- 1 Thủ Thuật Hướng dẫn Which actions are correct when nursing personnel are logrolling a patient quizlet? 2022
- 1.1 When logrolling a client the nurse should?
- 1.2 When logrolling a person the person is?
- 1.3 What does logrolling a client mean?
- 1.4 What is the most important action to ensure the nurse is in proper body toàn thân alignment when positioning a patient in bed?
- 1.5 Clip Which actions are correct when nursing personnel are logrolling a patient quizlet? ?
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Thủ Thuật Hướng dẫn Which actions are correct when nursing personnel are logrolling a patient quizlet? 2022
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- When logrolling a client the nurse should?When logrolling a person the person is?What does logrolling a client mean?What is the most important action to ensure the nurse is in proper body toàn thân alignment when positioning a patient in bed?
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Patient is turned in the same way a log would be rolled (as one unit)
A nurse is writing a procedure for logrolling a patient. Which of the following should be included in the procedure? Select all that apply.
Three staff members are required to logroll a patient.
A draw sheet is used to keep the patient’s head, neck, and shoulders in
alignment during the turn.
The staff person standing the patient’s head is responsible for giving directions and counting to 3 before each movement of the patient.
Logrolling is appropriate for a patient with a spinal injury or who has had spinal surgery.
Tightly rolled sheet or blanket placed against the lateral side of the thigh to prevent outward motion of the hip and leg
permanent plantar flexion of the foot
effects of immobility
blood clots, Pneumonia, Bone Demineralization, kidney stone, constipation (not moving) pressure ulcers (turn q 2h) urinary retention, depression
Nursing Measures to Prevent Respiratory Complications
Turn the patient from side to side every 2 hours
Elevate the head of the bed 45 degrees
Encourage coughing and deep breathing
Encourage use of the incentive spirometer
A nursing instructor educates a class of student nurses about how to prevent respiratory complications of immobility. The instructor properly emphasizes the importance of
Elevating the head of the patient’s bed 45
To prevent atelectasis and pneumonia, it is necessary to increase lung expansion, strengthen respiratory muscles, improve oxygen and carbon dioxide exchange, and improve the effectiveness of coughs. To prevent respiratory secretions from pooling in the lungs, elevate the head of the bed 45 degrees or more to promote lung expansion.
Nursing Measures to Prevent Cardiovascular Complications
the movement of extremities
Apply ordered devices to prevent pooling of blood in the legs
Gradually move the patient from lying to sitting or to a standing position
Change the patient’s position frequently
Remain with the patient the first few times getting out of bed and dangling
Preventing Musculoskeletal Complications
Maintain proper body toàn thân alignment
Keep the head, trunk, and hips in a straight
Prevent the legs from rotating in the hip socket medially or laterally
Maintain arms in correct alignment with the shoulders
A nurse is educating a patient about her diagnosis of osteoporosis. The nurse recognizes that osteoporosis
Can cause a patient to become hypercalcemic
Osteoporosis occurs due to a loss of minerals, including calcium, from the bones. The calcium leaves the bones and enters the
bloodstream, causing hypercalcemia. This in turn places the patient an increased risk for kidney stones because the excess calcium in the blood must then be filtered out by the kidneys.
A patient is 1 day post-op, and the physician has written an order for the patient to ambulate. When the patient asks why it is important to ambulate, the nurse explains that ambulation prevents complications related to immobility, which include:
Complications from immobility and prolonged bed rest include kidney stones, or renal calculi.
A patient has limited mobility because of a stroke. When the nurse responds promptly to his call button, he snaps, “What the heck took you so long to get here! You people are so lazy.” An appropriate response would be:
“You sound frustrated. What is the thing you are most
Immobile patients often feel fear, anger, and helplessness, and they may direct these emotions in inappropriate ways. This response acknowledges the patient’s explicit feelings (of frustration) and with an open-ended question invites the patient to participate in identifying and solving the real problem.
When caring for a bedridden patient, the nurse recognizes the importance of preventing the formation of a venous
thromboembolism (VTE). To prevent a VTE, the nurse should
Assist the patient in performing passive range-of-motion exercises.
Apply antiembolism stockings to prevent pooling of blood in the legs.
The nurse is caring for a patient who has a history of orthostatic hypotension. When providing patient education, the nurse emphasizes the importance of
Performing dorsal and
plantar flexion of the feet
To help decrease the workload of the heart and prevent hypotension, the patient should move the extremities, especially by dorsal and plantar flexion of the feet. This movement causes muscle contractions that help push the blood in the veins back to the heart.
As the nurse is helping a patient move from a lying to a sitting position, the patient suddenly develops signs of orthostatic hypotension. The nurse should
Help the patient into a semi-Fowler’s position to prevent syncope
When dangling the patient, assess the patient’s pulse and blood pressure for an increase or decrease of more than 20 beats per minute or 30 mm Hg, respectively. Assess the patient for complaints of dizziness, nausea, or pain. If the vital signs are outside these parameters, or if the patient complains of these symptoms, immediately assist the patient to Fowler’s or semi-Fowler’s position
to prevent possible syncope and injury.
A patient is on bedrest. To prevent pressure ulcers, the patient is provided a gel-filled mattress overlay, and:
The nurse inspects the patient’s bony prominences for redness least every 2 hours.
