Potter & Perry Fundamentals of Nursing: Immobility Questions) and Verified Answers | 100%, Exams of Nursing

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Immobility Questions) and Verified Answers |

100% Correct | Grade A+

An older adult has limited mobility as a result of a total knee replacement. During assessment you note that the patient has difficulty breathing while lying flat. Which of the following assessment data would support a possible pulmonary problem related to impaired mobility? (Select all that apply) a.) B/P = 128/ b.) respirations 26/min on room air c.) HR 114 d.) crackles over lower lobes heard on auscultation e.) pain reported as 3 on scale of 0 to 10 after medication - CORRECT ANSWERS B, C, D A patient has been on bed rest for over 4 days. On assessment, the nurse identifies the following as a sign associated with immobility: a.) decreased peristalsis b.) decreased heart rate c.) increased blood pressure d.) increased urinary output - CORRECT ANSWERS A The nurse puts elastic stockings on a patient following major abdominal surgery. The nurse teaches the patient that the stockings are used after a surgical procedure to __________________. - CORRECT ANSWERS promote venous return to the heart A nurse is teaching a community group about ways to minimize the risk of developing osteoporosis. Which of the following statements reflect understanding of what was taught? (Select all that apply) a.) "I usually go swimming with my family at the YMCA 3 times a week" b.) "I need to ask my doctor if I should have a bone mineral density check this year"

Immobility Questions) and Verified Answers |

100% Correct | Grade A+

c.) "If I don't drink milk at dinner, I'll eat broccoli or cabbage to get the calcium that I need in my diet" d.) "I'll check the label of my multivitamin. If it has calcium, I can save money by not taking another pill" e.) "My lactose intolerance should not be a concern when considering my calcium intake" - CORRECT ANSWERS A, B, C A nurse is caring for an older adult who has had a fractured hip repaired. In the first few postoperative days, which of the following nursing measures will best facilitate the resumption of activities of daily living for this patient? a.) encouraging use of an overhead trapeze for positioning and transfer b.) frequent family visits c.) assisting the patient to a wheelchair once per day d.) ensuring that there is an order for physical therapy - CORRECT ANSWERS A An older-adult patient has been bedridden for 2 weeks. Which of the following complaints by the patient indicates to the nurse that he or she is developing a complication of immobility? a.) loss of appetite b.) gum soreness c.) difficulty swallowing d.) left ankle joint stiffness - CORRECT ANSWERS D A patient is receiving 5000 units of heparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for the following signs of bleeding: (Select all that apply)

Immobility Questions) and Verified Answers |

100% Correct | Grade A+

a.) bruising b.) pale yellow urine c.) bleeding gums d.) coffee ground-like vomitus e.) light brown stool - CORRECT ANSWERS A, C, D The nurse is caring for a patient whose calcium intake must increase because of high risk factors for osteoporosis. Which of the following menus should the nurse recommend? a.) cream of broccoli soup with whole wheat cracker, cheese, and tapioca for dessert b.) hot dog on whole wheat bun with a side salad and an apple for dessert c.) low-fat turkey chili with sour cream with a side salad and fresh pairs for dessert d.) turkey salad on toast with tomato and lettuce and honey bun for dessert - CORRECT ANSWERS A The nurse evaluates that the NAP has applied a patient's sequential compression device (SCD) appropriately when which of the following is observed? (Select all that apply) a.) initial patient measurement is made around the calves b.) inflation pressure averages 40mmHg c.) patient's leg placed in SCD sleeve with back of knee aligned with popliteal opening on the sleeve d.) stockings are removed every 2 hours during application e.) yellow light indicates SCD device is functioning - CORRECT ANSWERS B, C A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measure are not taken:

Immobility Questions) and Verified Answers |

100% Correct | Grade A+

a.) myoclonus b.) pathological fractures c.) pressure ulcers d.) pruritus - CORRECT ANSWERS C The effects of immobility on the cardiac system include which of the following? (Select all that apply) a.) thrombus formation b.) increased cardiac workload c.) weak peripheral pulses d.) irregular heartbeat e.) orthostatic hypotension - CORRECT ANSWERS A, B, E To prevent complications of immobility, what would be the most effective activity on the first postoperative day for a patient whi has had abdominal surgery? a.) turn, cough, and deep breathe every 30 minutes while awake b.) ambulate patient to chair in the hall c.) passive ROM 4 times a day d.) immobility is not a concern the first postoperative day - CORRECT ANSWERS B Which of the following nursing interventions should be implemented to maintain a patent airway in a patient on bed rest? a.) isometric exercises b.) administration of low-dose heparin

