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Chapter 11: Safe Patient Handling and Mobility (SPHM)
Perry et al.: Clinical Nursing Skills & Techniques, 10th Edition
MULTIPLE CHOICE
1. A nurse should be aware of safety measures to prevent personal injury when lifting or moving patients. An appropriate principle to
follow is:
a. bend at the waist for lifting.
b. The lower the center of gravity, the greater the stability of the nurse
c. keep the weight to be lifted away from the body.
d. carry or hold the weight 1 to 2 feet above the waist.
ANS: B
Principles of Safe Body Mechanics When Transferring and Positioning Patients
Mechanical lifts and lift teams are essential when patient is unable to help. When a patient is able to help, remember these
principles:
• The lower the center of gravity, the greater the stability of the nurse.
• The equilibrium of an object is maintained as long as the line of gravity passes through its base of support.
• Facing the direction of movement prevents abnormal twisting of the spine.
• Dividing balanced activity between arms and legs reduces the risk for back injury.
• Leverage, rolling, turning, or pivoting requires less work than lifting.
• When friction is reduced between the object to be moved and the surface on which it is moved, less force is required to move it.
Tighten the stomach muscles and tuck the pelvis; this provides balance and protects the back. Bend at the knees; this helps to
maintain the nurse’s center of gravity and lets the strong muscles of the legs do the lifting. Keep the weight to be lifted as close to
the body as possible; this action places the weight in the same plane as the lifter and close to the center of gravity for balance.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Lifting KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
2. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
b. pressure ulcers.
c. Overexertion injuries
d. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
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d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
5. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
a. Diabetes mellitus
b. Myocardial infarction
c. A cerebrovascular accident
d. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
6. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
b. Have the patient move forward with the weak side.
c. Have the patient put on shoes with nonskid soles.
d. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
b. Using the three-person lift technique
c. Raising the head 30 degrees
d. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
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DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
9. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
10. When preparing to move a patient in bed, the nurse should:
a. expect that the patient’s comfort level will decrease.
b. make sure that all pillows used in the previous position stay in position.
c. raise the bed to a comfortable working height.
d. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
11. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
b. place a large pillow behind his head to prevent extension.
c. place a pillow behind his upper back.
d. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
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the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
a. support the arms in a flexed position level at the shoulders.
b. place a pillow under the lower legs.
c. place a small pillow under the patient’s abdomen.
d. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
14. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
15. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
b. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
c. frequently assess the patient and turn him more frequently.
d. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
16. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
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The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
17. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
a. Poor nutrition
b. Loss of sensation
c. Impaired muscle development
d. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
3. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
4. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
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c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
a. Thrombus
b. Pressure ulcer
c. Kyphosis
d. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
1. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
2. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
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DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
3. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
4. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
e. pressure ulcers.
f. Overexertion injuries
g. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
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Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
8. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
e. Diabetes mellitus
f. Myocardial infarction
g. A cerebrovascular accident
h. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
9. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
e. Have the patient move forward with the weak side.
f. Have the patient put on shoes with nonskid soles.
g. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
lOMoARcPSD|62409296
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
e. Using the three-person lift technique
f. Raising the head 30 degrees
g. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
12. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. When preparing to move a patient in bed, the nurse should:
e. expect that the patient’s comfort level will decrease.
f. make sure that all pillows used in the previous position stay in position.
g. raise the bed to a comfortable working height.
h. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
14. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
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e. place a large pillow behind his head to prevent extension.
f. place a pillow behind his upper back.
g. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
e. support the arms in a flexed position level at the shoulders.
f. place a pillow under the lower legs.
g. place a small pillow under the patient’s abdomen.
h. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
16. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
17. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
e. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
f. frequently assess the patient and turn him more frequently.
g. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
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DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
18. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
19. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
6. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
e. Poor nutrition
f. Loss of sensation
g. Impaired muscle development
h. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
8. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
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The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
9. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
10. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
e. Thrombus
f. Pressure ulcer
g. Kyphosis
h. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
5. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
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TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
6. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
7. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
8. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
h. pressure ulcers.
i. Overexertion injuries
j. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
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d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
10. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
11. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
i. Diabetes mellitus
j. Myocardial infarction
k. A cerebrovascular accident
l. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
12. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
h. Have the patient move forward with the weak side.
i. Have the patient put on shoes with nonskid soles.
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j. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
h. Using the three-person lift technique
i. Raising the head 30 degrees
j. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
15. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
16. When preparing to move a patient in bed, the nurse should:
i. expect that the patient’s comfort level will decrease.
j. make sure that all pillows used in the previous position stay in position.
k. raise the bed to a comfortable working height.
l. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
17. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
lOMoARcPSD|62409296
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
h. place a large pillow behind his head to prevent extension.
i. place a pillow behind his upper back.
j. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
i. support the arms in a flexed position level at the shoulders.
j. place a pillow under the lower legs.
k. place a small pillow under the patient’s abdomen.
l. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
18. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
19. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
h. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
i. frequently assess the patient and turn him more frequently.
