Ati lpn fundamentals - safety and mobility

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Question 1: View

A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?

A. Place the chair on the client's left side. B. Raise the height of the client's bed. C. Lock the wheels on the client's bed. D. Place the chair at a 90° angle to the bed.

Explanation

A) The chair should be placed on the client's stronger (right) side to facilitate a safer and more controlled transfer. The client can use their stronger side to assist in the movement.

B) The bed should be at a comfortable height, ideally level with the chair, to allow a smooth transfer. Raising the bed too high can make it difficult for the client to place their feet firmly on the ground, reducing stability.
C) Locking the wheels on the bed ensures stability and prevents movement while assisting the client with the transfer. This is a crucial safety measure to reduce the risk of falls or injuries during the transfer process.
D) The chair should be positioned at a 45° angle to the bed to allow for a more natural pivot and smoother transfer. A 90° angle can make the movement more difficult and awkward for the client.

Question 2: View

A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

A. Orthostatic hypotension increases a client's risk of a pulmonary emboli B. Orthostatic hypotension increases a client's risk of a fall. C. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.

Explanation

A) Orthostatic hypotension primarily affects blood pressure regulation and is not directly related to the risk of pulmonary emboli.
B) Orthostatic hypotension can cause dizziness and fainting upon standing, increasing the risk of falls.
C) Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of 20 mm Hg or more.
D) Orthostatic hypotension is primarily diagnosed based on changes in systolic blood pressure, not diastolic blood pressure.

Question 3: View

A charge nurse is reinforcing teaching with a newly licensed nurse about fall prevention strategies when caring for clients. Which of the following information should the nurse include in the teaching?

A. Provide under-bed lighting at night. B. Lock the wheels on the bed. C. Keep the bed in the high position. D. Apply socks on clients when ambulating. E. Place breaks on the clients’ wheelchairs.

Explanation

A) Providing under-bed lighting at night can help clients see better and avoid tripping over objects or cords.
B) This prevents the bed from moving unintentionally, reducing the risk of falls when clients are getting in or out of bed.
C) Keeping the bed at a low position actually helps prevent falls as it reduces the distance a patient can fall.
D) Socks can increase the risk of slipping, so they should be avoided or non-slip socks should be used.
E) Placing breaks on the clients’ wheelchairs can prevent them from rolling away or tipping over when transferring or sitting.

Question 4: View

A nurse is reinforcing teaching with a newly licensed nurse about health care-associated infections (HAIs). Which of the following examples should the nurse include as examples of HAIS?

A. A client who has pneumonia after being on a ventilator B. A client who has a bladder infection and has an indwelling urinary catheter C. A client who has a surgical site infection D. A client who has influenza acquired from a coworker E. A client who has an infection at their central line insertion site

Explanation

A) HAIs, are infections that clients acquire while receiving health care services in any setting, such as hospitals, clinics, or home care agencies. Ventilator-associated pneumonia is a common HAI.
B) Catheter-associated urinary tract infections are a common HAI.

C) Surgical site infections are a common HAI.

D) A client who has influenza acquired from a coworker is not an example of an HAI, because the infection was not related to the health care services they received.
E) Central line-associated bloodstream infections are a common HAI.

Question 5: View

A nurse is reinforcing teaching with a client about the musculoskeletal system. The nurse should include that which of the following is a fluid filled capsule that enables movement and flexibility?

A. Tendons B. Cartilage C. Ligaments D. Synovial joints E. Place breaks on the clients’ wheelchairs.

Explanation

A) Connect muscles to bones and aid in movement but are not fluid-filled capsules.

B) Provides cushioning between bones and aids in smooth movement but is not fluid- filled.
C) Connect bones to other bones and provide stability but are not fluid-filled capsules.
D) Synovial joints are surrounded by a fluid-filled capsule called the synovial membrane, which lubricates the joint and enables movement and flexibility.

Question 6: View

A nurse is preparing to lift a heavy object. Which of the following actions by the nurse indicates an understanding of body mechanics?

A. They stand close to the object being moved. B. They keep their feet together when lifting an object C. They twist their spine when lifting. D. They bend at the hip when lifting

Explanation

A) Standing close to the object helps maintain better leverage and reduces strain on the back.
B) Keeping the feet apart provides a stable base of support when lifting heavy objects.
C) Twisting the spine can lead to injury; proper lifting involves keeping the spine aligned.
D) Bending at the hips and knees while keeping the back straight is the correct technique to avoid strain on the back.

Question 7: View

A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?

A. Ask the client to stand for 5 seconds. B. Ask the client to place their feet on the floor. C. Ask the client to sit on the edge of the bed for 2 min. D. Ask the client to march in place.

Explanation

A) Standing requires more mobility and strength; it's not the first step in assessing mobility.
B) Placing feet on the floor assesses the client's ability to follow instructions and indicates readiness for further mobility assessments but is not the first step compared to sitting on the edge of the bed for 2 minutes.
C) This is the first action that the nurse should take to assess the client's mobility and balance. Sitting on the edge of the bed for 2 min allows the nurse to observe the client's posture, strength, coordination, and ability to maintain equilibrium.
D) This is a more advanced mobility assessment and should come after basic assessments like placing feet on the floor.

Question 8: View

A nurse is reinforcing teaching with a newly licensed nurse about age-related changes to vision in older adult clients. Which of the following should the nurse include as an example of an expected age-related change?

A. Increased flexibility of the lens. B. Reduced thickness of the natural lens. C. Reduced depth perception. D. Increased tone of eye muscles

Explanation

A) The lens tends to become less flexible with age, affecting accommodation.

B) The lens may become thicker with age, contributing to presbyopia.

C) Age-related changes such as decreased pupil size and changes in visual acuity can lead to reduced depth perception.
D) Aging can lead to decreased muscle tone, including in the eye muscles, which may affect accommodation and focus.

Question 9: View

A nurse is preparing to reposition a client. Which of the following actions should the nurse take first?

A. Place their feet in line with their shoulders. B. Pivot their feet in the direction of the move. C. Raise the height of the client's bed. D. Tighten their abdominal muscles.

Explanation

A) This is part of proper body mechanics but not the first action when repositioning a client.
B) Proper body mechanics involve pivoting rather than twisting the spine but is not the first action when repositioning a client.
C) Adjusting the bed height ensures the nurse is working at an optimal level to prevent strain during the repositioning process.
D) Engaging core muscles is important for stability during lifting and repositioning but is not the first action to take.

Question 10: View

A nurse is assisting with evaluating ergonomic practice in the workplace. Which of the following should the nurse identify as an example of safe ergonomic practice?

A. A nurse reaches across a client's bed to lift an object B. Nurses are required to work frequent overtime. C. Nurses are required to take breaks during a shift D. A nurse lifts a client by themselves

Explanation

A) Reaching across a bed can lead to strain and injury; it's not an example of safe ergonomic practice.
B) Overtime work can lead to fatigue and increased risk of injury, not a safe ergonomic practice.
C) Regular breaks allow for rest and recovery, reducing the risk of musculoskeletal injuries and promoting overall well-being.
D) Lifting clients alone can pose significant risks of injury, especially if the client is heavy or requires assistance.

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