1. The nurse is preparing to lift a patient. Which action will the nurse take

first?

a. Position a drawsheet under the patient.

b. Assess weight and determine assistance needs.

c. Delegate the task to a nursing assistive personnel.

d. Attempt to manually lift the patient alone before asking for assistance.

ANS: B

When lifting, assess the weight you will lift, and determine the assistance you

will need. The nurse has to assess before positioning a drawsheet or

delegating the task. Manual lifting is the last resort, and it is used when the

task at hand does not involve lifting most or all of the patient’s weight; most

facilities have a no-lift policy.

2. The nurse is caring for an older-adult patient who has been diagnosed

with a stroke. Which intervention will the nurse add to the care plan?

Encourage the patient to perform as many self-care activities as

a. possible.

b. Provide a complete bed bath to promote patient comfort.

c. Coordinate with occupational therapy for gait training.

d. Place the patient on bed rest to prevent fatigue.

ANS: A

Nurses should encourage the older-adult patient to perform as many self-care

activities as possible, thereby maintaining the highest level of mobility.

Sometimes nurses inadvertently contribute to a patient’s immobility by

providing unnecessary help with activities such as bathing and transferring.

Placing the patient on bed rest without sufficient ambulation leads to loss of

mobility and functional decline, resulting in weakness, fatigue, and increased

risk for falls. After a stroke or brain attack, a patient likely receives gait