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j. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
20. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
21. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
11. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
i. Poor nutrition
j. Loss of sensation
k. Impaired muscle development
l. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
12. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
lOMoARcPSD|62409296
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
13. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
14. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
15. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
i. Thrombus
j. Pressure ulcer
k. Kyphosis
l. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
9. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
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ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
10. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
11. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
12. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
k. pressure ulcers.
l. Overexertion injuries
m. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
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DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
9. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
13. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
14. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
m. Diabetes mellitus
n. Myocardial infarction
o. A cerebrovascular accident
p. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
15. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
lOMoARcPSD|62409296
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
k. Have the patient move forward with the weak side.
l. Have the patient put on shoes with nonskid soles.
m. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
k. Using the three-person lift technique
l. Raising the head 30 degrees
m. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
18. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
19. When preparing to move a patient in bed, the nurse should:
m. expect that the patient’s comfort level will decrease.
n. make sure that all pillows used in the previous position stay in position.
o. raise the bed to a comfortable working height.
p. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
20. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
lOMoARcPSD|62409296
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
k. place a large pillow behind his head to prevent extension.
l. place a pillow behind his upper back.
m. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
m. support the arms in a flexed position level at the shoulders.
n. place a pillow under the lower legs.
o. place a small pillow under the patient’s abdomen.
p. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
20. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
21. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
k. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
l. frequently assess the patient and turn him more frequently.
m. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
22. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
23. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
16. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
m. Poor nutrition
n. Loss of sensation
o. Impaired muscle development
p. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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17. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
18. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
19. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
20. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
m. Thrombus
n. Pressure ulcer
o. Kyphosis
p. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
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DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
13. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
14. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
15. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
16. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
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OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
10. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
n. pressure ulcers.
o. Overexertion injuries
p. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
11. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
16. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
17. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
q. Diabetes mellitus
r. Myocardial infarction
s. A cerebrovascular accident
t. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
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18. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
n. Have the patient move forward with the weak side.
o. Have the patient put on shoes with nonskid soles.
p. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
n. Using the three-person lift technique
o. Raising the head 30 degrees
p. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
21. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
22. When preparing to move a patient in bed, the nurse should:
q. expect that the patient’s comfort level will decrease.
r. make sure that all pillows used in the previous position stay in position.
s. raise the bed to a comfortable working height.
t. plan on moving the patient herself because other nurses are busy.
ANS: C
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Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
23. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
n. place a large pillow behind his head to prevent extension.
o. place a pillow behind his upper back.
p. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
q. support the arms in a flexed position level at the shoulders.
r. place a pillow under the lower legs.
s. place a small pillow under the patient’s abdomen.
t. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
22. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
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a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
23. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
n. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
o. frequently assess the patient and turn him more frequently.
p. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
24. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
25. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
21. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
q. Poor nutrition
r. Loss of sensation
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s. Impaired muscle development
t. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
22. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
23. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
24. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
25. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
q. Thrombus
r. Pressure ulcer
s. Kyphosis
t. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
17. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
18. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
19. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
20. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
q. pressure ulcers.
r. Overexertion injuries
s. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
13. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
19. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
20. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
u. Diabetes mellitus
v. Myocardial infarction
w. A cerebrovascular accident
x. An upper extremity fracture
ANS: C
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Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
21. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
q. Have the patient move forward with the weak side.
r. Have the patient put on shoes with nonskid soles.
s. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
q. Using the three-person lift technique
r. Raising the head 30 degrees
s. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
24. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
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DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
25. When preparing to move a patient in bed, the nurse should:
u. expect that the patient’s comfort level will decrease.
v. make sure that all pillows used in the previous position stay in position.
w. raise the bed to a comfortable working height.
x. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
26. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
q. place a large pillow behind his head to prevent extension.
r. place a pillow behind his upper back.
s. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
u. support the arms in a flexed position level at the shoulders.
v. place a pillow under the lower legs.
w. place a small pillow under the patient’s abdomen.
x. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
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alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
24. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
25. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
q. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
r. frequently assess the patient and turn him more frequently.
s. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
26. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
27. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
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Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
26. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
u. Poor nutrition
v. Loss of sensation
w. Impaired muscle development
x. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
27. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
28. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
29. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
30. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
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ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
u. Thrombus
v. Pressure ulcer
w. Kyphosis
x. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
21. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
22. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
23. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
24. Body balance is achieved when a wide _____________ exists.
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ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
14. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
t. pressure ulcers.
u. Overexertion injuries
v. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
15. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
22. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
lOMoARcPSD|62409296
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
23. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
y. Diabetes mellitus
z. Myocardial infarction
aa. A cerebrovascular accident
bb. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
24. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
t. Have the patient move forward with the weak side.
u. Have the patient put on shoes with nonskid soles.
v. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
t. Using the three-person lift technique
u. Raising the head 30 degrees
v. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
lOMoARcPSD|62409296
27. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
28. When preparing to move a patient in bed, the nurse should:
y. expect that the patient’s comfort level will decrease.
z. make sure that all pillows used in the previous position stay in position.
aa. raise the bed to a comfortable working height.
bb. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
29. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
t. place a large pillow behind his head to prevent extension.
u. place a pillow behind his upper back.
v. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
y. support the arms in a flexed position level at the shoulders.
z. place a pillow under the lower legs.
aa. place a small pillow under the patient’s abdomen.
bb. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
26. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
27. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
t. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
u. frequently assess the patient and turn him more frequently.
v. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
28. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
lOMoARcPSD|62409296
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
29. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
31. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
y. Poor nutrition
z. Loss of sensation
aa. Impaired muscle development
bb. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
32. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
33. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
34. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
lOMoARcPSD|62409296
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
35. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
y. Thrombus
z. Pressure ulcer
aa. Kyphosis
bb. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
25. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
26. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
lOMoARcPSD|62409296
27. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
28. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
16. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
w. pressure ulcers.
x. Overexertion injuries
y. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
17. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
lOMoARcPSD|62409296
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
25. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
26. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
cc. Diabetes mellitus
dd. Myocardial infarction
ee. A cerebrovascular accident
ff. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
27. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
w. Have the patient move forward with the weak side.
x. Have the patient put on shoes with nonskid soles.
y. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
w. Using the three-person lift technique
x. Raising the head 30 degrees
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y. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
30. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
31. When preparing to move a patient in bed, the nurse should:
cc. expect that the patient’s comfort level will decrease.
dd. make sure that all pillows used in the previous position stay in position.
ee. raise the bed to a comfortable working height.
ff. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
32. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
w. place a large pillow behind his head to prevent extension.
x. place a pillow behind his upper back.
y. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
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Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
cc. support the arms in a flexed position level at the shoulders.
dd. place a pillow under the lower legs.
ee. place a small pillow under the patient’s abdomen.
ff. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
28. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
29. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
w. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
x. frequently assess the patient and turn him more frequently.
y. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
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30. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
31. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
36. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
cc. Poor nutrition
dd. Loss of sensation
ee. Impaired muscle development
ff. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
37. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
38. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
39. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
40. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
cc. Thrombus
dd. Pressure ulcer
ee. Kyphosis
ff. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
29. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
30. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
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ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
31. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
32. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
18. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
z. pressure ulcers.
aa. Overexertion injuries
bb. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
19. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
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reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
28. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
29. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
gg. Diabetes mellitus
hh. Myocardial infarction
ii. A cerebrovascular accident
jj. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
30. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
z. Have the patient move forward with the weak side.
aa. Have the patient put on shoes with nonskid soles.
bb. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
lOMoARcPSD|62409296
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
z. Using the three-person lift technique
aa. Raising the head 30 degrees
bb. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
33. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
34. When preparing to move a patient in bed, the nurse should:
gg. expect that the patient’s comfort level will decrease.
hh. make sure that all pillows used in the previous position stay in position.
ii. raise the bed to a comfortable working height.
jj. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
35. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
z. place a large pillow behind his head to prevent extension.
aa. place a pillow behind his upper back.
bb. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
gg. support the arms in a flexed position level at the shoulders.
hh. place a pillow under the lower legs.
ii. place a small pillow under the patient’s abdomen.
jj. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
30. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
31. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
z. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
aa. frequently assess the patient and turn him more frequently.
bb. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
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Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
32. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
33. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
41. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
gg. Poor nutrition
hh. Loss of sensation
ii. Impaired muscle development
jj. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
42. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
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43. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
44. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
45. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
gg. Thrombus
hh. Pressure ulcer
ii. Kyphosis
jj. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
33. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
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Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
34. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
35. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
36. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
20. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
cc. pressure ulcers.
dd. Overexertion injuries
ee. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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21. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
31. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
32. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
kk. Diabetes mellitus
ll. Myocardial infarction
mm. A cerebrovascular accident
nn. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
33. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
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7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
cc. Have the patient move forward with the weak side.
dd. Have the patient put on shoes with nonskid soles.
ee. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
cc. Using the three-person lift technique
dd. Raising the head 30 degrees
ee. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
36. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
37. When preparing to move a patient in bed, the nurse should:
kk. expect that the patient’s comfort level will decrease.
ll. make sure that all pillows used in the previous position stay in position.
mm. raise the bed to a comfortable working height.
nn. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
38. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
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When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
cc. place a large pillow behind his head to prevent extension.
dd. place a pillow behind his upper back.
ee. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
kk. support the arms in a flexed position level at the shoulders.
ll. place a pillow under the lower legs.
mm. place a small pillow under the patient’s abdomen.
nn. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
32. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
33. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
lOMoARcPSD|62409296
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
cc. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
dd. frequently assess the patient and turn him more frequently.
ee. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
34. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
35. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
46. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
kk. Poor nutrition
ll. Loss of sensation
mm. Impaired muscle development
nn. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
47. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
lOMoARcPSD|62409296
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
48. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
49. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
50. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
kk. Thrombus
ll. Pressure ulcer
mm. Kyphosis
nn. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
lOMoARcPSD|62409296
COMPLETION
37. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
38. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
39. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
40. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
22. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
ff. pressure ulcers.
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gg. Overexertion injuries
hh. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
23. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
34. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
35. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
oo. Diabetes mellitus
pp. Myocardial infarction
qq. A cerebrovascular accident
rr. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
36. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
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With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
ff. Have the patient move forward with the weak side.
gg. Have the patient put on shoes with nonskid soles.
hh. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
ff. Using the three-person lift technique
gg. Raising the head 30 degrees
hh. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
39. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
40. When preparing to move a patient in bed, the nurse should:
oo. expect that the patient’s comfort level will decrease.
pp. make sure that all pillows used in the previous position stay in position.
qq. raise the bed to a comfortable working height.
rr. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
41. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
ff. place a large pillow behind his head to prevent extension.
gg. place a pillow behind his upper back.
hh. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
oo. support the arms in a flexed position level at the shoulders.
pp. place a pillow under the lower legs.
qq. place a small pillow under the patient’s abdomen.
rr. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
34. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
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If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
35. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
ff. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
gg. frequently assess the patient and turn him more frequently.
hh. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
36. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
37. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
51. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
oo. Poor nutrition
pp. Loss of sensation
qq. Impaired muscle development
rr. Poor circulation
ANS: A, B, C, D
lOMoARcPSD|62409296
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
52. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
53. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
54. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
55. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
oo. Thrombus
pp. Pressure ulcer
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qq. Kyphosis
rr. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
41. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
42. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
43. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
44. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
lOMoARcPSD|62409296
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
24. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
ii. pressure ulcers.
jj. Overexertion injuries
kk. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
25. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
37. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
38. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
ss. Diabetes mellitus
tt. Myocardial infarction
uu. A cerebrovascular accident
vv. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
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Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
39. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
ii. Have the patient move forward with the weak side.
jj. Have the patient put on shoes with nonskid soles.
kk. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
ii. Using the three-person lift technique
jj. Raising the head 30 degrees
kk. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
42. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
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43. When preparing to move a patient in bed, the nurse should:
ss. expect that the patient’s comfort level will decrease.
tt. make sure that all pillows used in the previous position stay in position.
uu. raise the bed to a comfortable working height.
vv. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
44. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
ii. place a large pillow behind his head to prevent extension.
jj. place a pillow behind his upper back.
kk. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
ss. support the arms in a flexed position level at the shoulders.
tt. place a pillow under the lower legs.
