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Clinical Skills Exam2, Quizzes of Nursing

New Jersey City University (NJCU)Nursing

Evolve Skills Questions For NCHP class

Typology: Quizzes

2023/2024

Uploaded on 07/08/2024

SallySango 🇺🇸

3 documents

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Assisting with Moving a Patient in Bed

1. When preparing to move a patient in bed, what will the nurse do

first?

A.Assemble adequate help to move the patient.

B.Assess the patient's ability to help with moving.

C.Determine the patient's weight.

D.Decide on the most effective means of moving the patient.

Rationale:Assessing the patient's ability to help is the first thing the

nurse must do, since the answer determines how much help is

needed with the move. The patient's weight is important to know, but it

is not the first action the nurse must take. The most effective means of

moving the patient will be determined in part by whether the patient is

able to help.

2. When preparing to move a patient in bed with the help of an

assistant, which posture will both caregivers use to ensure their own

safety?

A.Stand with the knees locked.

B.Stand with the feet together.

C.Flex the hips and knees.

D.Shift the body weight from the front leg to the back leg.

Rationale:Flexing the hips and knees is the safest posture for both

caregivers to assume when moving a patient in bed. Standing with the

knees locked could injure the legs or the back. Standing with the feet

together could injure the legs or the back. The body weight should be

shifted from the back leg to the front leg.

3. A patient who weighs 200 lbs. needs to be moved up in bed with

the aid of a friction-reducing device. The nurse will prepare for this

move by assembling how many caregivers?

A.A minimum of two

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Assisting with Moving a Patient in Bed

When preparing to move a patient in bed, what will the nurse do first? A. Assemble adequate help to move the patient. B. Assess the patient's ability to help with moving. C. Determine the patient's weight. D. Decide on the most effective means of moving the patient. Rationale: Assessing the patient's ability to help is the first thing the nurse must do, since the answer determines how much help is needed with the move. The patient's weight is important to know, but it is not the first action the nurse must take. The most effective means of moving the patient will be determined in part by whether the patient is able to help.
When preparing to move a patient in bed with the help of an assistant, which posture will both caregivers use to ensure their own safety? A. Stand with the knees locked. B. Stand with the feet together. C. Flex the hips and knees. D. Shift the body weight from the front leg to the back leg. Rationale: Flexing the hips and knees is the safest posture for both caregivers to assume when moving a patient in bed. Standing with the knees locked could injure the legs or the back. Standing with the feet together could injure the legs or the back. The body weight should be shifted from the back leg to the front leg.
A patient who weighs 200 lbs. needs to be moved up in bed with the aid of a friction-reducing device. The nurse will prepare for this move by assembling how many caregivers? A. A minimum of two

B. None, since the device does all the lifting during the move C. At least three D. The nurse can carry out this move without assistance Rationale: Since a friction-reducing device will be used and the client weighs 200 lbs., a minimum of three to four people are needed to move this patient safely. The device does not function independently, and the nurse cannot use it without the help of other caregivers. The nurse cannot carry out this move by himself or herself.

In which position will the nurse place the patient to move him or her up in bed? A. Supine with the head of the bed at a 30-degree angle B. Sitting in the bed C. Supine with the head of the bed flat D. Prone with the head of the bed flat Rationale: Placing the patient in the supine position with the head of the bed flat is the recommended position to use to move a patient up in bed. The patient should not be supine with the head of the bed at a 30-degree angle, sitting, or prone when being moved up in bed.
A patient will be moved up in bed with the use of a friction-reducing device. How will the nurse place this device under the patient? A. Lift the patient to place the device directly under him or her. B. Remove the drawsheet, and replace it with the device. C. Roll the patient from side to side, and place the device under the drawsheet. D. Sit the patient up in the bed, and place the device behind the shoulders. Rationale: The patient will be rolled from side to side and the device placed under the drawsheet. The patient is not lifted in order to place the device under him or her. The device must be placed under the

patient. The 30-degree lateral or side-lying position requires the head of bed to be lowered completely or as low as the patient can tolerate. The patient is positioned on the side. Lying on the side will not promote maximal breathing space and respirations would be difficult for the patient. In the prone position, the patient is positioned flat and on the abdomen. Lying flat on the abdomen would not facilitate respirations and is a difficult position for the patient to maintain.

