A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?

When observed posteriorly, the hips and shoulders form an ‘’S’’ pattern

When observed laterally, the spinal curves align in a reversed S pattern

the arms should be crossed over the chest or in the lap

LThe feet should be close together with toes pointed out

Answer and Explanation

The Correct Answer is B

A) When observed posteriorly, the hips and shoulders form an "S" pattern: This is not a normal finding. A normal alignment should have the shoulders and hips in a straight line when observed posteriorly. An "S" pattern could indicate issues such as scoliosis or other postural abnormalities that require further assessment.

B) When observed laterally, the spinal curves align in a reversed S pattern: This is the normal finding. The spine should form a reversed "S" curve when observed laterally. This curve includes a cervical curve (forward), a thoracic curve (backward), and a lumbar curve (forward). This curvature allows for optimal shock absorption and proper weight distribution during standing and movement.
C) The arms should be crossed over the chest or in the lap: This is not a normal finding for body alignment. Arms should be relaxed at the sides or slightly away from the body in a natural, neutral position. Crossing arms can indicate discomfort or tension, which may affect the patient’s posture.

D) The feet should be close together with toes pointed out: This is not the normal body alignment. Feet should be shoulder-width apart with toes pointing forward in a neutral position when standing. Toes pointed out may indicate abnormal posture or gait patterns, such as muscle imbalances or discomfort.

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Correct Answer is A

Explanation

A) Reach around the pack and open the top flap away from the body: The nurse should open the top flap of the sterile pack first by pulling it away from the body. This ensures that the sterile contents of the pack are not contaminated by touching the body or clothing. It is important to open the flap away from the body and face to maintain the sterility of the field and prevent any potential contamination.

B) Move to the opposite side of the pack to open the fourth flap: Moving to the opposite side of the pack to open the fourth flap is not necessary. The nurse should open the pack from the side where it is placed, and typically the sterile pack has a specific order for opening the flaps to maintain a sterile field. Opening the fourth flap from the opposite side would not be the most efficient or safest practice.

C) Place the pack on a sterile work surface: While placing the sterile pack on a sterile work surface is important, this step is not directly related to opening the sterile pack. Ensuring the work surface is sterile is crucial, but the question specifically addresses the proper way to open the pack, which involves how to handle the flaps safely.

D) Open the right flap with the left hand: It is essential to avoid crossing over sterile areas or using non-dominant hands for opening the pack's flaps in a manner that could risk contamination. Each flap should be opened in a controlled way, usually with the dominant hand, and this action must follow the correct sequence to prevent any potential contamination, especially when handling the pack’s sterile contents.

A. Complete an incident report. B. Request the risk manager obtain consent for HIV testing from the client. C. Consent to postexposure treatment with antiretroviral medications. D. Wash the site of injury with soap and water.

Correct Answer is D

Explanation

A) Complete an incident report: While it is essential to complete an incident report, this is not the first action to take. Completing the report documents the event but should come after immediate steps are taken to prevent further complications and ensure the nurse's safety. The priority is to first address the injury and ensure the site is properly cleaned.

B) Request the risk manager obtain consent for HIV testing from the client: Requesting consent for HIV testing from the client is important, but it is not the first priority. The immediate action should focus on treating the injury and reducing the risk of infection. Once the injury is addressed, the next step is to assess the potential for exposure and initiate testing or other preventive measures.
C) Consent to postexposure treatment with antiretroviral medications: Postexposure prophylaxis (PEP) with antiretroviral medications is an important step after a needle-stick injury, especially if the source patient has an unknown HIV status or is known to be HIV-positive. However, this step should come after immediate wound care and before initiating any further testing or preventive treatments.

D) Wash the site of injury with soap and water: The first and most crucial step after a needle-stick injury is to immediately wash the wound thoroughly with soap and water. This action helps reduce the risk of infection by removing any potential contaminants from the needle or the environment. After cleaning the wound, the nurse should then proceed with further steps, such as reporting the incident, obtaining consent for HIV testing, and considering PEP if indicated.

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A nurse is assessing the body alignment of a standing patient. Which finding will the nurse report as normal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?

Correct Answer is A

Explanation

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the first?

Correct Answer is D

Explanation

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