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NURS 299 exam 4 With Questions And 100% ALL DETAILED CORRECT ANSWERS
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JACKLINENURS 299 exam 4 With Questions And 100% ALL
DETAILED CORRECT ANSWERS
Terms in this set (135)
A patient has been hospitalized with a 1. High-flow oxygen therapy by mask
serious flulike infection and is on bed rest. 3. Temperature 38.6°C (101.6°F)
He is receiving multiple medications 5. Initiates little movement
through two different IV infusions and is on 6. Reduced conscious response
high-flow oxygen therapy by oxygen mask. 7. bed rest
Currently the patient's head of bed is
elevated to semi-Fowler position. The
patient initiates little movement and
responds only to being shaken. Vitals signs
are temperature, 38.6°C (101.6°F); heart
rate, 88 beats/min; blood pressure 140/84
mm Hg; and respirations, 20. Which of the
following assessment findings suggest that
the patient has a risk for an immobility
complication? (Select all that apply.)
1. High-flow oxygen therapy by mask
2. Positioned semi-Fowler
3. Temperature 38.6°C (101.6°F)
4. Receiving multiple medications
5. Initiates little movement
6. Reduced conscious response
7. bed rest
1/28
,A nurse is caring for a patient who was in 4. Setting times to discuss relationship of hopelessness to injuries
an auto accident and has entered rehab
after a 6-day hospitalization. The patient
had multiple internal injuries and has
nursing diagnoses of Hopelessness and
Impaired Mobility at time of discharge. The
nurse’s assessment revealed the patient
asking nurses to let him stay in bed and the
patient having limited involvement in
hygiene and a loss of appetite. The patient
has a cast on his nondominant left hand
and has reduced movement in the right
lower leg, which is splinted. The health care
provider has ordered the patient to
ambulate 3 times a day. Which of the
following is a priority for the rehab nurse?
1. Providing assistance with meals
2. Teaching patient exercises to strengthen
right leg
3. Making preferred hygiene products
available to the patient to use
4. Setting times to discuss relationship of
hopelessness to injuries
A patient has been on bed rest for over 5 1. Decreased peristalsis
days. Which of these findings during the
nurse's assessment may indicate a
complication of immobility?
1. Decreased peristalsis
2. Decreased heart rate
3. Increased blood pressure
4. Increased urinary output
2/28
, Place the following steps in the correct 7. Lower head of bed completely or as low as patient can tolerate. One nurse on
order for repositioning a patient in the 30- each side of bed.
degree lateral side-lying position using two 6. Position patient on side of bed in opposite direction toward which patient is to be
nurses. turned, then move upper and lower trunk.
4. Flex patient's knee that will not be next to mattress, after being turned. Keep foot
1. Using knee and hip for leverage, nurse on mattress. Nurse places one hand on patient's upper bent leg.
rolls patient onto side. 1. Using knee and hip for leverage, nurse rolls patient onto side.
2. Nurse facing patient's back places hands 2. Nurse facing patient's back places hands under patient's dependent shoulder and
under patient's dependent shoulder and brings shoulder blade forward.
brings shoulder blade forward. 5. Place hands under dependent hip and bring hip slightly forward so angle from hip
3. Place pillows under semiflexed upper to mattress is approximately 30 degrees.
leg level at hip from groin to foot. 3. Place pillows under semiflexed upper leg level at hip from groin to foot.
4. Flex patient's knee that will not be next
to mattress, after being turned. Keep foot
on mattress. Nurse places one hand on
patient's upper bent leg.
5. Place hands under dependent hip and
bring hip slightly forward so angle from hip
to mattress is approximately 30 degrees.
6. Position patient on side of bed in
opposite direction toward which patient is
to be turned, then move upper and lower
trunk.
7. Lower head of bed completely or as low
as patient can tolerate. One nurse on each
side of bed.
The effects of immobility on the cardiac 1. Thrombus formation
system include which of the following? 2. Increased cardiac workload
(Select all that apply.) 5. Orthostatic hypotension
1. Thrombus formation
2. Increased cardiac workload
3. Weak peripheral pulses
4. Irregular heartbeat
5. Orthostatic hypotension
3/28
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