When repositioning a patient, what can the nurse do to prevent the patient's hips from rolling outward? A. Apply therapeutic boots to the feet. B. Place sandbags along the legs. C. Place a small pillow at the lumbar region of the back. D. Place a pillow under the calves. Rationale: Placing sandbags along the legs will prevent the hips from rolling outward. Therapeutic boots, a small pillow at the lumbar region of the back or a pillow under the calves will not prevent the hips from rolling outward.
The nurse is preparing to move a patient with hemiplegia into the prone position. What action should the nurse take when rolling the patient onto her side? A. Place a small pillow under the shoulder. B. Use the affected arm as a guide during rolling. C. Place a pillow on the abdomen. D. Place rolled bath blankets along the dependent leg. Rationale: When rolling a patient with hemiplegia onto her side while moving into the prone position, the nurse should place a pillow on the patient's abdomen. Placing a small pillow under the shoulder will not help when rolling a patient with hemiplegia onto her side while moving into the prone position. The nurse should not use the affected arm as a guide when rolling a patient with hemiplegia onto her side while moving into the prone position. The nurse should not place rolled bath

blankets along the dependent leg when rolling the hemiplegic patient onto her side while moving into the prone position.

The nurse is preparing to logroll a patient in bed. Why are two assistants needed on the side toward which the patient is being turned? A. To position the pillows B. To keep the spine in alignment C. To roll the patient as a unit D. To ease the patient back onto the support pillows Rationale: Two assistants are needed to roll the patient as a unit, using one smooth, continuous motion. One assistant grasps the draw sheet at the lower hips and thighs, and the other assistant grasps the draw sheet at the patient’s shoulders and lower back. The pillows are positioned by the nurse who is standing on the side from which the patient was turned. Two assistants are not needed to keep the patient’s spine straight while logrolling a patient. Two assistants are not needed to ease the patient back onto the support pillows.

Performing Range-of-Motion Exercises

Which patient is most at risk of developing permanently impaired mobility? A. A 72-year-old woman hospitalized for anemia associated with diabetic nephropathy (kidney disease) B. A 55-year-old woman with mental illness who had become malnourished C. An 11-year-old boy who sustained a fractured pelvis during a fall from his tree house D. A 79-year-old man recovering from surgery to release a contracture of the connective tissue in his hand

The nurse notes that a patient's left elbow is resistant to extension and flexion while performing range of motion exercises. What is the appropriate nursing action? A. Move the joint through the full range of motion exercises. B. Perform range of motion to the left elbow until resistance is met. C. Omit all the range of motion exercises until the health care provider is notified. D. Inform the health care provider that the patient is uncooperative with exercising. Rationale: The nurse would stop the range of motion exercises because resistance is met. The range of motion exercises should not continue until pain is felt by the patient. The nurse would not move the left elbow joint through the full range of motion because resistance is met. Range of motion exercises should not be omitted. When you note resistance within a joint, do not force the joint motion. Consult with the health care provider or a physical therapist. The nurse would not notify the health care provider without information to support the patient is uncooperative with exercising.
Which of the following are basic guidelines when assisting a patient with passive range of motion? A. Exercises should be continued until the point of fatigue and pain. B. Exercises should be done frequently to lessen pain for the patient. C. Each joint is exercised to the point of resistance but not pain. D. Exercises should be performed without the support to each joint. Rationale: Joints should be exercised slowly, smoothly, and rhythmically to the point of resistance, but pain should not be felt by the patient. Uncomfortable reactions should be reported. Joints should never be exercised to the point of fatigue or pain. Exercises should be done twice a day to improve joint mobility and increase circulation. Pain will not be lessened with exercising. Pain should not be felt by the patient. Use a variety of support measures, cupping with your

hand under joint or cradling the distal portion with arm. Support measures prevent muscle strain or injury to the patient.