The nurse should inspect the patient’s bony prominences for redness least every 2 hours. If redness is found, the nurse should massage around the area but not apply
pressure directly to it.
During shift report, a nurse is informed that a patient is using an incentive spirometer. The nurse correctly understands that:
The incentive spirometer helps to prevent atelectasis.
An incentive spirometer is used to help the patient take 10 to 20 deep inhalations every hour, thereby reducing the likelihood of atelectasis, or collapse of the lungs.
A physician has written an order to instruct the patient to turn, cough, and deep breathe. When teaching the patient to turn, cough, and deep breathe, the nurse explains that these actions will help to prevent
Atelectasis, the collapse of lung tissue affecting part or all of a lung, can occur due to the inability of the lung to fully expand. It may also occur when a patient does not take full, deep breaths to keep the
alveoli open. When the alveoli collapse, oxygen and carbon dioxide exchange is impaired, resulting in lowered oxygen in the blood, or hypoxemia.
An immobile patient who has been alert; coherent; and oriented to time, place, and person says, “I keep hearing a cat crying, but I know there can’t be a cat in here, can there?” Which of the following would be an appropriate response?
“Of course there’s no cat
here. You must be hearing things. That happens sometimes when a patient is on bedrest and there isn’t enough to do. If you keep hearing a cat, just ignore it.”
This patient is probably experiencing low-level sensory deprivation and needs more stimulation. This response affirms the patient’s grasp on reality (no cat), explains the neurological process work, and begins to engage the patient in identifying solutions to the problem.
who has been mostly immobile for a week complains of feeling weak all over as he sits up with assistance. The nurse correctly understands this weakness to be
a result of loss of muscle tone and contractures of the muscles.
Muscles begin to lose size, tone, and strength after a few days of disuse, and tendons and ligaments begin to change within 4 to 6 days, leading to reduced flexibility and shortening and tightening of the muscles. Thus, the patient who
has been immobile for a week feels that movement is difficult.
A male patient on bedrest tells the nurse he thinks he could empty his bladder more completely if he could stand while urinating. The nurse should:
Request an order from the physician to permit the patient to stand while urinating.
Males may be best able to empty the bladder by standing when urinating. When a patient is on bedrest, it is
necessary to obtain a physician’s order before assisting the patient to stand.
When educating a patient about nursing measures to prevent gastrointestinal complications, the nurse should teach the importance of
Taking a stool softener as needed
Taking a laxative or stool softener as needed, according to physician’s orders, helps prevent constipation.
nursing instructor knows a student needs further review when the student describes position of function as:
the greatest range of motion a joint can move.
The term position of function means aligning the extremities to maintain the potential for their use and movement by avoiding nerve damage. Range-of-motion exercises can also help the patient maintain abilities, but this is not what position of function refers to.
patient’s chart shows orders to wear sequential compression devices and to receive range-of-motion exercises every 8 hours. The nurse correctly understands that:
Both treatments can help prevent the formation of venous thrombosis.
Sequential compression devices are applied to the lower legs to move blood toward the heart and thereby prevent venous thrombosis. Range-of-motion exercises can also help maintain circulation and prevent clots, and they can
alleviate gastrointestinal complications of immobility.
When educating a class of nursing students, the nursing instructor emphasizes the importance of recognizing preventable causes of death. The nursing instructor teaches that the most preventable cause of death during hospitalization is
An embolism has been identified as the most preventable cause of death during hospitalization.
A patient has fallen onto the floor and is too weak to stand up without assistance. Which of the following types of equipment is best suited to this situation?
When health-care staff use a lift to move a patient, they first place a sling under the patient and then use the hydraulic, battery-powered, or ceiling lift to raise the patient from the bed, chair, or in this case, floor. This is the safest way to move a
patient who cannot sit or stand.
An immobile patient has not had a bowel movement for 3 days and reports not feeling hungry. The nurse should consider the possibility that:
A lack of activity has caused a decline in peristalsis.
Immobility can reduce the activity of the smooth muscle of the small intestine, resulting in a decline of peristalsis and constipation.
patient in a nursing home has had a stroke and is largely immobile. When explaining the potential complications of immobility to the patient’s family, the nurse would not include:
increased urine volume.
The human body toàn thân is designed to be mobile, and immobility can have many adverse consequences. These include urinary retention, but immobility does not increase urine volume
When logrolling a client the nurse should?
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 toàn thân. Two nurses will transfer an older adult client from her bed to a chair later in the day.
When logrolling a person the person is?
Logrolling is a technique used to turn a patient whose body toàn thân must all times be kept in a straight alignment (like a log). This technique is used for the patient who has a spinal injury. Logrolling is used for the patient who must be turned in one movement, without twisting.
What does logrolling a client mean?
Logrolling is a common patient care procedure performed by many health care workers. The purpose of logrolling is to maintain alignment of the spine while turning and moving the patient who has had spinal surgery or suspected or documented spinal injury.
What is the most important action to ensure the nurse is in proper body toàn thân alignment when positioning a patient in bed?
Promote body toàn thân alignment with pillows.
Support proper body toàn thân alignment in Sims’ position by placing a pillow underneath the patient’s head and under the upper arm to prevent internal rotation. Place another pillow between the legs.
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