uu. place a small pillow under the patient’s abdomen.
vv. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
lOMoARcPSD|62409296
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
36. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
37. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
ii. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
jj. frequently assess the patient and turn him more frequently.
kk. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
38. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
39. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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MULTIPLE RESPONSE
56. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
ss. Poor nutrition
tt. Loss of sensation
uu. Impaired muscle development
vv. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
57. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
58. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
59. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
60. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
lOMoARcPSD|62409296
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
ss. Thrombus
tt. Pressure ulcer
uu. Kyphosis
vv. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
45. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
46. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
47. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
48. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
lOMoARcPSD|62409296
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
26. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
ll. pressure ulcers.
mm. Overexertion injuries
nn. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
27. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
40. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
41. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
ww. Diabetes mellitus
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xx. Myocardial infarction
yy. A cerebrovascular accident
zz. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
42. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
ll. Have the patient move forward with the weak side.
mm. Have the patient put on shoes with nonskid soles.
nn. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
ll. Using the three-person lift technique
mm. Raising the head 30 degrees
nn. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
45. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
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The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
46. When preparing to move a patient in bed, the nurse should:
ww. expect that the patient’s comfort level will decrease.
xx. make sure that all pillows used in the previous position stay in position.
yy. raise the bed to a comfortable working height.
zz. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
47. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
ll. place a large pillow behind his head to prevent extension.
mm. place a pillow behind his upper back.
nn. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
ww. support the arms in a flexed position level at the shoulders.
xx. place a pillow under the lower legs.
yy. place a small pillow under the patient’s abdomen.
zz. support the patient’s head with a small pillow.
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ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
38. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
39. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
ll. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
mm. frequently assess the patient and turn him more frequently.
nn. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
40. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
41. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
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ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
61. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
ww. Poor nutrition
xx. Loss of sensation
yy. Impaired muscle development
zz. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
62. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
63. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
64. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
65. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
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c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
ww. Thrombus
xx. Pressure ulcer
yy. Kyphosis
zz. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
49. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
50. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
51. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
52. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
28. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
oo. pressure ulcers.
pp. Overexertion injuries
qq. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
29. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
43. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
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ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
44. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
aaa. Diabetes mellitus
bbb. Myocardial infarction
ccc. A cerebrovascular accident
ddd. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
45. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
oo. Have the patient move forward with the weak side.
pp. Have the patient put on shoes with nonskid soles.
qq. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
oo. Using the three-person lift technique
pp. Raising the head 30 degrees
qq. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
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OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
48. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
49. When preparing to move a patient in bed, the nurse should:
aaa. expect that the patient’s comfort level will decrease.
bbb. make sure that all pillows used in the previous position stay in position.
ccc. raise the bed to a comfortable working height.
ddd. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
50. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
oo. place a large pillow behind his head to prevent extension.
pp. place a pillow behind his upper back.
qq. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
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the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
aaa. support the arms in a flexed position level at the shoulders.
bbb. place a pillow under the lower legs.
ccc. place a small pillow under the patient’s abdomen.
ddd. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
40. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
41. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
oo. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
pp. frequently assess the patient and turn him more frequently.
qq. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
42. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
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The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
43. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
66. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
aaa. Poor nutrition
bbb. Loss of sensation
ccc. Impaired muscle development
ddd. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
67. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
68. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
69. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
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c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
70. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
aaa. Thrombus
bbb. Pressure ulcer
ccc. Kyphosis
ddd. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
53. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
54. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
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DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
55. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
56. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
30. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
rr. pressure ulcers.
ss. Overexertion injuries
tt. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
31. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
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Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
46. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
47. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
eee. Diabetes mellitus
fff. Myocardial infarction
ggg. A cerebrovascular accident
hhh. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
48. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
rr. Have the patient move forward with the weak side.
ss. Have the patient put on shoes with nonskid soles.
tt. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
rr. Using the three-person lift technique
ss. Raising the head 30 degrees
tt. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
51. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
52. When preparing to move a patient in bed, the nurse should:
eee. expect that the patient’s comfort level will decrease.
fff. make sure that all pillows used in the previous position stay in position.
ggg. raise the bed to a comfortable working height.
hhh. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
53. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
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rr. place a large pillow behind his head to prevent extension.
ss. place a pillow behind his upper back.
tt. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
eee. support the arms in a flexed position level at the shoulders.
fff. place a pillow under the lower legs.
ggg. place a small pillow under the patient’s abdomen.
hhh. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
42. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
43. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
rr. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
ss. frequently assess the patient and turn him more frequently.
tt. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
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DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
44. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
45. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
71. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
eee. Poor nutrition
fff. Loss of sensation
ggg. Impaired muscle development
hhh. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
72. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
73. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
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The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
74. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
75. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
eee. Thrombus
fff. Pressure ulcer
ggg. Kyphosis
hhh. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
57. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
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TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
58. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
59. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
60. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
32. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
uu. pressure ulcers.
vv. Overexertion injuries
ww. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
33. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
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d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
49. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
50. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
iii. Diabetes mellitus
jjj. Myocardial infarction
kkk. A cerebrovascular accident
lll. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
51. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
uu. Have the patient move forward with the weak side.
vv. Have the patient put on shoes with nonskid soles.
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ww. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
uu. Using the three-person lift technique
vv. Raising the head 30 degrees
ww. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
54. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
55. When preparing to move a patient in bed, the nurse should:
iii. expect that the patient’s comfort level will decrease.
jjj. make sure that all pillows used in the previous position stay in position.
kkk. raise the bed to a comfortable working height.
lll. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
56. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
lOMoARcPSD|62409296
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
uu. place a large pillow behind his head to prevent extension.
vv. place a pillow behind his upper back.
ww. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
iii. support the arms in a flexed position level at the shoulders.
jjj. place a pillow under the lower legs.
kkk. place a small pillow under the patient’s abdomen.
lll. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
44. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
45. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
uu. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
vv. frequently assess the patient and turn him more frequently.