Why would the nurse ask a physical therapist to perform passive ROM exercises for a patient with lower extremity injuries sustained in a motor vehicle crash? A. The patient is an older adult or has a chronic condition. B. The patient is reluctant to perform the exercises because he is worried about reinjury. C. The patient has orthopedic trauma. D. The patient has pain exacerbated by exercise. Rationale: Specialized expertise is usually required to perform passive ROM exercises for a patient with orthopedic trauma or spinal cord injury. The patient's age or the existence of a chronic medical condition generally does not necessitate additional expertise. If a patient is concerned about injury, the nurse can address the patient's anxiety by explaining the procedure, easing into the exercises, and offering continual reassurance. If the provider is aware that the patient's pain is worse with exercise and the provider nevertheless orders the exercise, the nurse can offer pain medication before the intervention, as prescribed, and exercise the patient as tolerated.

Transferring From a Bed to a Stretcher

The nurse is preparing to use a slide board to transfer a patient from the bed to a stretcher. How many additional people will the nurse need to help with this transfer? A. Four B. Two C. One D. None

The nurse and his or her assistants are using a slide board to move a patient from the bed to a stretcher. The nurse, standing alone on the side of the bed opposite the stretcher, will perform which action during this move? A. Hold the slide board. B. Pull the draw sheet. C. Hold the patient's head stationary. D. Lock the brakes on the stretcher. Rationale: The nurse, standing alone, will hold the slide board in place as the two assistants pull the draw sheet. The nurse will not hold the patient's head during the move; this action may be performed by an optional assistant. The nurse cannot lock the brakes on the stretcher while standing on the opposite side of the bed. The brakes should be locked prior to the transfer of the patient.
After moving a patient from the bed to a stretcher, what will the nurse do next? A. Lock the wheels on the stretcher. B. Cover the patient with a blanket. C. Raise the head of the stretcher if doing so is not contraindicated. D. Unlock the wheels of the bed. Rationale: The nurse raises the head of the stretcher if doing so is not contraindicated. The wheels of the stretcher will have been locked before moving the patient from the bed to the stretcher. Covering the patient with a blanket will occur after the side rails are raised on the stretcher. Unlocking the wheels of the bed is not an action the nurse will take after transferring a patient from the bed to the stretcher.

Transferring From a Bed to a Wheelchair Using a

Transfer Belt

When preparing to safely transfer a patient from a bed to a wheelchair using a transfer belt, the nurse would do what first? A. Coordinate extra help. B. Assess the patient's vital signs. C. Assess the patient's physiological capacity to transfer. D. Determine whether to transfer the patient to a wheelchair or chair. Rationale: Assessing the patient's physiological capacity to transfer determines the patient's ability to tolerate and assist with the transfer and whether special adaptive techniques are necessary. The nurse must determine whether extra help is needed before arranging for such assistance. Assessing vital signs is not the first action the nurse would take. Determining whether to transfer the patient to a wheelchair or chair is not the first action the nurse would take.
Which instruction would the nurse give a patient who is able to assist with transfer from a bed to a wheelchair using a transfer belt? A. "When I count to three, please rock yourself into a standing position." B. "Please hold on to my waist while I help you stand." C. "Please tell me how I can best help you get up off the bed and stand up." D. "Please push down onto the mattress with both hands and stand when I count to three." Rationale: Telling the patient to push against the mattress is the best instruction the nurse can give because it teaches the patient how to help achieve a standing position during the transfer. The patient and nurse rock together for three counts. The patient would not be instructed to hold on to the nurse's waist. Doing so is not a safe action. Asking the patient to advise the nurse does not instruct the patient on moving from the bed to a wheelchair.

A patient has been transferred to a wheelchair with a transfer belt. What is one action the nurse would take to position the patient safely in the chair? A. Remove the wheelchair leg rests. B. Ask the patient to rate his or her pain level. C. Lower the foot rests, and place the patient's feet on them. D. Remove the transfer belt. Rationale: The nurse lowers the foot rests and places the patient's feet on them once the patient has been positioned in the wheelchair. Doing so supports the patient's feet and keeps them from dragging and creating a falling hazard when the chair is moved. Removing the leg rests will not help position the patient safely in the wheelchair. Asking about the patient's pain is not relevant to safe positioning, since a patient may be comfortable even when positioned unsafely. Removing the transfer belt will not help position the patient safely in the wheelchair.

