A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Rolls the client to one side of the bed

Reaches over the bed to straighten the fitted sheet

Lowers the side rail on the side of the bed closest to the AP

Raises the bed to waist level

Answer and Explanation

The Correct Answer is B

A. Rolling the client to one side of the bed is an appropriate action to change the linens.
B. Reaching over the bed to straighten the fitted sheet can cause strain and potential injury to the AP's back and should be corrected.
C. Lowering the side rail on the side of the bed closest to the AP is necessary for changing the linens safely.
D. Raising the bed to waist level is an appropriate action to ensure proper body mechanics and prevent injury.

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Correct Answer is C

Explanation

A. Labeling the feeding bag is important for ensuring the safety and monitoring of feeding times, but it is not the first action.
B. Hanging the feeding bag at the correct height ensures proper flow of the feeding but is not the first action.
C. Aspirating the client's stomach contents is the first action to check for residuals and ensure the placement of the NG tube is correct, preventing aspiration.
D. Warming the feeding to room temperature is important for client comfort but is not the first action.

A. Sleep on a soft mattress. B. Avoid prolonged sitting. C. Apply heat for 10 min every hour. D. Sleep in a side-lying position with flexed knees. E. Try padded shoe insoles.

Correct Answer is ["B","D","E"]

Explanation

Rationale:
A. Sleeping on a firm mattress is generally recommended to support the spine and prevent back strain.
B. Avoiding prolonged sitting helps reduce pressure on the lower back and can prevent back pain.
C. Applying heat intermittently can provide temporary relief but does not prevent back strain.
D. Sleeping in a side-lying position with knees flexed helps maintain natural spinal curvature and reduces strain on the back.
E. Padded shoe insoles may provide comfort. Proper arch support can improve posture and reduce stress on the lower back.

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A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Nursing Test Bank

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A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?

Correct Answer is C

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Correct Answer is ["B","D","E"]

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