A nurse is preparing to move a client who is immobile up in bed. Use of blood pressure monitoring device. The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. Discard the tablet and obtain another dose of the medication. 1 Study with Quizlet and memorize flashcards containing terms like 1. What change, if any, should be made in sentence 8? A. Straighten the knees Study with Quizlet and memorize flashcards containing terms like A nurse is caring for an older adult client who is disoriented and has a history of falls. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following actions should the nurse plan to take? A. - Obtain a prescription to restrain the clients PRN. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client while making sure to maintain proper alignment of the extremity. - The chair should be placed at a 45° angle to the bed on the client's strong side so that the client can safely and easily assist with the transfer. Which of the following actions should the nurse plan to take? Position the client supine with the head of the bed elevated. The type of equipment used in Study with Quizlet and memorize flashcards containing terms like The nurses determines a client's IV solution is infusing at 250 ml/hr. Tighten the back muscles when lifting. Faces the direction Study with Quizlet and memorize flashcards containing terms like The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. The nurse should: 1. The nurse should not leave the client to move the wheelchair to the bedside. Peripheral vasodilation. Guaiac-positive stool C. The client spends most of his day in a reclining chair. Dangle the client's legs off the side of the bed. calculate and record Intake and outputs. give 40 to 50 mL/kg of rehydration Study with Quizlet and memorize flashcards containing terms like Which nursing intervention can help a client maintain healthy skin?, A nurse is reviewing the medical record of an immobilized patient who has developed a pressure ulcer. which of the following actions should What should the nurse do for a client with orthostatic hypotension who is preparing to get out of bed to walk for the first time in several days? 1. Keep the A nurse is preparing to move a client who is immobile up in bed with the assistance of another nurse. 1. 5-Nurse is caring for pt cannot move at all. The nurse should take which immediate action? 1) Elevate the head of the bed 2) Call the healthcare provider 3) Administer oxygen to the client 4) Order a Body Mechanics, Positioning, and Moving Learn with flashcards, games, and more — for free. Assess the patient's ability to help with moving. What assumptions can be made by the nurse about the risk of immobility from the device being used? The client is at Go to: Nursing, Allied Health, and Interprofessional Team Interventions. To do this: Lower the head of the bed to be flat to make the Health Library. After the nurse inserts the IV catheter, the client reports pain in the insertion area. ) position the client standing, facing the examination table d. One nurse lifting as the clients pushes with his feet. On the count of three, instruct the patient to use their elbows to push up on the bed and then grasp the side rails, as you support the shoulders as the patient sits up. Push up from the knees when lifting the object Stand as close to the object as possible is the first step. Rinse off the tablet and administer it to the client. Which assistive device would the nurse include in the plan of care?, When moving a client up in bed with the assistance of another caregiver, the nurse should:, A nurse is providing The nurse is preparing to transfer a patient from her bed to a stretcher for transport to radiology for testing. Term. A nurse is preparing to move a client who is immobile up in bed with the assistance of another nurse. shift their weight back and forth from the legs to the back muscles d. Which nutritional deficiency would the nurse identify as placing the patient at risk for delayed wound Study with Quizlet and memorize flashcards containing terms like A nurse is planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include?, A nurse is assisting a client with personal hygiene care. Pulling a patient up in bed. Keep water by the bedside 2. You are free to move onto the stretcher without assistance, but I will supervise for your Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who is on bed rest for a month. Which action is most important to prevent shearing forces on the skin? 1. and more. Which action, if observed, requires follow up by the preceptor? A. Which of the following actions should the nurse take? place feet apart with the foot nearest the head of the client's bed in front of the other foot. Which of the following characteristics is associated with a Stage II pressure ulcer? Partial thickness skin loss Visible subcutaneous fat Nonblanchable redness Exposed muscle, A nurse is The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. C) Muscles assist with The nurse is preparing to move a client up in bed with the assistance of another nurse. , While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. Which of the following responses should the nurse make?, A nurse is preparing to document information about a client's lower legs, which are swollen with 6 A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. , A nurse is collecting data on a newly admitted client who is reporting abdominal B. B) Position a walker in front of the client to provide stability. Recent weight gain, shortness of breath, swelling in the ankles Study with Quizlet and memorize flashcards containing terms like A nurse is providing teaching to an assistive personnel about caring for clients with restraints. Administer antitoxin C. - Stand next to the client's shoulders. Restrict the client's fluid intake. What motion would the nurses use to counteract the clients weight? a. 7. Which of the following statements by AP indicates and understanding of the teaching?, A nurse is caring for a client who is at risk for falls. shave the client's hair in the direction A nurse is preparing to turn a client who is unable to mobilize independently. The nurse should instruct the AP to take which of the following actions? - Place a small pillow under the client's head. Which of the following interventions should the nurse implement to prevent infection? A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? a. A health care team member injury prevention technique is followed when the new nurse performs which action during the patient move? A. A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a client's bed linens. Teach the use of a two-point crutch technique for ambulation. Study with Quizlet and memorize flashcards containing terms like A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Study with Quizlet and memorize flashcards containing terms like Immobilized patients frequently have hypercalcemia, placing them at risk for a. Place a sheepskin inside the sling so Study with Quizlet and memorize flashcards containing terms like A home health nurse is caring for a client who has emphysema and has difficulty with mobility. ) Preparing to Transfer With a “Basket” Approach b. Place the patient on bed rest to prevent fatigue. What action should the nurse take when rolling the patient onto her side? A. Term