A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
Evaluate the client's ability to help with repositioning
Reposition the client without the use of assistive devices.
Raise the side rails on both sides of the client's bed during repositioning
Discuss the client's preferences for determining a repositioning schedule
The Correct Answer is A
Rationale:
A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.
B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.
C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.
D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Pupil diameter 6 mm: Dilated pupils may indicate CNS stimulation or sensitivity, but this finding is less immediately life-threatening than significant hypotension. Pupil size should still be monitored, especially for signs of overdose or neurologic changes.
B. Blood pressure 80/40 mm Hg: Severe hypotension is a critical adverse effect of IV morphine that can compromise perfusion to vital organs. It requires immediate attention to prevent shock, making this the highest priority finding to report.
C. Urinary output 120 mL/4 hr: While this output is slightly below normal, it does not yet indicate acute kidney injury. Continued monitoring is warranted, but it is not the most urgent issue compared to hypotension.
D. Bowel movement 5 days ago: Constipation is a common side effect of opioids, but it typically develops gradually and can be managed with bowel protocols. It is not as urgent as hypotension and can be addressed after stabilizing the client.
Correct Answer is C
Explanation
Rationale:
A. "Manually expressing my milk will decrease my milk supply": Milk supply is maintained by frequent emptying of the breast. Manual expression, like breastfeeding or pumping, actually stimulates continued milk production through the supply-and-demand mechanism.
B. "After 5 to 10 minutes when the breasts emptied, my baby should be removed from the breast”: Infants should not be removed from the breast based on time alone. Breastfeeding duration varies, and babies should be allowed to nurse until they release the breast or show signs of fullness.
C. "The more my baby is at the breast sucking, the more milk I will produce”: Milk production is driven by infant demand. Frequent suckling stimulates prolactin release, encouraging ongoing milk synthesis and maintaining an adequate supply.
D. "My baby should always start on the same breast when feeding”: Breastfeeding should be alternated between breasts to promote equal milk production and prevent engorgement. Starting on the same breast consistently may lead to uneven milk supply.
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