RNSG 1430 Mobility Quiz 2020 – San Antonio College | RNSG1430 Mobility Quiz 2020

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RNSG 1430 Mobility Quiz 2020 – San Antonio College RNSG 1430 Mobility Quiz 2020 RNSG 1430 Mobility Answer each question and provide a rationale for the answer. List all references in APA f... ormat. 1. A client who was in a car accident and broke his femur has been immobilized for 5 days. When the nurse gets this client out of bed for the first time, a nursing diagnosis related to the safety of this client will be: A. Pain B. Impaired skin integrity C. Altered tissue perfusion D. Risk for activity intolerance Rationale: Patient is at risk for falling due to the immobilization of five days, weakness and loss of strength in his bones and muscles is closely related to extended period of time with inactivity. 2. The nurse is caring for a client who has right-sided weakness. The nurse needs to help the client walk. What should the nurse do while walking with the client? A. Hold the client’s left hand while walking B. Hold the client’s right hand while walking C. Put a gait belt on the client and provide support on the left side D. Put a gait belt on the client and provide support on the right side Rationale: You must support a client on the affected side when using a gait belt to help the patient maintain balance. You must also stand behind the patient and hold on to the gait belt as they walk. 3. A client has been diagnosed with osteoarthritis (OA), tells a clinic nurse about the inability to ambulate and staying on bed rest because of hip stiffness. In addition to teaching the client measures to reduce joint stiffness, which referral for the client should the nurse plan to discuss with the health care provider? A. Social worker B. Occupational therapy C. Arthritis Foundation D. Physical Therapy Rationale: The management goals for patients with osteoarthritis is to maintain or improve joint mobility. Aerobic exercise and lower extremity strength training decreases the symptoms of osteoarthritis and prevents progression. Therapy helps the patient adopt some self-management strategies. 4. A client is admitted to the rehab unit following a Right total hip replacement (THR). The client is 3 days post-op. Doctor’s order states: activity is weight bearing as tolerated with assistance. Which nursing intervention should be implemented? A. Assisting the client to get out of bed on the left side so the client can stand to use the urinal B. Assisting the client using a gait belt to the commode C. Log rolling client on the right side to assist the client out of bed D. Assisting the client to the bathroom, which has grab bars, an elevated toilet seat, using a walker, and partial weight bearing of the right leg. Rationale: The client will have pain after surgery, their movement will be limited and to stop the prosthesis from getting misplaced you have to make sure the patient is taking special measures, like the grab bars to help them ease down to the toilet seat, and the elevated toilet seat to minimize hip joint flexion as it can lead to a misplaced prosthesis, this also includes why they need help getting to the restroom and partial bearing on the right leg, or the affected leg, the patient needs to be aware that there will be limits to their positioning including abduction, internal/external rotation, hyperextension and acute flexion. 5. To prevent circulatory compromise after a right total knee replacement, a nurse should ensure that the client is: A. flexing both feet and exercising uninvolved joints every hour while awake B. using the CPM machine every 2 hours for 30 minutes (wrong because not every patient will do this time may need less) C. Assisted up to the chair as soon as the effects of anesthesia have worn off D. Using the trapeze to life the buttocks off the bed and then rotating each leg intermittently Rationale: A patient with TKA should be ambulating after the first postoperative day, before discharge a patient should be able to attend physical therapy, to avoid flexion of the knee a device is put on the knee immediately after surgery, allowing the rest of the joints to move freely and exercise. 6. The nurse is assessing a resident who is 3 days post-op following a right total hip replacement. While assisting the resident up to the chair- which of the following findings require the nurse to intervene immediately? A. Reddened area on the Sacrum B. Voiding concentrated urine, 50ml/hr C. Capillary refill 3 seconds, dorsiflexon and sensation intact, pedal pulses palpable D. Hip incision well approximated with 5 steri- strips in place. Rationale: Red on the sacrum is an immediate concern. Especially with patients who have been on bedrest, laying in bed for an extended period of time leads to pressure on certain points of the body and if the patient is immobilized and not moved it can cause this reddened to become an ulcer, then if untreated it can lead to infection. References Taylor, C. (10/2014). Fundamentals of Nursing. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469898032/ Taylor, C. (10/2014). Fundamentals of Nursing. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469898032/ Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ Tutorial: Skills Modules 2.0 Module: Ambulation, Transferring, Range of Motion; Step-By-Step Viewing Ambulation – nurse assist. (n.d.). Retrieved January 23, 2018, from https://student.atitesting.com/SkillsModules Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical- Surgical Nursing, 13th Edition. [Bookshelf Online]. Retrieved from https://bookshelf.vitalsource.com/#/books/9781469863801/ [Show More]

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