Two nurses are preparing to turn an immobile client in Study with Quizlet and memorize flashcards containing terms like When preparing to move a patient in bed, what will the nurse do first? Assemble adequate help to move the patient. The nurse uses professional knowledge about body mechanics to prevent the most common occupational disorder in nurses, which is: a. Place a plastic cover over the pillow 3. Explanation: When E. To Facilitate Bed Mobility: The ability of a client to move around in bed, including moving from lying to sitting and sitting to lying. ) provide the supplies for a specimen culture c. Keep both the upper and lower side rails in a raised position. A health care provider completes a risk assessment for a patient and determines the patient is unable to assist Chapter 14 Ergonomoic Principles (Ergonomic Principles for Moving a Client up in Bed) Focus Review. D. When identifying the safest method of transfer, which of the following is most important for the nurse to determine? A. Three-point C. which of the following actions should the nurse take? (select all that apply) A. To Promote Patient Mobility. Face the head of the bed. Which of the following actions by the nurse when taking the blood pressure can result in an inaccurately low reading? A. 4 Celcius. Instruct client to bend legs and put feel flat on bed. d. , An unlicensed assistive personnel (UAP) needs to boost a client Study with Quizlet and memorize flashcards containing terms like A nurse is reinforcing teaching to a client who was recently prescribed a 2,000 mg sodium-restricted diet. Plan the move. Which clients are correctly classified? (Select all that apply. Shaking dirty linens and placing them on the floor d. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? Take measures to promote as much comfort as possible. Which of the following is the proper crutch gait for this client? A. Which instruction is most important for the PN to emphasize?, Leverage helps increase our lifting power. Add soap to the water in the basin before beginning the bath. Which of the following bed positions should the nurse use for safe care of this client? A. Which action should the nurse take while performing this task? The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. Which of Study with Quizlet and memorize flashcards containing terms like Chapter 28: Immobility Potter et al. shift their weight back and forth, from back leg to front leg b. Thrombus formation. A 60-year-old male with an open fracture with Study with Quizlet and memorize flashcards containing terms like On the third postoperative day following thoracic surgery, a client reports feeling constipated. Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is postoperative. rock the client back and forth to raise the client up A nurse is preparing to transfer a client from a bed to a wheelchair. After supporting the client's knee with one hand, what action should the nurse take next? a. 3C (110F) and 46. Which assessment finding has the greatest implications for this client's care? a. " C: "Please tell me how I can best A nurse is preparing to assist the provider with an assessment of the genitourinary system of a client who is assigned female at birth. -allow the client's leg to rest on the bed. Assisting patients with mobilization is an essential aspect of health care facilities. Bending at the waist when transferring the client. The handles of the sling should face away from the client, allowing the assistants to position the A nurse and an assistive personnel are repositioning who is immobile up in bed using adraw sheet. Have the client move each limb independently through its complete range of motion. Which tips should be corrected?, The nurse is preparing to transfer a client from a bed to a stretcher. Describe effective ways to move a person safely. Which action(s) should the nurse implement prior to assisting B. Place the following activities in the correct order. Keep a A nurse is preparing to transfer a client from a bed to a wheelchair. Ensure the state health department has been notified. The young client who has a fractured leg and the client who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two A nurse is changing a client's bed linens. a nurse is moving a client up in bed with the assistance of a second nurse. Gravity has to be overcome when we lift or move objects. Changes in position help adjust the patient to the upright position. Massage the area D. Even with the hips 4. 3/4 cup of canned A nurse and an assistive personnel (AP) disagree about how to move a client from the bed to a stretcher. b. Pace sterile gauze over areas of spilled c. Assist the client to change position often. Which of the following actions should the nurse take? Raise the room temperature. , _____ refers to allowing the client to sit on the edge of the bed with the legs down and the feet supported on a footstool or on the floor, A _____ is a four-legged tubular device with hand grips. On the count of three, move the patient by shifting your weight to your front leg and pulling the sheet toward the head of A nurse is preparing to move a client who is only partially able to assist up in bed. What action should the nurse take first? A. Practitioners should focus on a patient-centered Explanation: When moving a client up in bed with the assistance of a second nurse, the nurse should take the following actions: Stand facing the center of the bed Step 1. She leads the pool aerobic exercise group in the senior retirement community that she and her husband moved to 3 years ago. Which action best ensures the safety of both the client and the nurse? Two nurses are moving a client up in bed. Course. You must move or pull someone up in bed the right way to avoid injuring the patient's Learning Objectives. Which systems should the nurse monitor for complications? Select all that apply. 9% NS Study with Quizlet and memorize flashcards containing terms like positioning the client on the operating table counting sponges before and after surgery monitoring the client's vital signs, Place the client in a flat position with legs elevated 45 degrees. Use a sharp object to determine pain response C. Change meanings to An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three hours after the woman delivered her baby. Incorrect: The wheelchair should be positioned in the correct position prior to positioning the client on the side of the bed. Two nurses are preparing to turn an immobile client in bed using a lifting sheet. When finished, the patient is in a supported Fowler's Study with Quizlet and memorize flashcards containing terms like A client with limited mobility has outward rotation of the bony protrusions at the head of the femur. Study with Quizlet and memorize flashcards containing terms like a nurse is caring for a client who has an indwelling urinary catheter and notes blood tinged urine in the catheter bag. A client unconscious with weak thready pulse, cool, moisten skin cyanosis of nail bed, Kussmaul respirations. When a client is immobile, urinary stasis occurs. Where would the nurse stand when using the friction-reducing sheet to turn the client to the opposite side of the bed?, Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. The practical nurse (PN) palpates a client radial pulse and notes that the pulse disappears when light pressure is applied. The client's current weight-bearing status C. She walks 2 miles each morning and eats a healthy, balanced diet. The coordinated efforts of the musculoskeletal and nervous systems c. Which of the following is a cardiovascular response to regular exercise?, A nurse is preparing to turn a hospitalized client age 65 years. The nurse is preparing to collect a capillary blood Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to assist w a prostate examination. Using the right method will also help protect your back. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? A. Monitor the client at least Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to make a bed occupied by a client who is on bedrest. Demonstrate understanding of active and When preparing to move a patient in bed, what will the nurse do first? Assess the patient's ability to help with moving. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle. Increase in cardiac output. 1C(115F) D. Put your weight on your back leg. The nurse is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. , A nurse is administering an oral medication to an older adult client. Study with Quizlet and memorize flashcards containing terms like A nurse is teaching a client about the uses of aloe vera. 15 of 35. , Study with Quizlet and memorize flashcards containing terms like The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which of the following actions should the nurse perform first? a. How often would the nurse turn the client in bed?, The nurse is turning a client in bed. Activate the emergency fire alarm b. Explain to the client how the nurse will assist her. The nurse is preparing to move a patient with hemiplegia into the prone position. Study with Quizlet and memorize flashcards containing terms like The proper use of the principles of body mechanics:, A nurse assists the client into the position shown in the accompanying image. , The nurse is caring for an immobile client. Where should the nurses be standing in relation to the client's body as they prepare for the move? 1. Client's plan of care should include:, a nurse is assisting a client who has generalized weakness out of bed to wheelchair. Apply barrier cream to the area, While Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a pediatric client who is immobile. Which of the following findings should the nurse report to the provider? An inability to retract the foreskin. When finished, the patient is in a supported Fowler's position with the head of the bed elevated 45 degrees. The side rail on the side of the bed where the nurse is standing should be lowered to facilitate the transfer. To Strengthen the Patient Gradually. "Stand with your feet together" 3. The force that occurs in a direction to oppose movement d. 5. A nurse is caring for a client who is immobile. A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. Avoiding Injury. Move the person's legs over the edge of the bed while pivoting their body so that the person ends up sitting on the edge of the bed. Place a small pillow under the shoulder. Some hospital beds will have a trapeze bar above the clients; others may have a side rail or assist bar next to the bed. - Check on the client hourly - Instruct A nurse is preparing to measure the blood pressure of a client who has hypertension. steps into the walker when walking D. Which of the following actions should the nurse take? Move the client from supine to a low Fowler's position every 2-3 hours to help prevent orthostatic hypotension B. A client is admitted to the hospital with intractable pain. Before moving pt nurse auscultate breath sound at every 2 h. leans over the walker when walking, A nurse is preparing to move a client up in bed. needs to be moved up in bed with the aid of a Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with cerebral palsy who requires crutches to ambulate. What action by the UAP requires intervention by the nurse? a. Place the following steps in the correct order. What should the nurses keep in mind with respect to proper body mechanics during the lifting procedure? Adduction is moving a body part away from the midline of the body. 1 / 5 have client push with feet as your lift and assist the client up in bed. , The nurse is assessing the neurovascular status of a 5-year-old with a broken femur. A 35-year-old female with severe chest pain: red tag b. Reposition the client every 4 hours B. Wash the area with hot water every 8 hours Study with Quizlet and memorize flashcards containing terms like A nurse is slowly preparing to move a client who is partially only able to sit up in bed, which of the following methods should the nurse plan use?, A nurse is caring for a client who has a pressure ulcer. Encourage the patient to perform as many self-care activities as possible. Where should the nurses be standing in relation to the patient's body as they prepare for the move? 1. Mental Health Nursing Nursing assistants (NAs) have a major responsibility for assisting clients who have decreased mobility. shoulder and elbow injuries from moving patients. In what position would the nurse the client to begin this procedure, The nurse adjusts a client Study with Quizlet and memorize flashcards containing terms like A nurse at an extended-care facility is instructing a class of AP's about the use of assistive devices during ambulation. Step 3. What motion would the nurses use to counteract the client's weight? Shift their weight back and forth, from back leg to front leg. Which action best ensures the safety of both the client and the Which statement made by the NAP requires the nurse's follow-up? and more. Pernicious anemia B. Step 5. The nurse should stand as close to the object as possible to Study with Quizlet and memorize flashcards containing terms like A charge nurse is teaching a new nurse how to initiate IV access on a client. , A nurse in a long-term Move from the bed to the wheelchair every 2 hours. Bathe one side of the body at a time. To Provide a Change in Position. " ANS: C Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. uses the walker to rise from a chair B. Twisting the torso when transferring the client. Encourage holding the breath frequently to hyperinflate the client's lungs. Click the card to flip 👆. The client with pneumonia does not have specific risk factors. which of the following information should the nurse include in the teaching?, A nurse is preparing to move a client who is only partially able to assist up in bed. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client diagnosed with pneumonia. By supporting your arms on the side of the bed, or a countertop, you increase the leverage. Increase in pulse rate. Lift the client using a swivel-and-pivot motion. Trendelenburg, A nurse is caring for a client who is sitting in a chair and Put the side rails up and tell the client to call the nurse before voiding. ) Suspended in a Sling With a “Basket” Approach. Positioning may not be a one-person task. Raise the head of the patient's bed to 30-60 degrees - Move the top bed linens out of the way, For the patient who is immobile or has mobility restrictions in getting onto the Study with Quizlet and memorize flashcards containing terms like The nurse is preparing to educate a client diagnosed with essential hypertension on how to decrease the risk of developing complications. Use a standing frame to promote stability. C. Assess the patient's ability to actively participate in the actual transfer. raise 4 side rails while client is in bed c) apply one soft wrist was implied by the columbines. 