Chapter 15: Safe Patient Handling, Transfer, and Positioning

Chapter 15: Safe Patient Handling, Transfer, and Positioning

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. A patient’s physical mobility is impaired because of paralysis of both lower extremities. Which is the best method for the nurse to use to place the patient in semi-Fowler’s position?

a.	Help the patient push up in bed by bending his or her knees.
b.	Raise the head of the bed to 45 degrees and pull the patient to it.
c.	Roll the patient to one side using pillows to support his or her back.
d.	Pull the patient to the head of the bed (HOB) using a drawsheet and then raise the HOB.

 

 

ANS:  D

With the assistance of another staff member and using a drawsheet, the nurse bends the patient’s knees to reposition the legs, pulls the patient to the HOB, elevates the HOB to 45 degrees, and removes wrinkles from the drawsheet. The patient is unable to push up because of paralysis. Elevating the HOB first increases the force needed to move the patient up in the bed and the risk of injury. Rolling the patient to the side achieves Sims’ or lateral position or assists with logrolling; rolling the patient may be necessary to place the drawsheet under him or her before moving the patient up in bed.

 

DIF:    Cognitive Level: Apply                   REF:   Page 412| Page 414-415

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Implementation

 

2. The nurse is caring for a patient after a motor vehicle accident and instructs the patient to avoid turning independently because the spine is unstable. Which explanation should the nurse use to explain the purpose of the safeguards in relation to the patient’s injury?

a.	They prevent a sudden deterioration in vital signs.
b.	They keep the neck and spine in straight alignment.
c.	They facilitate efficient, comprehensive assessment.
d.	They help to maintain straight alignment of the legs.

 

 

ANS:  B

The nurse does not allow the patient to turn to the side unassisted because an unstable spine cannot maintain normal alignment since the integrity of one or more vertebrae is disrupted. If the patient moves, he or she risks exacerbating the spinal cord injury by abnormal movements of vertebral bone fragments. To maintain patient safety, the nurse turns the patient by logrolling and thereby keeps the head, neck, and spine in straight alignment, thus preventing bone fragments from shifting and potentially increasing the damage. Keeping the patient in the supine position is ideal for maintaining hemodynamic stability and facilitating assessments. The primary purpose of logrolling is to maintain alignment of the neck and spine.

 

DIF:    Cognitive Level: Analyze                REF:   Page 418

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Implementation

 

3. The nurse and an assistant are moving a dependent patient from the supine to the lateral position. Which should the nurse implement to begin repositioning?

a.	Support the upper arm and leg with pillows.
b.	Move the patient away from the center toward a side of the bed.
c.	Elevate the patient’s head with two or three pillows.
d.	Wedge a pillow under the abdomen and chest.

 

 

ANS:  B

The nurse and assistant move the patient to one side of the bed to create space on the bed for turning and avoid dangling the patient’s arms and legs over the side of the bed. The nurse supports the upper arm and leg after the patient is turned. Usually one pillow under the head is suitable for the lateral position; two or three pillows hyperflex the patient’s head. If necessary, a pillow is wedged under the patient’s chest and hips to support the patient in the lateral position, allowing him or her to relax in this position.

 

DIF:    Cognitive Level: Comprehend          REF:   Page 416-417

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Planning

 

4. After 3 hours in the supine position, an older patient tells the nurse that he or she is stiff and too uncomfortable to move. Which is the best nursing intervention to maintain skin integrity?

a.	Find an assistant to help move the patient to lateral position now.
b.	Express concern about the discomfort and promise to come back.
c.	Assess the patient’s need for pain medication before repositioning.
d.	Explain how important repositioning is for preventing pneumonia.

 

 

ANS:  C

Lying motionless is common behavior for patients in pain. This older patient is likely to have thin, fragile skin and by not moving for 3 hours, has an increased risk of skin breakdown from tissue hypoxia. The nurse assesses the patient’s pain and determines a need for pain medication before attempting to reposition him or her. To preserve skin integrity and promote patient comfort, the nurse moves the patient to another position to facilitate the flow of oxygen-rich blood to the tissue, to assess the entire back for skin breakdown, and to provide hygiene if necessary. Expressing concern about the pain does nothing to assess or treat the discomfort. Explaining the need to reposition to prevent pneumonia is helpful when the patient is comfortable enough to pay attention to what is being said.

 

DIF:    Cognitive Level: Analyze                REF:   Page 419

OBJ:   NCLEX: Safe and Effective Care     TOP:   Nursing Process: Implementation