Which actions are correct when nursing personnel are logrolling a patient quizlet?
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Medical Language Accelerated2nd EditionAndrew Cavanagh, Steven Jones 568 solutions Log roll Patient is turned in the same way a log would be rolled (as one unit) A nurse is writing a procedure for logrolling a patient. Which of the following should be included in the procedure? Select all that apply. Three staff members are required to logroll a patient. Trochanter roll Tightly rolled sheet or blanket placed against the lateral side of the thigh to prevent outward motion of the hip and leg Foot drop permanent plantar flexion of the foot effects of immobility blood clots, Pneumonia, Bone Demineralization, kidney stone, constipation (not moving) pressure ulcers (turn q 2h) urinary retention, depression Nursing Measures to Prevent Respiratory Complications Turn the patient from side to side every 2 hours A nursing instructor educates a class of student nurses about how to prevent respiratory complications of immobility. The instructor properly emphasizes the importance of Elevating the head of the patient's bed 45 degrees To prevent atelectasis and pneumonia, it is necessary to increase lung expansion, strengthen respiratory muscles, improve oxygen and carbon dioxide exchange, and improve the effectiveness of coughs. To prevent respiratory secretions from pooling in the lungs, elevate the head of the bed 45 degrees or more to promote lung expansion. Nursing Measures to Prevent Cardiovascular Complications Encourage
the movement of extremities Preventing Musculoskeletal Complications Maintain proper body alignment A nurse is educating a patient about her diagnosis of osteoporosis. The nurse recognizes that osteoporosis Can cause a patient to become hypercalcemic Osteoporosis occurs due to a loss of minerals, including calcium, from the bones. The calcium leaves the bones and enters the bloodstream, causing hypercalcemia. This in turn places the patient at an increased risk for kidney stones because the excess calcium in the blood must then be filtered out by the kidneys. A patient is 1 day post-op, and the physician has written an order for the patient to ambulate. When the patient asks why it is important to ambulate, the nurse explains that ambulation prevents complications related to immobility, which include: Renal calculi Complications from immobility and prolonged bed rest include kidney stones, or renal calculi. A patient has limited mobility because of a stroke. When the nurse responds promptly to his call button, he snaps, "What the heck took you so long to get here! You people are so lazy." An appropriate response would be: "You sound frustrated. What is the thing you are most concerned about?" Immobile patients often feel fear, anger, and helplessness, and they may direct these emotions in inappropriate ways. This response acknowledges the patient's explicit feelings (of frustration) and with an open-ended question invites the patient to participate in identifying and solving the real problem. When caring for a bedridden patient, the nurse recognizes the importance of preventing the formation of a venous thromboembolism (VTE). To prevent a VTE, the nurse should Assist the patient in performing passive range-of-motion exercises. Apply antiembolism stockings to prevent pooling of blood in the legs. The nurse is caring for a patient who has a history of orthostatic hypotension. When providing patient education, the nurse emphasizes the importance of Performing dorsal and plantar flexion of the feet To help decrease the workload of the heart and prevent hypotension, the patient should move the extremities, especially by dorsal and plantar flexion of the feet. This movement causes muscle contractions that help push the blood in the veins back to the heart. As the nurse is helping a patient move from a lying to a sitting position, the patient suddenly develops signs of orthostatic hypotension. The nurse should next Help the patient into a semi-Fowler's position to prevent syncope When dangling the patient, assess the patient's pulse and blood pressure for an increase or decrease of more than 20 beats per minute or 30 mm Hg, respectively. Assess the patient for complaints of dizziness, nausea, or pain. If the vital signs are outside these parameters, or if the patient complains of these symptoms, immediately assist the patient to Fowler's or semi-Fowler's position to prevent possible syncope and injury. A patient is on bedrest. To prevent pressure ulcers, the patient is provided a gel-filled mattress overlay, and: The nurse inspects the patient's bony prominences for redness at least every 2 hours. The nurse should inspect the patient's bony prominences for redness at least every 2 hours. If redness is found, the nurse should massage around the area but not apply pressure directly to it. During shift report, a nurse is informed that a patient is using an incentive spirometer. The nurse correctly understands that: The incentive spirometer helps to prevent atelectasis. An incentive spirometer is used to help the patient take 10 to 20 deep inhalations every hour, thereby reducing the likelihood of atelectasis, or collapse of the lungs. A physician has written an order to instruct the patient to turn, cough, and deep breathe. When teaching the patient to turn, cough, and deep breathe, the nurse explains that these actions will help to prevent Atelectasis Atelectasis, the collapse of lung tissue affecting part or all of a lung, can occur due to the inability of the lung to fully