Immobility 3 Questions Flashcards
(15 cards)
Which devices promote venous return?
A. Incentive spirometer
B. Graduated compression stocking
C. Sequential compression devices
Both B and C
What must the nurse do to prevent impaired circulation or DVT?
A. Assess for virchow’s triad
B. Assess for DVT
C. Determine the correct size of compression stocking
C. Determine the correct size of compression stocking
What is virchow’s triad?
hypercoagulability
Venous wall abnormalities
Blood stasis
When should the nurse limit sitting in a chair to 1 hour?
A. For every patient
B. Only for disabled patients
C. When the patient can’t sit normally or verbalize pain
C. When the patient can’t sit normally or verbalize pain
What should the nurse do for a patient that is completely incapable in relation to the integumentary system
A. Teach to shift weight every 15 minutes
B. Supportive devices
C. Turn every 1-2 hours
C. Turn every 1-2 hours
What should the nurse do to mobilize secretions in relation to the respiratory system?
A. Turn every 15 minutes
B. Reposition every 1-2 hours, cough, deep breath
C. Use incentive spirommeter while awake
D. Maintain fluid intake
Both B C and D
What should the nurse be looking for when assessing the musculoskeletal system?
A. Stress, agitation, depression
B. Skin break down, pressure injury
C. Atrophy, contractures, ROM
C. Atrophy, contractures, ROM
What should the nurse be looking for when assessing the cardiovascular system?
A. Constipation, fluid, softer stool
B. Pneumonia, respiratory difficulty
C. PVS, orthostatic hypotension, DVT
C. PVS, orthostatic hypotension, DVT
When should the nurse perform a fall risk assessment?
A. For older patients
B. For young children
C. For all patients
C. For all patients
What is a bed alarm and when is it used?
A. An alarm that sounds when patient leaves bed or chair. Used for fall risk patients.
B. An alarm that sounds when patient sits in bed or chair. Used for all fall risk patients.
B. An alarm that sounds when patient sits in bed or chair. Used for all fall risk patients.
When should the nurse file an incident report?
A. When a patient is at high fall risk
B. When a patient gets up from chair
C. When a patient falls
C. When a patient falls
SELECT ALL THAT APPLY
Which of the follwoing is true of restraints
- Should be used for any combative patient
- A last resort for patient safety
- The degree of restraint does not matter
- Least restrictive first
- Documentation of lead up is not important
- Can’t interfere with treatment plan
- Can be attached to bed rails
- An order must be obtained within 1 hour of applying restraints
- Can be used as needed
- Adult restraint orders are good for up to 4 hours
- Client consent is not necessary
- Assess client at least every 2 hours
- A last resort for patient safety
- Least restrictive first
- Can’t interfere with treatment plan
- An order must be obtained within 1 hour of applying restraints
- Adult restraint orders are good for up to 4 hours
- Assess client at least every 2 hours
True or false:
Restraints should never be in a knot
True
True or false:
Restraints should be removed at least every 2 hours to allow for positioning and ADLs
True
SELECT ALL THAT APPLY:
- Never raise all 4 side rails
- Make sure head can’t fit between the matress and rail
- Patient’s attentional set may be impaired during outburst
- 2 fingers in restraints
- Tubes should NEVER be placed under clothes
- Never raise all 4 side rails
- Make sure head can’t fit between the matress and rail
- Patient’s attentional set may be impaired during outburst
- 2 fingers in restraints