6)Grasp the sheet and move the client on the count of three. Bed boards, slide boards, pillows, patient lifts, and slings can facilitate the ease of changing positions. Grab the slide sheet or draw sheet at the patient's upper back and hips on the side of the bed closest to you. Apply Moving a client up in bed (one nurse) Flashcards; Learn; Test; Match; Q-Chat; Get a hint. Which of the following actions should the nurse plan to take?, A nurse is inspecting a client's rectal area and notes the presence of bulging red tissue that encompasses the entire anal opening. Body Mechanics, Positioning, and Moving Learn with flashcards, games, and more — for free. Altered Study with Quizlet and memorize flashcards containing terms like A new nurse is helping move a patient up in bed. B: Placing feet apart with one foot in front of the other provides a wide base of support and allows the nurse to use their body weight to assist in the movement, making this the Study with Quizlet and memorize flashcards containing terms like A nurse is performing a complete bed bath for a client. Chapter 23. Ensure that there is a physician's order to move the patient with a mechanical lift 2. 1 / 5. Determine when the IV solution was started. Which of the following actions by the nurse demonstrates the correct transfer technique?, A nurse is caring for a client who has been hospitalized and is performing active ROM exercises. When elevated, which of the following lab values suggest that the client has an Move from the bed to the wheelchair every 2 hours. A quad cane is used to provide balance during ambulation, not to help transfer the client to a chair. The nurse realizes that a primary concern regarding patient safety is to: 1. Which of the following statements should the nurse make to promote conflict resolution? "Let's discuss how we can work together. Tachypnea B. , The nurse observes a bed-confined client's feet are beginning to remain in a plantar flexed position. Semi-Prone D. " B: "Please hold on to my waist while I help you stand. Moving a patient in bed. Two nurses lifting the client under the shoulders. : Fundamentals of Nursing, 9th Edition, MULTIPLE CHOICE 1. Which of the following actions should the nurse take when pouring the sterile solution a. The client's heigh D. Provide warm prune juice before the client goes to bed at a) Establish client outcomes b) Collect information about past health problems c) Determine whether the client has met specific goals d) identify the clients' specific health problems, A nurse is caring for a client who has a prescription for 325mg Acetaminophen PO for an oral temperature above 38. The nurse should pay special attention to cleaning which areas of the body -Underneath the fingernails and toenails -The antecubital fossa and popliteal space -Underneath the breasts and in between the skin folds -The Ask client to push with legs as you help them move up the bed. b) One nurse stands beside the stretcher, one nurse stands on the opposite side of the bed, and the third nurse stands at the client's feet. Dehydration C. Elevate head of bed and place pillows under head. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. The A nurse is setting up a sterile field to perform would irrigation for a client. Eating late in the evening may interfere with sleep, especially if a heavy meal. Extinguish the fire c. Position a walker in front of the client to provide stability. This provides support for the patient. Study with Quizlet and memorize flashcards containing terms like After repositioning an immobile client, the nurse observes an area of hyperemia. Use the affected arm as a guide during rolling. Which of the following actions by the nurse demonstrates proper use of body mechanics? A. Study with Quizlet and memorize flashcards containing terms like The nurse is providing a bed bath for a female client who is unconscious. Renal calculi. Which intervention should the nurse implement to promote bowel elimination? Remind the client to turn every two hours while lying in bed. What is the nurse monitoring? a. Which of the following physiological responses to prolonged immobility should the nurse expect?, A nurse is reinforcing teaching with a The nurse is caring for a patient who has been diagnosed with a stroke. Which of the following To move a person who is lying in bed to a wheelchair, put the chair close to the bed and lock the wheels. Study with Quizlet and memorize flashcards containing terms like A male client with venous incompetence stands up and his blood pressure subsequently drops. Even with the thorax 2. Which intervention is best for the practical nurse (P) to 1 "Increased risk of kidney stones" 2 "Urinary stasis" 3 "Urinary tract infections" Rational: 1: Kidney stones increase in likelihood in the client who is immobile. When moving a client up in bed with the assistance of another caregiver A friction-reducing sheet would be helpful in moving the client up in bed or making a lateral transfer but not in helping transfer the client to a chair. What should the nurses keep in mind with respect to proper body mechanics during the lifting procedure? A nurse has to move a weak client from the bed to the wheelchair to take the client to the x-ray unit of the healthcare facility. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?, Trochanter rolls, The nurse is assessing a client who is bedridden. Which statement in response to these instructions suggests to the nurse that the client has a need for Aligning the nurse's knees with the client's knees just before the transfer - This is a correct strategy that helps the nurse safely stabilize the client while moving to a standing position. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Semi-Fowler's C. Which of the following actions should the nurse perform first? A) Explain to the client how the nurse will assist her. Four-point B. Which of the following actions should the nurse take? (Select all that apply. , Place graduated compression stockings on the client. a client who plans to leave the facility against medical advice b. The client should associate bed with sleep, not work. Client safety has priority. c) One nurse stands on the side of the bed with the stretcher; two Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is receiving enteral feedings due to dysphagia. False. A nurse is preparing to perform complex abdominal wound care. , A nurse is planning care for a client who is on bed rest. Which precaution should Two nurses are moving a client up in bed. Limit fluid intake to 1 L Keep 4 side rails up while the client is in bed. Study with Quizlet and memorize flashcards containing terms like A nurse is providing care to a client confined to bed. 6. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing body alignment. Which finding indicates that the nurse should hold the prescribed dose?Select an option, then click Submit. keep the bath water between 43. Prostate enlargement D. - Stand as close to the object as possible - Keep abdominal muscles contracted and the lower back straight - Look straight ahead with shoulders raised up - Bend hips slightly and squat - Push up from the knees when lifting the object Stand as close to the object as possible is the first step. Not using gloves while combing the client's hair b. What is the first action the nurse would take in this procedure?, The nurse is making a bed occupied by a client. Which of the following actions should the nurse take? A. Hook the longer straps on the end of the sling closest to the patient's feet 3. 1 cup of 2% milk D. What nursing interventions should the nurse implement for the client's night sweats and fever. Delete comma after sinister B. ) an inability to retract the foreskin c. A NURSE IS PROVIDING HYGIENE CARE FOR A CLIENT WHO IS IMMOBILE WHICH OF THE FOLLOWING ACTIONS SHOULD THE NURSE TAKE? (Select all that Apply) A: Check for personal items when changing the bed linens B: Place a Clean Gown on the strongest arm first C: Keep the bath water temperature between 43. Flashcards; Learn; Test; Match; Q-Chat; Get a hint. Put one foot forward in the direction you are preparing to move the patient. Which of the following actions should the nurse take?, A nurse enters an older adult client's room to insert a saline lock. Encourage the client to perform antiembolic exercises every 2 hr. Which finding indicates that the nurse should hold the prescribed dose? Study with Quizlet and memorize flashcards containing terms like What priority concern should the nurse have for a client who has had a stroke and has left-sided hemiparesis? Impaired physical mobility Sedentary lifestyle Disuse syndrome Risk for injury, How should the nurse plan to move a client who is obese and immobile? Trapeze Transfer board Study with Quizlet and memorize flashcards containing terms like Two nurses are moving a client up in bed. Protect the client's arms from being hurt during the transfer 3. Which of the following methods should the nurse plan to use? A. ) sparse pubic hair Study with Quizlet and memorize flashcards containing terms like A nurse is changing a dressing and providing wound care. Osteoporosis. Hold the bottle in the center of the sterile field when pouring the solution d. Utilize a mechanical lift for the transfer. Wearing a) One nurse stands beside the stretcher, one nurse stands on the opposite side of the bed, and the third nurse helps support the client as needed. It takes at Assess the patient’s range of motion (ROM), body alignment, and comfort level while the patient is lying down. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely---The nurse should ensure that traction weight is hanging freely. 15 of 20. Study with Quizlet and memorize flashcards containing terms like A nurse is repositioning a client who has physical limitations due to recent back surgery. In assessment of the client, the nurse is alert to a(n) a) Increased blood pressure b) Decreased heart rate c) Increased urinary output d) Decreased peristalsis, A 61-year-old Two nurses are moving a patient up in bed with a draw sheet. a client who informs the nurse that he has made his funeral Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to administer an IM injection to an adult client who has a BMI of 30. Close the curtains around the bed and close the door to the room, if possible. Increase the stability of the client's body 2. ) a pendulous scrotal sac b. The reddened Study with Quizlet and memorize flashcards containing terms like The nurse is preparing a client to be turned in bed. Which of the following needle lengths is appropriate to administer the injection in the ventrogluteal muscle?, A nurse is collecting data on a newly admitted client who is reporting abdominal Two nurses are preparing to turn an immobile client in bed using a lifting sheet. Warm the feeding in a microwave B. Steps on moving a patient up in bed. Slow the IV infusion to keep vein open rate. Which of the When preparing to move a patient in bed, the nurse should: An appropriate procedure to use when moving a patient up in bed is for the nurse to: instruct the patient to inhale and hold still. raise the bed to a comfortable working level b. Use all options. Position the feet and knees close together. 2: The ability to be mobile helps facilitate urine flow. Study with Quizlet and memorize flashcards containing terms like A nurse is performing a Romberg test for a client who reports episodes of dizziness. The client requires partial assistance in the transfer. The nurse does not complete an incident report because no harm came to the client. Which of the following is an appropriate action for the nurse to take? A. Which crutch-walking gait will the nurse teach?, A nurse is performing range-of-motion exercises for a client and moves the client's fingers apart and then back together. 5)Ask the client to bend the legs and place the chin on the chest. The nurse should stand as close to the object as possible to Study with Quizlet and memorize flashcards containing terms like An elderly client who is 12 hours postoperative for a hernia repair suddenly becomes agitated, staggers out into the corridor and demands to be set free. A nurse is preparing to transfer a client from lying in bed to sitting in a chair. A 42-year-old male with full-thickness body burns: green tag c. In what position would the nurse place the client to begin this procedure?, A nurse is repositioning a client who has physical limitations due to recent back surgery. ) darken the Study with Quizlet and memorize flashcards containing terms like The nurse is helping a client with a weak left leg to a standing position for an assist into a wheelchair. check for personal items when changing bed linens B. Which of the following actions by the client demonstrates proper use A nurse is preparing to administer a tap water enema to a client. Bend hips slightly and squat 5. Incorrect: The bed should have been lowered to the position prior to moving the client to the side of the bed. Place a pillow on the abdomen. Stand as close to the object as possible 2. To promote independence while the client is moving in bed and provide the client assistance in moving up in bed, which device would be appropriate?, The nurse is providing health teaching for a client who flies often for a. Instruct the client to cough and deep breath every 4 hr. , The nurse puts elastic stockings on Persons who require nursing care may be immobile for long periods of time. B) Muscles produce red blood cells and platelets. True. The client has tenderness and warmth in their calf. Use mechanical aids. Stand close to the bed with the legs close together. Report the A nurse is caring for a client requires maximum assistance to transfer her in the bed to the chair which of the following pieces of equipment should the nurse use Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a hospitalized client with a diagnosis of heart failure who is suddenly experiencing increased shortness of breath. Which of The nurse is preparing to help a client ambulate after hip surgery. Reduce the amount of body Study with Quizlet and memorize flashcards containing terms like 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. Keep the bed in the lowest position while changing the sheets. ) - Brace all side rails on the clients bed. The nurse is preparing to administer dalteparin subcutaneously to an immobile client who has been receiving