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ww. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
46. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
47. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
76. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
iii. Poor nutrition
jjj. Loss of sensation
kkk. Impaired muscle development
lll. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
77. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
lOMoARcPSD|62409296
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
78. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
79. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
80. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
iii. Thrombus
jjj. Pressure ulcer
kkk. Kyphosis
lll. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
61. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
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ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
62. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
63. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
64. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
34. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
xx. pressure ulcers.
yy. Overexertion injuries
zz. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
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DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
35. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
52. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
53. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
mmm. Diabetes mellitus
nnn. Myocardial infarction
ooo. A cerebrovascular accident
ppp. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
54. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
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OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
xx. Have the patient move forward with the weak side.
yy. Have the patient put on shoes with nonskid soles.
zz. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
xx. Using the three-person lift technique
yy. Raising the head 30 degrees
zz. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
57. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
58. When preparing to move a patient in bed, the nurse should:
mmm. expect that the patient’s comfort level will decrease.
nnn. make sure that all pillows used in the previous position stay in position.
ooo. raise the bed to a comfortable working height.
ppp. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
59. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
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d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
xx. place a large pillow behind his head to prevent extension.
yy. place a pillow behind his upper back.
zz. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
mmm. support the arms in a flexed position level at the shoulders.
nnn. place a pillow under the lower legs.
ooo. place a small pillow under the patient’s abdomen.
ppp. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
46. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
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TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
47. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
xx. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
yy. frequently assess the patient and turn him more frequently.
zz. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
48. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
49. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
81. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
mmm. Poor nutrition
nnn. Loss of sensation
ooo. Impaired muscle development
ppp. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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82. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
83. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
84. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
85. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
mmm. Thrombus
nnn. Pressure ulcer
ooo. Kyphosis
ppp. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
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DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
65. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
66. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
67. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
68. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
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OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
36. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
aaa. pressure ulcers.
bbb. Overexertion injuries
ccc. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
37. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
55. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
56. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
qqq. Diabetes mellitus
rrr. Myocardial infarction
sss. A cerebrovascular accident
ttt. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
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57. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
aaa. Have the patient move forward with the weak side.
bbb. Have the patient put on shoes with nonskid soles.
ccc. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
aaa. Using the three-person lift technique
bbb. Raising the head 30 degrees
ccc. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
60. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
61. When preparing to move a patient in bed, the nurse should:
qqq. expect that the patient’s comfort level will decrease.
rrr. make sure that all pillows used in the previous position stay in position.
sss. raise the bed to a comfortable working height.
ttt. plan on moving the patient herself because other nurses are busy.
ANS: C
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Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
62. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
aaa. place a large pillow behind his head to prevent extension.
bbb. place a pillow behind his upper back.
ccc. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
qqq. support the arms in a flexed position level at the shoulders.
rrr. place a pillow under the lower legs.
sss. place a small pillow under the patient’s abdomen.
ttt. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
48. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
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a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
49. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
aaa. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
bbb. frequently assess the patient and turn him more frequently.
ccc. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
50. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
51. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
86. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
qqq. Poor nutrition
rrr. Loss of sensation
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sss. Impaired muscle development
ttt. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
87. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
88. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
89. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
90. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
qqq. Thrombus
rrr. Pressure ulcer
sss. Kyphosis
ttt. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
69. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
70. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
71. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
72. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
38. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
ddd. pressure ulcers.
eee. Overexertion injuries
fff. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
39. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
58. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
59. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
uuu. Diabetes mellitus
vvv. Myocardial infarction
www. A cerebrovascular accident
xxx. An upper extremity fracture
ANS: C
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Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
60. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
ddd. Have the patient move forward with the weak side.
eee. Have the patient put on shoes with nonskid soles.
fff. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
ddd. Using the three-person lift technique
eee. Raising the head 30 degrees
fff. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
63. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
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DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
64. When preparing to move a patient in bed, the nurse should:
uuu. expect that the patient’s comfort level will decrease.
vvv. make sure that all pillows used in the previous position stay in position.
www. raise the bed to a comfortable working height.
xxx. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
65. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
ddd. place a large pillow behind his head to prevent extension.
eee. place a pillow behind his upper back.
fff. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
uuu. support the arms in a flexed position level at the shoulders.
vvv. place a pillow under the lower legs.
www. place a small pillow under the patient’s abdomen.
xxx. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
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alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
50. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
51. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
ddd. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
eee. frequently assess the patient and turn him more frequently.
fff. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
52. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
53. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
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Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
91. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
uuu. Poor nutrition
vvv. Loss of sensation
www. Impaired muscle development
xxx. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
92. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
93. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
94. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
95. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
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ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
uuu. Thrombus
vvv. Pressure ulcer
www. Kyphosis
xxx. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
73. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
74. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
75. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
76. Body balance is achieved when a wide _____________ exists.
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ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
40. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
ggg. pressure ulcers.
hhh. Overexertion injuries
iii. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
41. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
61. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
lOMoARcPSD|62409296
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
62. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
yyy. Diabetes mellitus
zzz. Myocardial infarction
aaaa. A cerebrovascular accident
bbbb. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
63. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
ggg. Have the patient move forward with the weak side.
hhh. Have the patient put on shoes with nonskid soles.
iii. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
ggg. Using the three-person lift technique
hhh. Raising the head 30 degrees
iii. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
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66. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
67. When preparing to move a patient in bed, the nurse should:
yyy. expect that the patient’s comfort level will decrease.
zzz. make sure that all pillows used in the previous position stay in position.
aaaa. raise the bed to a comfortable working height.
bbbb. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
68. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
ggg. place a large pillow behind his head to prevent extension.
hhh. place a pillow behind his upper back.
iii. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
yyy. support the arms in a flexed position level at the shoulders.
zzz. place a pillow under the lower legs.
aaaa. place a small pillow under the patient’s abdomen.
bbbb. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
52. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
53. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
ggg. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
hhh. frequently assess the patient and turn him more frequently.
iii. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
54. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
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KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
55. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
96. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
yyy. Poor nutrition
zzz. Loss of sensation
aaaa. Impaired muscle development
bbbb. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
97. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
98. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a.
Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
99. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head
erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
lOMoARcPSD|62409296
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
100. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
yyy. Thrombus
zzz. Pressure ulcer
aaaa. Kyphosis
bbbb. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
77. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
78. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
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79. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
80. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
42. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
jjj. pressure ulcers.
kkk. Overexertion injuries
lll. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
43. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
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DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
64. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
65. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
cccc. Diabetes mellitus
dddd. Myocardial infarction
eeee. A cerebrovascular accident
ffff. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
66. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
jjj. Have the patient move forward with the weak side.
kkk. Have the patient put on shoes with nonskid soles.
lll. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
jjj. Using the three-person lift technique
kkk. Raising the head 30 degrees
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lll. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
69. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
70. When preparing to move a patient in bed, the nurse should:
cccc. expect that the patient’s comfort level will decrease.
dddd. make sure that all pillows used in the previous position stay in position.
eeee. raise the bed to a comfortable working height.
ffff. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
71. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
jjj. place a large pillow behind his head to prevent extension.
kkk. place a pillow behind his upper back.
lll. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
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Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
cccc. support the arms in a flexed position level at the shoulders.
dddd. place a pillow under the lower legs.
eeee. place a small pillow under the patient’s abdomen.
ffff. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
54. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
55. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
jjj. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
kkk. frequently assess the patient and turn him more frequently.
lll. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
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56. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
57. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
101. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
cccc. Poor nutrition
dddd. Loss of sensation
eeee. Impaired muscle development
ffff. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
102. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
103. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.)
a. Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
104. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a.
Head erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
105. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
cccc. Thrombus
dddd. Pressure ulcer
eeee. Kyphosis
ffff. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
81. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
82. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
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ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
83. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
84. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
44. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
mmm. pressure ulcers.
nnn. Overexertion injuries
ooo. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
45. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
lOMoARcPSD|62409296
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
67. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
68. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
gggg. Diabetes mellitus
hhhh. Myocardial infarction
iiii. A cerebrovascular accident
jjjj. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
69. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
mmm. Have the patient move forward with the weak side.
nnn. Have the patient put on shoes with nonskid soles.
ooo. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
lOMoARcPSD|62409296
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
mmm. Using the three-person lift technique
nnn. Raising the head 30 degrees
ooo. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
72. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
73. When preparing to move a patient in bed, the nurse should:
gggg. expect that the patient’s comfort level will decrease.
hhhh. make sure that all pillows used in the previous position stay in position.
iiii. raise the bed to a comfortable working height.
jjjj. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
74. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
lOMoARcPSD|62409296
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
mmm. place a large pillow behind his head to prevent extension.
nnn. place a pillow behind his upper back.
ooo. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
gggg. support the arms in a flexed position level at the shoulders.
hhhh. place a pillow under the lower legs.
iiii. place a small pillow under the patient’s abdomen.
jjjj. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
56. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
57. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
mmm. prevent the patient from lying on his right side until he no longer wishes to lie on
that side.
nnn. frequently assess the patient and turn him more frequently.
ooo. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
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Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
58. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
59. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
106. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
gggg. Poor nutrition
hhhh. Loss of sensation
iiii. Impaired muscle development
jjjj. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
107. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
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108. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.)
a. Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
109. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a.
Head erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
110. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
gggg. Thrombus
hhhh. Pressure ulcer
iiii. Kyphosis
jjjj. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
85. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
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Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
86. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
87. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
88. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
46. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
ppp. pressure ulcers.
qqq. Overexertion injuries
rrr. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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47. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
70. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
71. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
kkkk. Diabetes mellitus
llll. Myocardial infarction
mmmm. A cerebrovascular accident
nnnn. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
72. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
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7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
ppp. Have the patient move forward with the weak side.
qqq. Have the patient put on shoes with nonskid soles.
rrr. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
ppp. Using the three-person lift technique
qqq. Raising the head 30 degrees
rrr. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
75. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
76. When preparing to move a patient in bed, the nurse should:
kkkk. expect that the patient’s comfort level will decrease.
llll. make sure that all pillows used in the previous position stay in position.
mmmm. raise the bed to a comfortable working height.
nnnn. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
77. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
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When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
ppp. place a large pillow behind his head to prevent extension.
qqq. place a pillow behind his upper back.
rrr. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
kkkk. support the arms in a flexed position level at the shoulders.
llll. place a pillow under the lower legs.
mmmm. place a small pillow under the patient’s abdomen.
nnnn. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
58. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
59. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
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being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
ppp. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
qqq. frequently assess the patient and turn him more frequently.
rrr. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
60. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
61. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
111. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
kkkk. Poor nutrition
llll. Loss of sensation
mmmm. Impaired muscle development
nnnn. Poor circulation
ANS: A, B, C, D
Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
112. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
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ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
113. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.)
a. Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
114. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a.
Head erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
115. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
kkkk. Thrombus
llll. Pressure ulcer
mmmm. Kyphosis
nnnn. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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COMPLETION
89. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
90. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
91. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
92. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
48. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop.
sss. pressure ulcers.
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ttt. Overexertion injuries
uuu. contractures.
ANS: C
The greatest risk factor for overexertion injuries in health care workers is the manual lifting, moving, and repositioning of patients.
