A nurse is assisting a coworker with moving a client up in bed using a draw sheet. Which of the following actions should the nurse take?

Place both feet apart and shift from the back to the front leg when moving the client up in bed.

Position the client's arms at their sides prior to moving them up in bed.

Elevate the head of the client's bed 30° prior to moving the client.

Bend at the waist when grasping the draw sheet when moving the client up in bed.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This choice reflects the correct technique for maintaining balance and using proper body mechanics when assisting with moving a client up in bed. Shifting weight from the back to the front leg while keeping the feet apart provides a stable base and reduces the risk of injury to the nurse.

Choice B rationale:

Positioning the client's arms at their sides before moving them up in bed is not a necessary step and may not contribute significantly to the process. The primary focus should be on proper body mechanics and the use of assistive devices, such as a draw sheet, to ensure safe patient handling.

Choice C rationale:

Elevating the head of the client's bed 30° is not directly related to the task of moving the client up in bed using a draw sheet. While head elevation might have other clinical indications, it does not impact the technique of assisting with repositioning.

Choice D rationale:

Bending at the waist when grasping the draw sheet is incorrect body mechanics and can lead to strain on the nurse's back. Proper technique involves using the legs to bend and lift while keeping the back straight, reducing the risk of injury.

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Correct Answer is C

Explanation

Choice A rationale:

Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.

Choice B rationale:

Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.

Choice C rationale:

Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.

Choice D rationale:

Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.

A. Slowly instill 400 to 500 mL of the prescribed solution. B. Clamp the drainage tubing distal to the injection port. C. Use a syringe with a 19-gauge needle. D. Withdraw the irrigation solution into the syringe.

Correct Answer is A

Explanation

Choice A rationale:

During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.

Choice B rationale:

Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.

Choice C rationale:

Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.

Choice D rationale:

Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.

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A nurse is assisting a coworker with moving a client up in bed using a draw sheet. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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