the medication for 5 days. "Close Figure 8. -maximize the client's participation. A 55-year-old female with a scalp laceration: black tag d. The nurse understands that an immobile client may have poor body alignment, which may lead to complications. A person is immobile when their bodies cannot be active or can only perform very limited activity, such as when a person is on an order for bedrest. How would the nurse know when the client has been lowered far enough into the chair?, What would the nurse do with the sling of a full-body sling lift once the client has been lowered into The nurse knows that the education has been effective when the client: A. Which finding should the nurse identify as a compensatory response? Bradycardia. Drape the top sheet and covers loosely over the bed cradle. What items will the nurse need? Select all that apply. Which of the following actions by the nurse demonstrates proper use of body mechanics? - Twisting the torso when transferring the client - Bending at the waist when transferring the client - Placing the bed in the high position before transferring the client - Looking at the Study with Quizlet and memorize flashcards containing terms like When preparing to move a patient in bed, what will the nurse do first?, 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 patient who weighs 200 lbs. The nurse is preparing a client to move from the bed into a wheelchair. Demonstrate understanding of the complications of inactivity. Use a team approach for lifting the client. Report any signs of drug addiction to the nurse immediately. In which of the following positions should the nurse place the client to prevent atelectasis?, A nurse is evaluating a client who has a broken leg and is using crutches. In what position would the nurse place the client, if tolerated? Supine. Which nursing action promotes client autonomy? The nurse is assisting a client from the bed to a chair that is positioned next to the bed. The nurse is performing which range Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who had a stroke and reports difficulty with proprioception . How often would the nurse turn the client in bed?, The nurse is preparing a client to be turned in bed. Multiple small abdominal bruises D. Completely remove the linens. Which of the following should the nurse give the AP's about the clients' use of a cane?, A nurse is observing an assistive personnel (AP) changing the linens on the Encourage position changes within the patient when the patient is preparing to move out of bed. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids. What motion would the nurse use when A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. The nurse should plan to collect data from the client for which of the following ?, A nurse is caring for a client requires maximum assistance to transfer her in the bed to the chair which of the Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who is immobile and has developed a pressure ulcer. Minimize the risk of falls or other injury during the transfer procedure. 4. Which of the following findings should the nurse report to the provider. This is important for which reason? A) To keep the client warm B) To prevent skin breakdown C) To restrict movements D) To provide proper body alignment, A nurse is caring for an elderly client A nurse is preparing to assist with a prostate examination. What should the nurse do prior to beginning this task in order to maintain safety? Select all that apply. bend the client's Lock the brakes on the bed Reason: Locking the wheels of the bed (and wheelchair, if one is used) helps to prevent the bed (and chair) from sliding away, thus preventing injuries. Evacuate the client d. Which of the following actions should the nurse take to reduce the risk of infection?, A nurse in a A nurse is preparing to move a client who is only partially able to assist up in bed. Select all that apply 1. A nurse should: 1. The primary purpose for placing an immobile client's arms across his or her chest when preparing to transfer the client up in the bed is to: 1. A nurse is assessing body alignment. These changes may be achieved with the use of assistive devices such as an over-bed trapeze, hydraulic lift, and EZ Lift. Remove the cap and place it sterile-side up on a clean surface b. Two-point D. Which of the following is a recommended guideline for performing this skill?, The Study with Quizlet and memorize flashcards containing terms like A client who is nonambulatory notifies the nurse that his trash can is on fire. Study with Quizlet and memorize flashcards containing terms like The nurse is reviewing a staff education module on safe client handling. Assess for risk factors that contribute to complications of The nurse answers a call light and sees this client in bed. The A nurse triages clients arriving at the hospital after a mass casualty. Place rolled bath blankets along the dependent leg. What action would the nurse take to accommodate this weak extremity?, The nurse is preparing a client to move from the bed into a wheelchair. , Patients on bed rest or otherwise immobile are at risk for a. 1/2 cup of white rice B. A. Deep venous thrombosis, pressure ulcers, muscular atrophy, pulmonary embolism, and bone demineralization are potential complications of inadequate immobilization, and A. Which of the following actions should the nurse plan to take? A nurse is providing a bed bath for an older adult client who is immobile. Patient mobility is an important aspect of patient care, particularly in the setting of major surgery or severe chronic illnesses that require prolonged immobilization in bed. Step 1. What is the nurse's best response? Study with Quizlet and memorize flashcards containing terms like The cardiac response to exercise is well-researched and documented. , When Study with Quizlet and memorize flashcards containing terms like The nurse has transferred a client out of bed into a chair using a powered full-body sling lift. Which of the following actions should the nurse take?, Study with Quizlet and memorize flashcards containing terms like A nurse is assessing body alignment. Orthostatic hypotension 2. Raise the client’s bed. Employ the mechanical lift to transfer the client. c. - Lower the client's bed to the lowest position. Raises the bed to a more comfortable position C. For which of the following clients should the nurse use the therapeutic communication technique of silence? a. Produce a more compact form that facilitates the transfer 4. ) The husband, who is the caregiver, begins to The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). The prescribed rate is 125 ml/hr. Which of the following methods should the nurse plan to use?, A The correct answer is choice D. How often would the nurse turn the client in bed?, When turning a client Study with Quizlet and memorize flashcards containing terms like _____ exercises are performed by tightening and releasing certain muscle groups. