A nurse is caring for a group of clients who need positioning. Which client should the nurse prioritize?
A client with edematous lower extremities.
A client who has discomfort.
A client who reports dyspnea.
A client with an order to turn every 2 hours.
The Correct Answer is C
A. A client with edematous lower extremities: Edema requires positioning to promote venous return and reduce swelling, but it does not pose an immediate threat to oxygenation or life. While important, it is lower priority compared with acute respiratory compromise.
B. A client who has discomfort: Discomfort is important to address to maintain comfort and prevent agitation, but it is a lower priority than airway or breathing concerns. Pain management can be incorporated after addressing urgent physiologic needs.
C. A client who reports dyspnea: Dyspnea indicates impaired oxygenation and potential respiratory compromise. Prioritizing this client aligns with the ABC (Airway, Breathing, Circulation) principle, as maintaining adequate oxygenation is life-sustaining and requires immediate intervention.
D. A client with an order to turn every 2 hours: Scheduled turning prevents skin breakdown and pressure injuries but is a preventive measure. It is not more urgent than addressing a client experiencing dyspnea, which poses an immediate risk to safety and health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The UAP keeps the head of the bed flat when repositioning the client: Keeping the bed flat during repositioning can reduce strain on the client and caregiver. This is an appropriate action that maintains safety and comfort.
B. The UAP uses assistive transferring devices when transferring the client: Utilizing devices such as slide sheets or mechanical lifts reduces the risk of injury to both client and caregiver. This action aligns with safe patient handling principles.
C. The UAP places pillows to support the client's head, arms, and legs: Proper positioning with pillows prevents pressure injuries, promotes comfort, and maintains body alignment. This reflects correct delegation and care practices.
D. The UAP positions the client with the head of the bed at 45 degrees: Placing the client in a semi-Fowler’s position at 45 degrees may increase pressure on the sacrum and heels, raising the risk of pressure injuries in immobile older adults. The nurse should intervene and ensure proper positioning, typically less than 30 degrees, to minimize pressure.
Correct Answer is ["B","D","E"]
Explanation
A. Adjust the walker height so the client's arms are fully extended when holding the handles: The walker should be adjusted so the elbows are slightly flexed (about 20–30 degrees), not fully extended. Full extension can cause poor posture and increased risk of falls.
B. Stand slightly behind and on the affected side of the client when they are using a walker: Positioning yourself slightly behind and on the weaker or affected side allows the nurse to provide support and assist with balance, reducing fall risk during ambulation.
C. Have the client lift the device up and forward. Do not allow them to skid it along the floor: Standard walkers are designed to slide or “roll” along the floor; clients should not lift the walker. Lifting can cause instability and increase fatigue.
D. Instruct the client to move the walker forward and then move their affected side forward: Proper technique for weight-bearing ambulation with a walker involves moving the walker first, then stepping with the affected limb, followed by the unaffected limb. This ensures support and safety.
E. Ensure the client is wearing non-skid footwear before ambulating with the walker: Non-skid footwear improves traction and decreases the risk of slips and falls, which is essential for safe ambulation postoperatively.
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