Using A Hydraulic Lift

When preparing for safe patient transfer using a hydraulic lift, the nurse performs which action first? A. Assesses the patient for weakness, dizziness, or postural hypotension B. Arranges for at least three healthcare personnel to assist in the transfer C. Makes sure the patient agrees to the intervention D. Applies clean gloves Rationale: Assessing the patient for weakness, dizziness, or postural hypotension will help ensure the patient’s safety. Two nurses or NAP can safely transfer a patient with a hydraulic lift. The assistance of three healthcare personnel is not necessary. Securing the patient’s agreement does not help the nurse prepare for a safe transfer. It is not

necessary to wear gloves while transferring a patient with a hydraulic lift.

Which position is used when applying the sling to transfer a patient from the bed to a chair with a hydraulic lift? A. Prone B. Side-lying C. Supine D. Sims Rationale: The patient is placed in the supine position before he or she is transferred from the bed to a chair with a hydraulic lift. Prone, side-lying, and Sims are not positions used to transfer a patient with a hydraulic lift.
Which action would decrease a patient’s pain before a transfer with a hydraulic lift? A. Stop the transfer if the patient expresses or displays physical signs of pain. B. Explain the procedure to the patient before beginning the transfer. C. Administer a prescribed analgesic 30 to 60 minutes before the transfer. D. Postpone the transfer if the patient reports having physical pain or anxiety before the transfer. Rationale: Administering a prescribed analgesic 30 to 60 minutes before the transfer helps prevent unnecessary pain during the transfer by allowing time for the medication to take effect before the patient is moved. The remaining actions do not pertain to pain prevention.
What does the nurse do after attaching the hooks to the holes in the sling on a hydraulic lift? A. Lower the head of the bed. B. Remove the patient’s eyeglasses.

Rationale: Lack of resistance as the intradermal medication is injected indicates that the needle is not in the dermal layer and must be repeated. It is unnecessary to aspirate for blood return when giving an intradermal injection. A 6-mm bleb at the injection site indicates that the medication has been deposited into the dermis. A properly placed intradermal injection will resemble a mosquito bite.

Which statement might the nurse make to nursing assistive personnel (NAP) when caring for a patient who is prescribed an intradermal injection? A. “Be sure to wear clean gloves during the injection.” B. “Tell him it’s OK; the site should look like a mosquito bite.” C. “Immediately report any patient complaints of itching or dyspnea.” D. “Remind the patient to come back in 48 to 72 hours so we can evaluate the site.” Rationale: Reporting patient complaints is an acceptable role for NAP. NAP may not provide intradermal injections. Patient education may not be delegated to NAP.
Which finding tells the nurse that a patient may have had a positive reaction to a tuberculin test? A. A raised wheal the size of a mosquito bite B. A bruised area 10 mm or greater in diameter C. A hard, raised area 15 mm or greater in diameter D. A flat, reddened area 5 mm or greater in diameter Rationale: An indurated area 15 mm in diameter or larger is considered a positive response in anyone with no known risk factors for tuberculosis, such as immunosuppression or exposure to tuberculosis. Appearance of a raised wheal the size of a mosquito bite is the classic description of the site immediately after injection, not the sign of a positive test. Bruising does not indicate a positive reaction. Redness without induration does not indicate a positive test.