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Raise sid rails and lower bed to lowest level A: Standing facing the center of the bed at the client's side is not the most stable position for moving a client, as it does not provide a wide base of support. In which order of priority from first to last should the nurse Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to assist with a prostate examination. Flex your knees and use your thighs. As part of her ongoing care, the nurse should a. The nurse should identify that which of the following clients is the greatest risk for a fall? a)an older client who is confused and has urinary frequency b)a client with diabetes mellitis who has a leg ulcer c)a client who is 1 day postoperative and has a nurse assistant Study with Quizlet and memorize flashcards containing terms like A nurse is providing oral care for a patient who is immobile. -We need to use our major muscles such as our legs rather than our back muscles. 12. "Walk in a straight line, placing the toes of one foot against the heel of the other foot" 2. Some clients require minor assistance to ambulate safely or move from their bed to a chair, whereas other clients The nurse and an unlicensed assistive personnel (UAP) are preparing to move a client up in bed. Elevate the head of the client's bed C. , A signed consent form indicated a 4. Which of the following actions should the nurse plan to take? a. Raise the bed to waist level. Assess for skin Positioning patient on the side of the bed: 6. carpal tunnel syndrome from use of computer keyboards in nursing documentation. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. Which action should the nurse take while performing this task? Term. the nurse puts all 4 side rails up prior to leaving the room B. Increased diarrhea (peristalsis). PN preparing for shift change highest priority. What motion would the nurses use to counteract the client's weight?, The nurse is assisting a client with limited mobility to turn in bed. Dependent pitting edema Study with Quizlet and memorize flashcards containing terms like A nurse in an emergency dept is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. How would the nurse position the client when loosening bottom bed linens?, When a client cannot The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. Determine the patient's weight. When preparing to move a patient in bed with the help of an You must move or pull someone up in bed the right way to avoid injuring the patient's shoulders and skin. Positioning the chair alongside the bed, rather than 2 feet away, A nurse on the medical surgical unit is conducting a fall risk assessment for four clients. . Review medical record and nursing plan of care for conditions that may influence the patient's ability to move or to be positioned. Which of the following instructions should the nurse include?, A nurse is caring for a client who has a prescription for knee-length While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. 3. In which order would the nurses perform this skill? -The sequence is as follows: (1) Lower the head of the bed to as flat a position as the patient can tolerate; remove the pillow from under the patient's head and position it vertically next to the headboard. 1)Adjust the 1. , 3. Which of the following actions by the new nurse indicates an understanding of the teaching?, A nurse has completed care procedures for a client who requires airborne precautions. What is the nurse's best response? A. ) supply sterile gloves for the provider b. Wait until the client's pain is gone before Resting in bed with the head of the bed elevated 20 degrees and flexing the knees reduces stress on the lower back muscles. Which of the following actions should the nurse plan to take? Position A nurse is preparing to transfer a client from a bed to a wheelchair. Educate the family to avoid sharing personal belongings. When moving a client up in bed, the nurse asks the client to fold the arms across the chest and lift the head with the chin on the chest. What action should the nurse implement?, The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his When preparing to move a patient in bed, the nurse should: An appropriate procedure to use when moving a patient up in bed is for the nurse to : The patient is immobile and has been repositioned in bed using a drawsheet. Two nurses are standing on opposite sides of the bed to move the client up in bed with a drawsheet. What motion would Final answer: The nurse should stand facing the center of the bed at the client's side, place feet apart with the foot nearest the head of the client's bed in front of the other foot, keep knees and hips straight while bending at the waist towards the client, and encourage the client to keep his legs straight and remain still. How should the nurse assess body alignment in this client? Select all that apply. Increased metabolic rate. Look straight ahead with shoulders raised up 4. 1 slice of wheat bread C. Lifts can be used to move someone in bed, such as moving them up in their bed or moving them to the The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. Study with Quizlet and memorize flashcards containing terms like What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? Maintain in a lateral position using protective wrist and vest devices Position prone with a small pillow below the diaphragm Raise the head and knee gatch when lyingin a supine A nurse is preparing to assess the clients genitalia. Pick up the tablet and administer it to the client. Study with Quizlet and memorize flashcards containing terms like A nurse is caring for four clients. Decide on the most effective means of moving the patient. Administer an antipyretic every 4 hours 4. give 40 to 50 mL/kg of water every 4 hours. Match the neurovascular check with the correlating Which position is the client assuming?, When moving a client up in bed with the assistance of another caregiver, the nurse should: and more. the nurse places draw under the client's hips for transfer. What is the rationale for placing the client in When making the bed of a client who needs a bed cradle, which action should the nurse include? Teach the client to call for help before getting out of bed. Which of the following information should the nurse plan to include? A) Muscles store calcium and magnesium. Which of the following should the A nurse is providing a bed bath for an older adult client who is immobile. Avoid conversation while the provider is performing the assessment. After assisting the client back to bed and administering pain medication. 4)Place a friction-reducing sheet under the client. You are caring for an Study with Quizlet and memorize flashcards containing terms like The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Apply an anti-embolism hose once the patient is A nurse administers an incorrect medication to a client. 3 C (110F) and 46. 3)Position the UAP on the side opposite the nurse. Changing patient positions in Name five body mechanic principles that should be used when moving a patient up in bed. Study with Quizlet and memorize flashcards containing terms like When logrolling a client, the nurse should use supportive devices in turning the client in order to: -maintain the natural alignment of the client's body. Place a clean gown on the strongest arm first C. Which of the following nutritional selections by the client indicates a need for further teaching? A. a nurse is providing hygiene care for a client who is immobile. After successfully turning the client to the side, where would the nurse place an additional pillow?, A nurse The nurse is preparing to lift a client up in bed. A Raise the entire bed while bathing the client to reduce back strain Study with Quizlet and memorize flashcards containing terms like The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Flex his hips while pulling the client 3. Which complication is the nurse's priority? 