A nurse is planning to place a client into the Sims’ position.
Which of the following actions should the nurse plan to take?
Elevate the client’s feet with two pillows.
Raise the head of the client’s bed to a 30° angle.
Raise the head of the client’s bed to a 60° angle.
Place a pillow under the client’s flexed leg.
The Correct Answer is D
The correct answer is choice D. Placing a pillow under the client’s flexed leg is part of the Sims’ position, which is a way of lying on the left side, with the right hip and knee bent and the left arm behind the back.
It is used for vaginal and colonic examinations and natural childbirth.
Choice A is wrong because positioning the client’s arms at his sides is not part of the Sims’ position.
The left arm should be behind the back.
Choice B is wrong because elevating the client’s feet with two pillows is not part of the Sims’ position.
The lower leg should be straightened and the upper leg should be bent.
Choice C is wrong because raising the head of the client’s bed to a 30° angle is not part of the Sims’ position.
The bed should be flat or slightly tilted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. The client who says “I need to learn how to perform a dressing change on my leg” is indicating an acceptance of the limb loss and a readiness to learn self-care skills.
This is a positive sign of coping and adaptation after an amputation surgery.
Choice A is wrong because the client who says “I am going to have to find someone who can take care of my leg at home” is expressing dependency and denial of the limb loss.
The client needs to be encouraged to participate in self-care activities and rehabilitation.
Choice B is wrong because the client who says “I stay awake at night because I keep thinking about my leg” is experiencing phantom limb sensation, which is a common phenomenon after amputation.
The client may benefit from pain management, distraction techniques, and counseling.
Choice D is wrong because the client who says “I know my family means well, but I don’t want visitors seeing my leg right now” is showing signs of social isolation and low self-esteem.
The client needs emotional support and reassurance from the nurse and family members.
Normal ranges for vital signs after amputation are blood pressure 120/80 mm Hg, pulse 60-100 beats/min, respiratory rate 12-20 breaths/min, and temperature 36.5-37.5°C.
Correct Answer is A
Explanation
This is because a frayed electrical cord can pose a serious risk of electric shock or fire to the client and the nurse.
The nurse should act quickly to eliminate the hazard and ensure the safety of the client and others.
Choice B is wrong because accessing the facility’s maintenance protocol is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before following any protocol.
Choice C is wrong because reporting defective equipment is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before reporting it to the appropriate authority.
Choice D is wrong because requesting a replacement device is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before requesting a new one.
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