expand. It may also occur when a patient does not take full, deep breaths to keep the alveoli open. When the alveoli collapse, oxygen and carbon dioxide exchange is impaired, resulting in lowered oxygen in the blood, or hypoxemia. An immobile patient who has been alert; coherent; and oriented to time, place, and person says, "I keep hearing a cat crying, but I know there can't be a cat in here, can there?" Which of the following would be an appropriate response? "Of course there's no cat here. You must be hearing things. That happens sometimes when a patient is on bedrest and there isn't enough to do. If you keep hearing a cat, just ignore it." This patient is probably experiencing low-level sensory deprivation and needs more stimulation. This response affirms the patient's grasp on reality (no cat), explains the neurological process at work, and begins to engage the patient in identifying solutions to the problem. A patient who has been mostly immobile for a week complains of feeling weak all over as he sits up with assistance. The nurse correctly understands this weakness to be a result of loss of muscle tone and contractures of the muscles. Muscles begin to lose size, tone, and strength after a few days of disuse, and tendons and ligaments begin to change within 4 to 6 days, leading to reduced flexibility and shortening and tightening of the muscles. Thus, the patient who has been immobile for a week feels that movement is difficult. A male patient on bedrest tells the nurse he thinks he could empty his bladder more completely if he could stand while urinating. The nurse should: Request an order from the physician to permit the patient to stand while urinating. Males may be best able to empty the bladder by standing when urinating. When a patient is on bedrest, it is necessary to obtain a physician's order before assisting the patient to stand. When educating a patient about nursing measures to prevent gastrointestinal complications, the nurse should teach the importance of Taking a stool softener as needed Taking a laxative or stool softener as needed, according to physician's orders, helps prevent constipation. The nursing instructor knows a student needs further review when the student describes position of function as: the greatest range of motion a joint can move. A patient's chart shows orders to wear sequential compression devices and to receive range-of-motion exercises every 8 hours. The nurse correctly understands that: Both treatments can help prevent the formation of venous thrombosis. Sequential compression devices are applied to the lower legs to move blood toward the heart and thereby prevent venous thrombosis. Range-of-motion exercises can also help maintain circulation and prevent clots, and they can alleviate gastrointestinal complications of immobility. When educating a class of nursing students, the nursing instructor emphasizes the importance of recognizing preventable causes of death. The nursing instructor teaches that the most preventable cause of death during hospitalization is An embolism An embolism has been identified as the most preventable cause of death during hospitalization. A patient has fallen onto the floor and is too weak to stand up without assistance. Which of the following types of equipment is best suited to this situation? lift When health-care staff use a lift to move a patient, they first place a sling under the patient and then use the hydraulic, battery-powered, or ceiling lift to raise the patient from the bed, chair, or in this case, floor. This is the safest way to move a patient who cannot sit or stand. An immobile patient has not had a bowel movement for 3 days and reports not feeling hungry. The nurse should consider the possibility that: A lack of activity has caused a decline in peristalsis. Immobility can reduce the activity of the smooth muscle of the small intestine, resulting in a decline of peristalsis and constipation. 24.A patient in a nursing home has had a stroke and is largely immobile. When explaining the potential complications of immobility to the patient's family, the nurse would not include: increased urine volume. The human body is designed to be mobile, and immobility can have many adverse consequences. These include urinary retention, but immobility does not increase urine volume When logrolling a client the nurse should?When logrolling a client, the nurse should use supportive devices in turning the client in order to: maintain the natural alignment of the client's body. Two nurses will transfer an older adult client from her bed to a chair later in the day.
When logrolling a person the person is?Logrolling is a technique used to turn a patient whose body must at all times be kept in a straight alignment (like a log). This technique is used for the patient who has a spinal injury. Logrolling is used for the patient who must be turned in one movement, without twisting.
What does logrolling a client mean?Logrolling is a common patient care procedure performed by many health care workers. The purpose of logrolling is to maintain alignment of the spine while turning and moving the patient who has had spinal surgery or suspected or documented spinal injury.
What is the most important action to ensure the nurse is in proper body alignment when positioning a patient in bed?Promote body alignment with pillows.
Support proper body alignment in Sims' position by placing a pillow underneath the patient's head and under the upper arm to prevent internal rotation. Place another pillow between the legs.
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