Immobility 3

Question 1

Ankle pumps, foot circles, knee flexion, ambulation are examples of which type of ROM?

Answer 1

Active ROM

Question 2

Movement that is primarily performed by patient, but accompanied by the aid of team member is which type of ROM?

Answer 2

Assistive ROM

Question 3

Moving of joint through ROM without exertion by subject, usually done by examinar who moves the person’s body manually is which type of ROM?

Answer 3

Passive

Question 4

ROM angainst resistance is?

Answer 4

Resistive

Question 5

What is CPM?

Answer 5

Continuous passive motion machines

Question 6

How does the nurse prevent curled fingers?

Answer 6

Splints

Question 7

Compression stockings
Suquential compression devices are resources to promote?

Answer 7

Venous return

Question 8

What should the nurse do to prevent impaired circulation and DVT?

Answer 8

Determine the correct size of compression stocking

Question 9

What is virchow’s triad?

Answer 9

Hypercoagulability, venous wall abnormalities, blood stasis

Question 10

What should the nurse instruct an orthostatic hypotension patient to do?

Answer 10

Sit on the side of the bed to dangle feet for 1-2 minutes, 10 minutes before ambulation

Question 11

What intervention should the nurse perform to aid integumentary system?

Answer 11

Turn every 1-2 hours if patient is completely incapable of shifting their own weight.

Question 12

What should the nurse teach a capable patient to decrease skin breakdown?

Answer 12

Shift every 15 minutes

Question 13

What should nurse limit for a patient that can’t vebalize or can’t sit normally?

Answer 13

Limit sitting in chair to 1 hour

Question 14

What should be used to promote respiratory function and when?

Answer 14

Use incentive spirometer while awake

Question 15

What should the nurse do for a patient with metabolic risks?

Answer 15

High protein diet

Question 16

What should the nurse do for a patient with urinary issues?

Answer 16

Keep turned, sit up, hydrate

Question 17

What should the nurse do for a patiet with GI issues?

Answer 17

Increase fluid and fiber

Question 18

What should the nurse do for a patient with psychoneurological issues?

Answer 18

Encourage independence and motivate

Question 19

When should the bed be kept in the lowest potion and wheels locked?

Answer 19

When patient is alone in room

Question 20

What should the nurse perform on each client?

Answer 20

Fall risk

Question 21

True or false, 4 side rails should be up at all times?

Answer 21

FALSE
2 only

Question 22

Which type of restraint should be used on patients?

Answer 22

Least restrictive first

Question 23

True or false: restraints are used for provider safety.

Answer 23

False
Used for patient safety

Question 24

What should the provider do before implementing restraints?

Answer 24

Document the lead up

Question 25

True or false: An order must be received before restraints are implemented.

Answer 25

False Order within 1 hour of restraint implementation

Question 26

What do mittens do for clients?

Answer 26

Prevent client from dislodging equipment or scratching

Question 27

What is a freedom splint?

Answer 27

Often used to protect IV site

Question 28

True or false: A restrictive order is good for up to 48 hours

Answer 28

False 24 hours. Never as needed

Question 29

How often should the nurse asses a patient with restraints?

Answer 29

Every 2 hours

Question 30

How often should the nurse asses a patient with violent restraints?

Answer 30

Every 15 minutes

Question 31

True or false: The nurse should secure restraints to bed rails

Answer 31

FALSE Bar on bottom of bed

Question 32

What is attentional set?

Answer 32

Ability to pay attention

Question 33

What could prevent attentional set?

Answer 33

Pain and anxiety

Question 34

How many fingers should fit between restraints?

Answer 34

2 fingers