Immobility Questions) and Verified Answers |

100% Correct | Grade A+

c.) suctioning every 4 hours d.) use of incentive spirometer every 2 hours while awake - CORRECT ANSWERS D Place the following options in the order in which elastic stockings should be applied: a.) identify patient using 2 identifiers b.) smooth any creases or wrinkles c.) slide the remainder of the stocking over the patient's heel and up the leg d.) turn the stocking inside out until heel is reached e.) assess the condition of the patient's skin and circulation of the legs f.) place toes into foot of the stocking g.) use tape measure to measure patient's legs to determine proper stocking size - CORRECT ANSWERS A, E, G, D, F, C, B Which of the following are physiological outcomes of immobility? a.) increased metabolism b.) reduced cardiac workload c.) decreased lung expansion d.) decreased oxygen demand - CORRECT ANSWERS C A patient has been on bed rest for over 5 days. Which of these findings during the nurse's assessment may indicate a complication of immobility? a.) decreased peristalsis b.) decreased heart rate c.) increased blood pressure

Immobility Questions) and Verified Answers |

100% Correct | Grade A+

d.) increased urinary output - CORRECT ANSWERS A A patient is receiving 40 mg of enoxaparin subcutaneously every 12 hours while on prolonged bed rest to prevent thrombophlebitis. Because bleeding is a potential side effect of this medication, the nurse should continually assess the patient for what signs of bleeding? (Select all that apply) a.) bruising b.) pale yellow urine c.) bleeding gums d.) coffee ground-like vomitus e.) light brown stool - CORRECT ANSWERS A, C, D Place the following steps in the correct order for positioning a patient in the 30-degree lateral side- lying position. a.) raise side rail and go to opposite side of bed b.) lower side rail and flex patient's knee that will not be next to mattress. Keep foot on mattress and place one hand on patient's upper bent leg near hip and other hand on shoulder c.) lower head of bed if patient can tolerate it d.) roll patient onto side toward you e.) lower side rail and position patient on side of bed opposite the direction toward which patient is to be turned f.) place hands under patient's dependent shoulder and bring shoulder blade forward g.) place hands under patient's dependent hip and bring hip slightly forward so that angle from hip to mattress is approximately 30 degrees - CORRECT ANSWERS C, E, A, B, D, F, G A 46-year-old patient is admitted to the emergency department following an automobile accident. The patient has a pelvic fracture and is ordered on bed rest and place in an immobilization device to

Immobility Questions) and Verified Answers |

100% Correct | Grade A+

limit further injury until the fracture can safely be repaired. Which measurements would be appropriate for this patient to prevent complications of bed rest? (Select all that apply) a.) administer intravenous analgesic as ordered b.) have patient perform incentive spirometry c.) support patient in active assistive ROM exercises of upper extremities d.) provide patient a low-calorie diet e.) apply sequential compression devices to legs - CORRECT ANSWERS B, C, E A patient has an order for application for compression stockings. Place the following steps for application in the correct order. a.) place patient's toes into foot of stocking up to the heel; keep smooth b.) use tape measure to measure patient's leg for proper stocking size c.) slide stocking up over patient's calf until sock is completely extended d.) turn elastic stocking inside out until reaching the heel e.) slide remaining portion of stocking over patient's foot, covering toes. Be sure foot fits into toe and heel of stocking - CORRECT ANSWERS B, D, A, E, C An older-adult patient is admitted following a hip fracture and surgical repair. Before ambulating the patient postoperatively on the evening of surgery, which of the following would be most important to assess? (Select all that apply) a.) patient's usual dietary intake b.) time and date of the patient's last bowel movement c.) preadmission activity tolerance d.) baseline heart rate e.) patient's home living situation - CORRECT ANSWERS C, D

Immobility Questions) and Verified Answers |

100% Correct | Grade A+

A middle-aged adult patient has limited mobility following a total knee arthroplasty. During assessment, the nurse notes that the patient is having difficulty breathing while lying supine. Which assessment data support a pulmonary issue related to immobility? (Select all that apply) a.) oxygen saturation of 89% b.) irregular radial pulse c.) diminished breath sounds bilateral bases on auscultation d.) BP: 132/ e.) pain: reported at 3 on scale of 0 to 10 following medication f.) respiratory rate of 26 - CORRECT ANSWERS A, C, F