Question 1

The nurse is caring for a patient who is ordered to remain on bed rest.Which is the appropriate action of the nurse to facilitate emptying of the patient's bladder?

Accepted Answer

A)  Assist the patient to the bedside commode for voiding. 
B)  Insert an indwelling urinary catheter to bedside drainage. 
C)  Place the patient in high Fowler's position when using the bedpan. 
D)  Place the patient in Trendelenburg's position when using the bedpan. 
A)  Assist the patient to the bedside commode for voiding. 
B)  Insert an indwelling urinary catheter to bedside drainage. 
C)  Place the patient in high Fowler's position when using the bedpan. 
D)  Place the patient in Trendelenburg's position when using the bedpan.

Question 2

The patient refuses to get out of bed to ambulate after surgery.Which is the appropriate response of the nurse?

Accepted Answer

A)  "No problem.You should rest quietly in bed today so that you can heal." 
B)  "It is important to get out of bed and walk to prevent blood clots or pneumonia." 
C)  "I will notify your doctor that you refused and make a notation in your chart." 
D)  "You can have your next dose of pain medication after you get up and walk." 
A)  "No problem.You should rest quietly in bed today so that you can heal." 
B)  "It is important to get out of bed and walk to prevent blood clots or pneumonia." 
C)  "I will notify your doctor that you refused and make a notation in your chart." 
D)  "You can have your next dose of pain medication after you get up and walk."

Question 3

Which is the priority nursing diagnosis for a patient with orthostatic hypotension after several days of bed rest?

Accepted Answer

A)  Risk for falls related to light-headedness upon standing and getting out of bed 
B)  Dressing/grooming self-care deficit related to cognitive impairment and fatigue 
C)  Impaired bed mobility related to inability to move from supine to sitting position 
D)  Excess fluid volume related to insensible fluid loss due to prolonged immobility 
A)  Risk for falls related to light-headedness upon standing and getting out of bed 
B)  Dressing/grooming self-care deficit related to cognitive impairment and fatigue 
C)  Impaired bed mobility related to inability to move from supine to sitting position 
D)  Excess fluid volume related to insensible fluid loss due to prolonged immobility

Question 4

Which patient would benefit from the use of a hand roll?

Accepted Answer

A)  A patient with paralysis of the right hand after a left-sided stroke 
B)  A paraplegic patient who requires assistance moving up in the bed 
C)  A confused patient who is attempting to pull out the urinary catheter 
D)  A patient with lymphedema of the right arm and hand after mastectomy 
A)  A patient with paralysis of the right hand after a left-sided stroke 
B)  A paraplegic patient who requires assistance moving up in the bed 
C)  A confused patient who is attempting to pull out the urinary catheter 
D)  A patient with lymphedema of the right arm and hand after mastectomy

Question 5

Which intervention will help prevent the development of footdrop for a comatose patient?

Accepted Answer

A)  Place high-top tennis shoes on the patient's feet. 
B)  Place pillows under the legs to keep the heels off the mattress. 
C)  Apply sequential compression devices to the patient's feet. 
D)  Assist the patient to a lateral position whenever possible. 
A)  Place high-top tennis shoes on the patient's feet. 
B)  Place pillows under the legs to keep the heels off the mattress. 
C)  Apply sequential compression devices to the patient's feet. 
D)  Assist the patient to a lateral position whenever possible.

Question 6

A patient had surgery two days ago.Which intervention will be included in the plan of care for this patient wearing compression stockings?

Accepted Answer

A)  The patient's stockings should be removed at night for washing. 
B)  Slippers should not be applied over the stockings for ambulation. 
C)  Regular size stockings are for females and large size are for males. 
D)  Make sure that the patient's toes are not sticking out of the stockings. 
A)  The patient's stockings should be removed at night for washing. 
B)  Slippers should not be applied over the stockings for ambulation. 
C)  Regular size stockings are for females and large size are for males. 
D)  Make sure that the patient's toes are not sticking out of the stockings.

Question 7

Which interventions are appropriate for the patient at risk for peripheral neurovascular dysfunction related to casted right ankle?

Accepted Answer

A)  Regularly assess the patient's toes for warmth and capillary refill. 
B)  Apply graduated compression stockings to both legs to prevent DVT. 
C)  Encourage the patient to frequently wiggle the toes to increase circulation. 
D)  Educate the patient that numbness and tingling of the area is to be expected. 
E)  Elevate the ankle above the level of the heart and apply ice to the ankle area. 
A)  Regularly assess the patient's toes for warmth and capillary refill. 
B)  Apply graduated compression stockings to both legs to prevent DVT. 
C)  Encourage the patient to frequently wiggle the toes to increase circulation. 
D)  Educate the patient that numbness and tingling of the area is to be expected. 
E)  Elevate the ankle above the level of the heart and apply ice to the ankle area.

Question 8

Which scale is used to assess the patient's risk for development of pressure injury?

Accepted Answer

A)  Baker 
B)  Morse 
C)  Braden 
D)  Hendrich 
A)  Baker 
B)  Morse 
C)  Braden 
D)  Hendrich

Exam 29: Immobility

The nurse is caring for a patient who is ordered to remain on bed rest.Which is the appropriate action of the nurse to facilitate emptying of the patient's bladder?

The patient refuses to get out of bed to ambulate after surgery.Which is the appropriate response of the nurse?

Which is the priority nursing diagnosis for a patient with orthostatic hypotension after several days of bed rest?

Which patient would benefit from the use of a hand roll?

Which intervention will help prevent the development of footdrop for a comatose patient?

A patient had surgery two days ago.Which intervention will be included in the plan of care for this patient wearing compression stockings?

Which interventions are appropriate for the patient at risk for peripheral neurovascular dysfunction related to casted right ankle?

Which scale is used to assess the patient's risk for development of pressure injury?

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