Rationale 4: Moving in bed is not likely to cause postural hypotension.

Rationale 5: Bending to the floor can cause rapid changes in blood pressure upon standing up again.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Assess activity-exercise pattern, body alignment, gait, appearance and movement of joints, mobility capabilities and limitations, muscle mass and strength, activity tolerance, and problems related to immobility.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 1053

Question 25

Type: MCMA
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.

1. Hold the cane on the weaker side of the body.

2. Move the cane forward while the body weight is between both legs.

3. The length of the cane should permit the elbow to be fully extended.

4. Move the weaker leg forward while the weight is between the cane and the stronger leg.

5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

Correct Answer: 2, 4, 5

Rationale 1: The can should be held on the stronger side of the body to provide maximum support and appropriate body alignment while walking.

Rationale 2: The cane should be moved forward while the body weight is borne by both legs.

Rationale 3: The length should permit the elbow to be slightly flexed.

Rationale 4: The weaker leg is moved forward while the weight is borne by the cane and stronger leg.

Rationale 5: The stronger leg is moved forward while the weight is borne by the cane and weak leg.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Describe client teaching for clients who use mechanical aids for walking.

MNL Learning Outcome: 4.3.4. Implement strategies to promote mobility through the use of assistive devices.

Page Number: 1056

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