Such patient care tasks occur repeatedly during a nurse’s routine shift of care resulting in high rates of nursing injuries
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Nurses KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
49. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for
severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize?
a. This patient should be turned onto his back for meals.
b. This patient requires frequent position at least every 2 hours
c. This patient may be allowed to remain in his favorite position as long as he doesn’t complain of discomfort.
d. Skin breakdown is not an issue for this patient.
ANS: B
Patients with impaired nervous or musculoskeletal system functioning, patients with increased weakness, or those restricted to bed
rest benefit from therapeutic positioning. Correct positioning maintains patients’ body alignment and comfort. Immobilized patients
require vigilant nursing care with frequent repositioning to reduce the risk of physical complications, including pressure injuries,
reduced ventilation, muscle contractures, and deep vein thrombosis. In general, you reposition patients as needed and at least every
2 hours if they are in bed and 15-20 minutes if they are sitting in a chair or wheelchair (AHRQ, 2014, Swafford, 2016). At the same
time perform ROM exercises for patients. Research has not shown if particular positions (such as 30 degree lateral or sitting in 90
degree position, or frequencies of repositioning consistently reduce pressure injury development, more research is needed.
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require
more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the
center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient’s risk for falling. Dehydration or edema
may require more frequent position changes because patients are prone to skin breakdown.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Repositioning KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
73. Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a.
Fatigue
b. Muscle injury
c. Sensory disorientation
d. Orthostatic hypotension
ANS: D
A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop
in blood pressure) when transferred.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Orthostatic Hypotension KEY: Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity
74. A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury
during transfers?
oooo. Diabetes mellitus
pppp. Myocardial infarction
qqqq. A cerebrovascular accident
rrrr. An upper extremity fracture
ANS: C
Patients who are at high risk for complications from improper positioning and injury
during transfer include those with poor nutrition, poor circulation, loss of sensation,
alterations in bone formation or joint mobility, and impaired muscle development.
Certain conditions increase a patient’s risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss
from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus,
myocardial infarction, or upper extremity fracture does not increase the patient’s risk for injury to the same extent.
DIF: Cognitive Level: Application OBJ: Describe procedures for safely lifting patients.
TOP: Cerebrovascular Accident KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
75. To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the
bed.
b. Raise the head of the bed 30 degrees.
c. Turn the patient onto the side facing away from the nurse.
d. Move the patient’s legs over the side of the bed.
ANS: B
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With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient
and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse
after the head of the bed is raised 30 degrees. The patient’s legs are positioned over the edge of the bed after the head of the bed is
raised and the patient is turned to face the nurse.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
7. To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse
do? a. Grab the patient under the axilla to lift.
sss. Have the patient move forward with the weak side.
ttt. Have the patient put on shoes with nonskid soles.
uuu. Place the chair in a position 90 degrees opposite the bed.
ANS: C
Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Patients should never be
lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient’s
strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Assisting Patient to a Sitting Position on Side of Bed
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which
would be the best technique for transferring the patient? a. Using three nurses and a slide board
sss. Using the three-person lift technique
ttt. Raising the head 30 degrees
uuu. Having the patient keep arms to the side
ANS: A
Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet
beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from
bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can
tolerate. This maintains alignment of the spinal column. Cross the patient’s arms on the chest to prevent injury to the arms during
transfer.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
78. An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a.
lower the height of the bed.
b. lower the head of the bed.
c. place the sling from shoulders to knees.
d. keep the check valve open when the patient is seated in the chair.
ANS: C
The sling should extend from shoulders to knees (hammock) to support the patient’s body weight equally. Raise the bed to a high
position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the
patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left
open, the boom may continue to lower and injure the patient.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
79. When preparing to move a patient in bed, the nurse should:
oooo. expect that the patient’s comfort level will decrease.
pppp. make sure that all pillows used in the previous position stay in position.
qqqq. raise the bed to a comfortable working height.
rrrr. plan on moving the patient herself because other nurses are busy.
ANS: C
Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse’s center of gravity and
reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient’s comfort level should increase. The
nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the
positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
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TOP: Planning Patient Move KEY: Nursing Process Step: Planning MSC: NCLEX:
Physiological Integrity
80. An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed.
b. start by flexing the patient’s knees and hips.
c. place a pillow under the patient’s shoulders.
d. instruct the patient to inhale and hold still.
ANS: B
Have patient place feet flat on mattress, grasp either side rails or overhead trapeze and, on a count of 3, lift hips up and push legs so
body moves up in bed.
When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to
use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables
the nurse to assess body alignment and reduces the pull of gravity on the patient’s upper body. The nurse should remove the pillow
from under the patient’s head and shoulders and place the pillow at the head of the bed. This prevents striking the patient’s head
against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out,
thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in
moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving Patient Up in Bed KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler’s
position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with
pillows.
sss. place a large pillow behind his head to prevent extension.
ttt. place a pillow behind his upper back.
uuu. avoid using pillows if the patient does not have use of the hands and arms.
ANS: A
Place pillows long-wise under each leg (mid-thigh to ankle) to support the knee in slight flexion (avoids hyper extension) and to
allow the heels to float. Prevents hyperextension of knee and occlusion of popliteal artery from pressure from body weight. Heels
should not be in contact with bed. Floating heels prevents prolonged pressure of mattress on heels.
Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the
heels. This sometimes is referred to as “floating” heels. Rest the patient’s head against the mattress or on a small pillow. This
prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment.
Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the
arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from
the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion
contractures of arms and wrists.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Moving an Immobile Patient KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
13. In positioning the patient in the prone position, one way to improve breathing is to:
oooo. support the arms in a flexed position level at the shoulders.
pppp. place a pillow under the lower legs.
qqqq. place a small pillow under the patient’s abdomen.
rrrr. support the patient’s head with a small pillow.