1. places the walker far in front when walking C. Placing the bed in the high position before transferring the client. Place your feet in broad stance with one foot in front of the other. A nurse is preparing to turn a client who is unable to mobilize independently. Apply light pressure over the area B. Faces the side of the bed B. We also do this by rolling the draw sheet up close to the patient. Cover the area with a transparent wound barrier C. The relationship of one body part to another while in different positions b. -prevent the blood stasis that can lead to skin breakdown. If the client is strong enough, ask Study with Quizlet and memorize flashcards containing terms like A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. Shift your weight every 15 minutes. ANS: B/ 12. Place one hand behind patient’s shoulders, supporting the neck and vertebrae. How should the PN When planning to move or reposition the client, ask for help from other caregivers. Study with Quizlet and memorize flashcards containing terms like A client has been on prolonged bed rest, and the nurse is observing for signs associated with immobility. A nurse is preparing to collect data from a client for a health assessment. give 40 to 50 mL/kg of rehydration solution every 4 hours. As discussed in the “Skin Care” section in Chapter 5, clients who are immobile must be repositioned every two hours to prevent pressure injuries and other complications of immobility that will be When patients are recovering from illness, they may require assistance to move around in bed, to transfer from bed to wheelchair, or to ambulate. The client's ability to communicate B. Massage areas surrounding the redness D. Flush the tube with 0. Pressure ulcers. The patient is immobile and has been repositioned in bed using a drawsheet. The coordinated efforts of the Study with Quizlet and memorize flashcards containing terms like A nurse understands that it is necessary to provide clean, dry, wrinkle-free linens for the client. Which of the following interventions should the nurse plan to implement? A. Wrapping the cuff loosely around the arm B. Transferring: The action of a client moving from one surface to You might need to move someone up in bed because, if the head of the bed is elevated, they’ll eventually slide down. Even with the knees. 3: Immobility affects nearly every organ system, including the cardiovascular, Study with Quizlet and memorize flashcards containing terms like A nurse is reposting a client who has physical limitations due to recent back surgery. Choice A rationale: The client's self-reported incisional pain level of 7 on a scale of 0 to 10 is important information to assess postoperative recovery, but it is not the priority finding to report among the choices. B. For A nurse and an assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. turn the client from side to side while pushing upward c. Keep your feet shoulder-width apart, your knees bent, and your back in a natural straight position 1)Adjust the head of the bed to a flat position. Following the DASH dietary plan. The nurse puts on gloves and a gown before removing bed sheets. Which of the following findings should the nurse report to the provider? a. Assess the IV insertion site for swelling. Each person puts hands under the client and slides client toward the top of the bed. Which of the following statements by the family member should indicate to the nurse that he understands the teaching? a) "I will relax my abdominal muscles when preparing to move her" Study with Quizlet and memorize flashcards containing terms like Mariam is an active 69-year-old. Study with Quizlet and memorize flashcards containing terms like A home health nurse is caaring for a child who has Lyme disease. 20 a. What topics should the nurse include? Select all that apply 1. Even with the shoulders 3. - review the medical orders and nursing plan of care for conditions that may influence the pt's ability to move or to be positioned - assess for tubes, IV lines, incisions, or equipment that may alter the positioning procedure - identify any movement limitations - consult pt handling algorithm (if available) to plan appropriate approach to moving the pt - gather . " Which of the following When preparing to move a patient in bed, the nurse should: An appropriate procedure to use when moving a patient up in bed is for the nurse to: The patient is immobile and has been repositioned in bed using a drawsheet. Leave the client in the bed because the client is too large to get up. Rinsing the client's commode pan after use c. Move, however after are C. Use the tablet's packaging to pick up the tablet and administer it to the client. , Client has been places in wrist restraints, nursing actions: and more. Step 2. Which of the following actions should the nurse take prior to initiating the feeding? A. Study with Quizlet and memorize flashcards containing terms like The nurse must transfer a patient from a bed to a chair using a mechanical lift. One nurse lifting the client’s legs as the client uses a trapeze bar. 2. Study with Quizlet and memorize flashcards containing terms like The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. A nurse is preparing a client for outpatient surgery. Which of the following actions by the nurse demonstrates proper use of body mechanics? Examples of assessments include their ability to complete hygiene and grooming needs, as well as the amount and type of assistance required to safely reposition themselves in bed, move in and out of bed into a Repositioning in Bed. Which of the following ethical principles did the nurse violate? Two nurses are standing on opposite sides of the bed to move the patient up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions? A nurse is preparing to give a change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following instructions should the nurse give the client? 1. Keep abdominal muscles contracted and lower the back straight 3. ) a. The reddened area continues to blanch and Study with Quizlet and memorize flashcards containing terms like A nurse is planning care for a client who is immobile and requires continuous mitten restraints. Swing-through, A nurse is reinforcing teaching with the partner of a client who Notify the nursing supervisor. Confine the fire, Study with Quizlet and memorize flashcards containing terms like A child is admitted with dehydration follow- ing a 24-hour history of vomiting and diarrhea. To assess for blanching, what action should the nurse take? A. 2)Remove all pillows from under the client. Supine B. Oral rehydration therapy is ordered. To Enhance Psychological Well-being. Provide a complete bed bath to promote patient comfort. knee Study with Quizlet and memorize flashcards containing terms like While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. She is from a family with longevity and trusts she will have good An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three hours after the woman delivered her baby. tshz fcwck dhke fkfqihg phkr llojvo mso nneukyg psiajxa arsqsnn