1. A nurse is evaluating care of an immobilized patient. Which action will thenurse take?
a. Focus on whether the interdisciplinary team is satisfied
... [Show More] with the care.
Compare the patient’s actual outcomes with the outcomes in the care
b. plan.
Involve primarily the patient’s family and health care team to
c. determine goal achievement.
Use objective data solely in determining whether interventions have
d. been successful.
ANS: B
From your perspective as the nurse, you are to evaluate outcomes and
response to nursing care and compare the patient’s actual outcomes with theoutcomes
selected during planning. Ask if the patient’s expectations (subjective data) of care are
being met, and use objective data to determine the success of interventions. Just as it
was important to include the patient during the assessment and planning phase of the
care plan, it is essential to have the patient’s evaluation of the plan of care, not just the
patient’s familyand health care team.
2. A nurse is supervising the logrolling of a patient. To which patient is thenurse most
likely providing care?
a. A patient with neck surgery
b. A patient with hypostatic pneumonia
c. A patient with a total knee replacement
d. A patient with a Stage IV pressure ulcer
ANS: A
A nurse supervises and aids personnel when there is a health care provider’sorder to logroll a patient. Patients who have suffered from spinal cord injury orare
recovering from neck, back, or spinal surgery often need to keep the spinalcolumn in
straight alignment to prevent further injury. Hypostatic pneumonia, total knee replacement,
and Stage IV ulcers do not have to be logrolled.
3. The nurse is providing teaching to an immobilized patient with
impaired skin integrity about diet. Which diet will the nurse recommend?
a. High protein, high calorie
b. High carbohydrate, low fat
c. High vitamin A, high vitamin E
d. Fluid restricted, bland
ANS: A
Because the body needs protein to repair injured tissue and rebuild depleted protein
stores, give the immobilized patient a high-protein, high-calorie diet. A highcarbohydrate, low-fat diet is not beneficial for an immobilized patient.Vitamins B and C
are needed rather than A and E. Fluid restriction can be detrimental to the immobilized
patient; this can lead to dehydration. A bland diet is not necessary for immobilized
patients. [Show Less]