A patient begins to fall during ambulation. The nurse would

Keep his or her back bent while lowering the patient

Allow the patient to slide down his or her leg to the floor

Keep his or her knees straight while lowering the patient

Hold the patient upright

Answer and Explanation

The Correct Answer is B

A. Keeping the back bent while lowering the patient is not the most appropriate postion.
B. when a patient begins to fall, it is important to control the descent to minimize injury.
The nurse should widen their stance, bring the patient's body close to provide support, bend their knees, and use the strength of their thighs to lower the patient to the ground safely.

C. Keeping the knees straight while lowering the patient increases the risk of strain or injury to the nurse's back.
D. Holding the patient upright may not be feasible if the patient is already falling, and attempting to do so may result in injury to both the patient and the nurse.

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Correct Answer is D

Explanation

A. Changing the patient's position every 30 minutes can help prevent pressure sores but this is such a short interval. The recommended interval is at least every 2 hours.
B. Every 180 minutes (or every 3 hours) is too long of an interval between position changes for a patient at risk for skin impairment. Prolonged pressure on bony
prominences increases the risk of pressure ulcer development.

C. Every 60 minutes (or every hour) is more frequent than every 180 minutes but may

still not be sufficient for preventing pressure ulcers in an unconscious patient with limited mobility.
D. For an unconscious patient at risk for skin impairment, it is recommended to reposition the patient at least every two hours to prevent pressure ulcers and skin breakdown. This frequency is a balance between providing adequate skin protection and minimizing the risk of injury to the patient or strain to the healthcare provider.

A. Atelectasis B. Peristalsis C. Shearing D. Deep vein thrombosis

Correct Answer is B

Explanation

A. Atelectasis refers to the collapse of lung tissue due to blockage or pressure on the airways, commonly caused by immobility but primarily affects the respiratory system.
B. Peristalsis is the natural movement of the intestines that propels food and waste products through the digestive tract. Immobility can lead to decreased peristalsis, causing constipation and other gastrointestinal issues.
C. Shearing refers to the force that causes layers of tissue to move on each other, often leading to skin breakdown and pressure ulcers. It is not directly related to
the gastrointestinal system.

D. Deep vein thrombosis (DVT) is the formation of blood clots in deep veins,

typically in the legs, due to reduced blood flow and stasis caused by immobility. It primarily affects the circulatory system, not the gastrointestinal system.

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A patient begins to fall during ambulation. The nurse would

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

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