ANS: C
Placing a small pillow under the patient’s abdomen below the level of the diaphragm reduces pressure on the breasts of some
female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by
reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body
alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to
elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not
directly improve breathing. Turning the patient’s head to one side and supporting it with a small pillow is designed to reduce
flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.
DIF: Cognitive Level: Application
OBJ: Describe positioning techniques for the supported Fowler’s, supine, prone, 30-degree lateral side-lying, and Sims’ positions.
TOP: Hand Rolls
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
60. A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The
nurse should:
a. avoid moving the patient until he or she is motivated.
b. have family members move the patient around.
c. decrease the frequency of movement to be performed.
d. medicate the patient with a prescribed analgesic before moving.
ANS: D
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If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient’s comfort before moving.
Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing
complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient
and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.
DIF: Cognitive Level: Application
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Increasing Patient Mobility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
61. The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does
not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after
being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on
his right side continuously because he seems comfortable.
sss. prevent the patient from lying on his right side until he no longer wishes to lie on that
side.
ttt. frequently assess the patient and turn him more frequently.
uuu. allow the patient to lie on his right side until a pressure ulcer develops and he can no
longer lie on that side.
ANS: C
Patients contribute to repositioning through their own frequent movement .Often patients adopt positions that increase their pressure
injury risk. Patients routinely slip down in bed so routine monitoring of patient positions is important.
Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and
turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the
patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of
assessment and turning is to prevent complications of immobility.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Turning KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
62. The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning?
a. The wider the base of support, the greater the stability of the nurse.
b. The higher the center of gravity, the greater the stability of the nurse.
c. Facing in the opposite direction of movement prevents twisting.
d. Using either the arms or the legs reduces the risk for back injury.
ANS: A
The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the
nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs
reduces the risk for back injury.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Principles of Safe Patient Transfer and Positioning
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrity
63. The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a.
Under the small of the back
b. Behind the knees when supine
c. Parallel to lateral surface of highs
d. In the palm of the hand with fingers flexed
ANS: C
Place trochanter rolls or sandbags parallel to lateral surface of patient's thighs. Reduces external rotation of hip. Described with
patient in supported supine position.
Place rolled blanket (trochanter roll) or pillows firmly alongside patient's legs to help prevent the patient from leaning towards the
affected side. Ensures proper alignment. Prevents external rotation of hips, which contributes to muscle contractures. Described for
hemipleic pt in Fowler position.
DIF: Cognitive Level: Application OBJ: Describe the use of the trochanter.
TOP: Trochanter Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
116. Patients at risk for complications and/or injury from improper positioning include patients with which of the
following? (Select all that apply.)
oooo. Poor nutrition
pppp. Loss of sensation
qqqq. Impaired muscle development
rrrr. Poor circulation
ANS: A, B, C, D
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Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer.
Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility,
and impaired muscle development.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Risks for Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
117. The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the
nurse realizes that mobilization: (Select all that apply.) a. improves joint motion.
b. decreases circulation.
c. increases social activity.
d. enhances mental stimulation.
ANS: A, C, D
Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and
improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental
stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient’s rehabilitation.
DIF: Cognitive Level: Analysis
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Mobilization KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
118. The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.)
a. Correct posture
b. Maximal muscle strength
c. Effective body mechanics
d. Effective lifting techniques
ANS: A, C, D
The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting
techniques. Consider individual patient problems during transfer.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Preventing Self-Injury KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
119. Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a.
Head erect
b. Four-inch space between edge of seat and popliteal space
c. Vertebrae straight
d. Both feet elevated
ANS: A, C
Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on
buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably
flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior
surface of the knee.
DIF: Cognitive Level: Application
OBJ: Describe normal body alignment for standing, sitting, and lying down.
TOP: Normal Body Alignment for Sitting Position
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
120. Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis
b. Traction
c. Arterial insufficiency
d. Incontinence
e. Constipation
ANS: A, B, C, D
Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned
more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and
poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone
fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the
patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological
changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is
not a risk factor for immobility.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Risk Factors That Contribute to Complications of Immobility
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all
that apply.)
oooo. Thrombus
pppp. Pressure ulcer
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qqqq. Kyphosis
rrrr. Contractures
ANS: B, D
Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include
pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days
when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a
complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates
proper body alignment.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Complications of Poor Alignment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
COMPLETION
93. Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened
foot into a plantar-flexed position.
ANS:
Footdrop
Prevents plantar flexion contractures or footdrop by positioning patient's ankle in neutral dorsiflexion.
Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an
unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at
walking.
DIF: Cognitive Level: Comprehension
OBJ: Describe body mechanics and its importance in caring for patients.
TOP: Footdrop KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
94. A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal
independence is known as ________________.
ANS:
transferring
Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to
regain optimal independence as quickly as possible.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Transferring KEY: Nursing Process Step: Assessment MSC:
NCLEX: Physiological Integrity
95. The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.
ANS:
body alignment
The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the
body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.
DIF: Cognitive Level: Knowledge
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Body Alignment KEY: Nursing Process Step: Assessment MSC: NCLEX:
Physiological Integrity
96. Body balance is achieved when a wide _____________ exists.
ANS:
base of support
Spread your feet apart. Flex hips and knees Ensures balance with wide base of support. Flexing knees and hips lowers your center
of gravity to object to be raised.
The lower the center of gravity, the greater the stability of the nurse.
Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical
line can be drawn from the center of gravity through the base of support.
DIF: Cognitive Level: Comprehension
OBJ: Describe principles of safe patient transfer and positioning.
TOP: Base of Support KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb,
the nurse places _________________ in the patient’s hands.
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ANS:
hand rolls
For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is
designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in
opposition to the fingers.
DIF: Cognitive Level: Application
OBJ: Describe the procedures for helping a patient to move up in bed, helping a patient to a sitting position, logrolling a patient, and
transferring a patient from a bed to a chair.
TOP: Hand Rolls KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