In which site would it be inappropriate to administer an intradermal injection? A. Lower abdomen of an obese patient B. Upper back of a patient who is on bed rest C. Right deltoid of a high school softball pitcher D. Left forearm of a patient with right-sided weakness Rationale: The deltoid area is not an acceptable intradermal injection site for any patient. If the forearm and back cannot be used, it is acceptable to use sites routinely used for subcutaneous injections. The upper back is an acceptable intradermal injection site for a patient on bed rest. The left forearm is an acceptable intradermal injection site.
How can the nurse determine that the needle tip for an intradermal injection is in the dermis? A. A bleb the size of a mosquito bite will appear. B. The needle will enter at a 5- to 15-degree angle. C. The bulge of the needle tip will be visible through the skin. D. The needle will penetrate through the epidermis to a depth of about ⅛ inch. Rationale: Seeing the bump of the needle under the skin best ensures its proper placement in the dermis. A bleb will appear after the medication has been injected. A 5- to 15-degree angle of entry does not ensure that the needle is in the dermis. Reaching this depth does not ensure that the needle has been inserted properly.

Administering Intramuscular Injections

Which action by the nurse ensures patient safety when administering an intramuscular injection? A. Putting on clean gloves before administration B. Rotating injection sites

Rationale: Pulling back on the plunger will allow the nurse to determine if the needle is in a blood vessel, rather than in muscle tissue. Encouraging the patient to relax may decrease discomfort, but will not reduce the patient’s risk for injury. For an intramuscular injection, the needle must be inserted at a 90-degree angle. Pulling the skin taut when inserting the needle will not reduce the patient’s risk for injury.

Which site is most commonly used for intramuscular injections? A. Ventrogluteal B. Abdominal C. Deltoid D. Dorsogluteal Rationale: The ventrogluteal site is the preferred IM injection site for adults and children, but not for infants and toddlers. The abdomen is used for subcutaneous injections. The deltoid site is an appropriate choice for small volumes, but it is not the preferred site for intramuscular injections. The dorsogluteal site is contraindicated for intramuscular injections.
Which action by the nurse helps to ensure that the medication is delivered into the muscle when administering an intramuscular injection? A. Using a 1-inch needle B. Inserting the needle at a 45- to 60-degree angle C. Withdrawing the needle immediately after delivering the medication D. Aspirating for blood return before injecting the medication Rationale: Aspirating for blood return ensures that the medication will be delivered into muscle tissue, and not into a blood vessel. Selection of needle length will vary, depending on the age and size of the patient. For an intramuscular injection, the needle must be inserted at a 90-degree angle. To prevent medication from leaking out of the

muscle tissue, the needle is left in place for about 10 seconds once the medication has been delivered.

Administering Subcutaneous Injections

Which action would the nurse take to diminish tissue irritation when administering a subcutaneous injection to a patient of average size? A. Massage the site after administration. B. Make sure the volume of the medication is less than 2 mL. C. Administer the injection at a 45- to 90-degree angle. D. Wear clean gloves while administering the injection. Rationale: Delivering a volume of less than 2 mL by subcutaneous injection will reduce the likelihood of tissue irritation. Massaging the site after giving a subcutaneous injection is not recommended because doing so can damage tissue. Although administering a subcutaneous injection at a 45- to 90-degree angle is the correct technique, doing so will not prevent tissue irritation. Wearing clean gloves will protect the nurse from exposure to bloodborne pathogens, but doing so will not prevent tissue irritation.
Which needle would be most appropriate for the nurse to use when giving a subcutaneous injection to a patient of average height and weight? A. 20-gauge, ½-inch B. 22-gauge, 1-inch C. 25-gauge, ⅜-inch D. 27-gauge, 1-inch Rationale: The 25-gauge, ⅜-inch needle is the correct gauge and length for a subcutaneous injection. The 20-gauge, ½-inch needle diameter is too large for a subcutaneous injection. The 22-gauge, 1- inch needle and the 27-gauge, 1-inch needle are too long for a subcutaneous injection.

Clinical Skills Exam2, Quizzes of Nursing

Related documents

Partial preview of the text

Download Clinical Skills Exam2 and more Quizzes Nursing in PDF only on Docsity!

Assisting with Moving a Patient in Bed

Performing Range-of-Motion Exercises

Transferring From a Bed to a Stretcher

Transferring From a Bed to a Wheelchair Using a

Transfer Belt

Using A Hydraulic Lift

Administering Intramuscular Injections

Administering Subcutaneous Injections