A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?
Place a pillow under the client's knees when changing positions.
Use a sheet when repositioning the client onto his side.
Apply an immobilizing collar on the client prior to movement.
Instruct the client to keep his arms at his side when altering positions.
The Correct Answer is B
Rationale:
A. Place a pillow under the client's knees when changing positions: Elevating the knees with a pillow may be appropriate for comfort, but in a client with a thoracic spine injury, this can alter spinal alignment and increase the risk of further injury. Maintaining proper spinal alignment during all movements is more important than knee elevation.
B. Use a sheet when repositioning the client onto his side: Using a sheet for logrolling or turning helps maintain spinal alignment and allows multiple caregivers to move the client safely as a unit. This technique minimizes rotation or flexion of the spine, which is critical in preventing further spinal cord injury in clients with thoracic spine trauma.
C. Apply an immobilizing collar on the client prior to movement: Cervical collars are used for cervical spine injuries, not thoracic spine injuries. Applying a collar would not stabilize the thoracic spine and could give a false sense of security while performing repositioning.
D. Instruct the client to keep his arms at his side when altering positions: The client may need to assist in turning if possible, and keeping the arms rigidly at the side is not necessary. Restricting arm movement does not ensure spinal safety and may limit the client’s ability to participate safely in repositioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Compare the current infusion with the prescription in the client's medication record: The first action is to verify the actual prescription against the current IV infusion. This ensures that the client is receiving the correct medication, dose, and rate, and allows the nurse to identify any errors or discrepancies before taking further action.
B. Submit a written warning for the nurse involved in the incident: Disciplinary action is not appropriate as an initial step. The priority is client safety and verifying facts, not assigning blame. Investigations or corrective actions follow after assessment and verification.
C. Complete an incident report and place it in the client's medical record: Incident reports are used to document discrepancies or errors, but they should not be placed in the medical record. They are submitted to risk management or quality assurance separately. Filing in the medical record could create legal and confidentiality issues.
D. Contact the charge nurse to see if the prescription was changed: While notifying the charge nurse may be necessary, it should occur after verifying the prescription and confirming the discrepancy. Immediate assessment and comparison to the medication record take priority to ensure client safety.
Correct Answer is A
Explanation
Rationale:
A. "I will change my baby's diaper at least every 4 hours.": Frequent diaper changes help keep the circumcision site clean and dry, reducing the risk of infection and irritation from urine or stool. Keeping the area free from moisture allows proper healing and minimizes discomfort for the newborn. This reflects correct home care following a circumcision.
B. "I will wash the penis with soap and warm water until the circumcision has healed.": Using soap on the circumcision site can cause irritation and delay healing. The area should be gently cleansed with warm water only, allowing the natural healing process to occur without additional chemical irritation from soaps or wipes containing alcohol or fragrances.
C. "I will apply topical lidocaine following each diaper change.": Topical anesthetics such as lidocaine are not recommended for routine circumcision care because they may cause toxicity or be absorbed unpredictably in newborns. Pain is managed through comfort measures such as swaddling, breastfeeding, or using petroleum jelly, not through anesthetic application.
D. "I will apply an ice pack to my baby's penis twice daily to decrease swelling.": Applying ice to a newborn’s circumcision site is unsafe and can cause tissue injury due to extreme temperature sensitivity. Mild swelling is expected and resolves naturally; the recommended care involves gentle cleansing and protecting the site with petroleum jelly not cold therapy.
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