exam 4 NCLEX questions

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156 terms SMloveforyou Preview Exam 4 76 terms lane A nurse is preparing an exercise program for a patient who has COPD. Which instructions would the nurse include in a teaching plan for this patient? Select all that apply.

• Instruct the patient to avoid sudden position changes

that may cause dizziness.

• Recommend that the patient restrict fluid until after

exercising is finished.

• Instruct the patient to push a little further beyond

fatigue each session.

• Instruct the patient to avoid exercising in very cold or

very hot temperatures.

• Encourage the patient to modify exercise if weak or ill.
• Recommend that the patient consume a high-carb,

low-protein diet.A, D A nurse is providing range-of-motion exercises for a patient who is recovering from a stroke. During the session, the patient complains that she is "too tired to go on." What would be priority nursing actions for this patient? Select all that apply.

• Stop performing the exercises.
• Decrease the number of repetitions performed.
• Reevaluate the nursing care plan.
• Move to the patient's other side to perform exercises.
• Encourage the patient to finish the exercises and then

rest.

• Assess the patient for other symptoms.

A, C, F

A nurse is ambulating a patient for the first time following surgery for a knee replacement. Shortly after beginning to walk, the patient tells the nurse that she is dizzy and feels like she might fall. Place these nursing actions in the order in which the nurse should perform them to protect

the patient:

• Grasp the gait belt.
• Stay with the patient and call for help.
• Place feet wide apart with one foot in front.
• Gently slide patient down to the floor, protecting her

head.

• Pull the weight of the patient backward against your

body.

• Rock your pelvis out on the side of the patient.

C, F, A, E, D, B

Which patient would the nurse refer to a specialist based on failure to achieve these milestones?

• A 4-month-old infant who is unable to roll over
• A 6-month-old infant who is unable to hold his head up

himself

• An 11-month-old infant who cannot walk unassisted
• An 18-month-old toddler who cannot jump

B A nurse is caring for a patient who has been hospitalized for a spinal cord injury following a motor vehicle accident.Which action would the nurse perform when logrolling the patient to reposition him on his side?

• Have the patient extend his arms outward and cross his

legs on top of a pillow.

• Stand at the side of the bed in which the patient will be

turned while another nurse gently pushes the patient from the other side.

• Have the patient cross his arms on his chest and place

a pillow between his knees.

• Place a cervical collar on the patient's neck and gently

roll him to the other side of the bed.C A nurse is caring for a patient in a long-term care facility who has had two urinary tract infections in the past year related to immobility. Which finding would the nurse expect in this patient?

• Improved renal blood supply to the kidneys
• Urinary stasis
• Decreased urinary calcium
• Acidic urine formation

B

A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing.The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity?

• Dorsal recumbent position
• Lateral position
• Fowler's position
• Sims' position

C A nurse is caring for a patient who is on bed rest following a spinal injury. In which position would the nurse place the patient's feet to prevent footdrop?

• Supination
• Dorsiflexion
• Hyperextension
• Abduction

B A nurse is assisting a postoperative patient with conditioning exercises to prepare for ambulation. Which instructions from the nurse are appropriate for this patient? Select all that apply.

• Do full-body pushups in bed six to eight times daily.
• Breathe in and out smoothly during quadriceps drills.
• Place the bed in the lowest position or use a footstool

for dangling.

• Dangle on the side of the bed for 30 to 60 minutes.
• Allow the nurse to bathe the patient completely to

prevent fatigue.

• Perform quadriceps two to three times per hour, four to

six times a day.

B, C, F

A nurse is instructing a patient who is recovering from a stroke how to use a cane. Which step would the nurse include in the teaching plan for this patient?

• Support weight on stronger leg and cane and advance

weaker foot forward.

• Hold the cane in the same hand of the leg with the

most severe deficit.

• Stand with as much weight distributed on the cane as

possible.

• Do not use the cane to rise from a sitting position, as

this is unsafe.A

A patient has a fractured left leg, which has been casted.Following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the patient?

• Use the axillae to bear body weight.
• Keep elbows close to the sides of the body.
• When rising, extend the uninjured leg to prevent

weight bearing.

• To climb stairs, place weight on affected leg first.

B A nurse working in a long-term care facility uses proper patient care ergonomics when handling and transferring patients to avoid back injury. Which action should be the focus of these preventive measures?

• Carefully assessing the patient care environment
• Using two nurses to lift a patient who cannot assist
• Wearing a back belt to perform routine duties
• Properly documenting the patient lift

A A nurse is assisting a patient who is 2 days postoperative from a cesarean section to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient's knees buckle and she tells the nurse she feels faint. What is the appropriate nursing action?

• Wait a few minutes and then continue the move to the

chair.

• Call for assistance and continue the move with the help

of another nurse.

• Lower the patient back to the side of the bed and

pivot her back into bed.

• Have the patient sit down on the bed and dangle her

feet before moving.C A patient who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehabilitation center. The nurse caring for the patient correctly tells the aide not to place the patient in which position?

• Side-lying
• Fowler's
• Sims'
• Prone

D