A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Have the client hold a pillow over the abdomen to cough and deep breathe.

Encourage the client to eat all of the meals that are sent.

Offer fruit juice at least twice during both the day and evening shifts.

Lower the bed prior to helping the client to move up in bed.

Answer and Explanation

The Correct Answer is D

Choice A: Have the client hold a pillow over the abdomen to cough and deep breathe is not the most important instruction because it is not related to repositioning. This is a good practice to prevent respiratory complications after surgery, but it can be done at any time.

Choice B: Encourage the client to eat all of the meals that are sent is not the most important instruction because it is not related to repositioning. This is a good practice to promote nutrition and healing after surgery, but it can be done at any time.

Choice C: Offer fruit juice at least twice during both the day and evening shifts is not the most important instruction because it is not related to repositioning. This is a good practice to prevent dehydration and constipation after surgery, but it can be done at any time.

Choice D: Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning.

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Correct Answer is D

Explanation

Choice A: Remind the UAP to dry between the client’s toes completely is not the best action because it does not address the risk of spillage and wetness on the bed. Drying between the toes is important to prevent fungal infections, but it can be done after removing the basin.

Choice B: Advise the UAP that this procedure is damaging to the skin is not the best action because it is not accurate and may cause confusion. Soaking the foot in warm water is not harmful to the skin, unless it is too hot or too long.

Choice C: Add skin cream to the basin of water while the foot is soaking is not the best action because it does not solve the problem and may waste the cream. Skin cream should be applied after drying the foot, not mixed with water.

Choice D: Remove the basin of water from the client’s bed immediately is the best action because it prevents potential hazards such as soaking, infection, or electric shock. The nurse should ensure that the bed is dry and clean before continuing with the bath.

A. To ambulate without discomfort. B. To avoid pain-causing activity. C. To show evidence of incision healing. D. To take analgesics as prescribed.

Correct Answer is A

Explanation

Choice A Reason: This is correct because it reflects a measurable and realistic goal that addresses the client's problem of activity intolerance related to pain. Ambulation promotes circulation, prevents complications, and enhances recovery.

Choice B Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Avoiding pain-causing activity may lead to immobility and further complications.

Choice C Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Incision healing is an expected outcome of wound care, not activity.

Choice D Reason: This is incorrect because it does not address the problem of activity intolerance related to pain. Taking analgesics as prescribed may help relieve pain, but it does not promote activity.

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A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. Which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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