Nursing Fundamentals

Before transferring a patient from the bed to a stretcher, which assessment data does the nurse need to gather? (Select all that apply.)

• Patient’s weight

• Patient’s activity tolerance

• Patient’s level of mobility

• Recent laboratory values

• Nutritional intake

A 51-year-old adult comes to a medical clinic for an annual physical exam. The patient is found to be slightly overweight and reports being inactive, walking only 2 to 3 times a week with his wife after work. He has good muscle strength and coordination of lower extremities. Which of the following recommendations from the Physical Activity Guidelines for Americans should the nurse suggest? Choose all that apply

• Move more and sit less throughout the day.

• Participate in at least 90 minutes a week of moderate-intensity aerobic physical activity.

• Perform muscle-strengthening activities using light weights on 2 or more days a week.

• Walk at a vigorous pace with wife at least 150 minutes over five days a week.

• Focus on balance training.

Family members have asked for a meeting with the nursing staff of an assisted-living residential center to discuss the feasibility of their mother using a walker. The family is worried that her health is declining; they wonder whether she can use the walker safely. Which of the following instructions should the nurse give the family after assessing that it is safe for the woman to use a walker? (Select all that apply.)

• A walker is useful for patients who have impaired balance.

• The patient uses a walker by pushing the device forward.

• Leaning over the walker improves the patient’s balance.

• Walkers should not be used on stairs.

• If the patient has difficulty advancing the walker, a walker with wheels is an option.

The nurse is caring for an older adult in a long-term care setting. The nurse reviews the medical record to find that the patient has progressive loss of total bone mass. The patient’s history and tendency to take smaller steps with feet kept closer together will most likely result in which of the following?

• Increase the patient’s risk for falls and injuries

• Result in less stress on the patient’s joints

• Decrease the amount of work required for patient movement

• Allow for mobility in spite of the aging effects on the patient’s joints

The following statements are the recommended guidelines on performing hand washing according to WHO, EXCEPT

• Before patient contact

• After body fluid exposure risk

• Before doing hand hygiene

• After contact with patient surrounding

• None of the above

In medical hand washing, it is important to keep hands lower than the elbows, so that water flows from arms to the fingertips; the rationale behind this technique is:

• Prevent the nurses’ clothes to get wet which can lead to contamination

• The position is ergonomically correct

• Hands are more contaminated than forearms

• To maintain the flow of water directly in the sink and prevent splashing water to the surrounding area

With open gloving technique which hand is a glove placed on first

• Right hand

• Dominant hand

• Left hand

• Non-Dominant hand

Upon assessing a 28-year-old patient’s temperature, you notice the temperature you have taken is 39.0C. What will be your next step?

• Notify the physician

• Reassess the temperature after a few minutes and ask patient for any other symptoms

• Document your findings

• Have a co-worker re-check the temperature

Some patient may have such shallow respirations that a nurse may have difficulty assessing their respirations. What would be the most appropriate nursing action to properly assess for the patient’s respiration?

• Use a stethoscope and auscultate the lung sounds

• Hook the patient to a cardiac monitor

• Tell your co-worker to check the patient’s respiratio

• Have the patient in high fowlers position

What is the primary purpose of hand hygiene in nursing practice?

• To prevent the spread of infection

• To keep hands moisturized

• To reduce the need for gloves

• To make hands smell pleasant