A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?

Roll the client as one unit in a smooth, continuous motion.

Flex the client's knees.

Place the client's arms at their sides.

Place the client on the side of the bed nearest the direction they will be turned.

Answer and Explanation

The Correct Answer is A

- Rationale for A: Rolling the client as one unit helps maintain spinal alignment and prevents further injury. It ensures that no additional strain is placed on the injured area, which could exacerbate pain or cause further damage. This method distributes the client's weight evenly and avoids twisting movements that could be harmful.

- Rationale for B: While flexing the client's knees may be part of the process to prepare for repositioning, it is not the most critical action to take. Flexing the knees alone does not ensure the safety of the client's lower back and could potentially lead to discomfort or injury if not done in conjunction with other measures.

- Rationale for C: Placing the client's arms at their sides is not advisable as it does not provide any support or stability during the repositioning process. Arms should be positioned in a way that they do not bear weight or interfere with the movement, ensuring the client's comfort and safety.

- Rationale for D: While placing the client on the side of the bed nearest the direction they will be turned may seem practical, it is not the primary action to ensure the client's safety. This position does not address the need for maintaining proper spinal alignment or the smooth, controlled movement required to protect the lower back injury.

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Correct Answer is A

Explanation

A. Using a straw can increase the risk of aspiration for someone with dysphagia by bypassing the proper oral control needed for swallowing safely.
B. Adjusting the head of the bed to 90° is an appropriate position for someone with dysphagia during meals, promoting safer swallowing.
C. Taking frequent breaks while eating allows for safe swallowing and prevents fatigue.
D. Tucking the chin when swallowing is a proper technique for aiding safe swallowing for someone with dysphagia.

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. B. Recheck the client's BP in her other arm for comparison. C. Request that another nurse check the client's BP in 30 min. D. Reposition the client supine and recheck her BP.

Correct Answer is B

Explanation

A: The width of the BP cuff should actually be 40% of the client's upper arm circumference, not 50%. Using a cuff that's too large can result in a falsely low reading, while a cuff that's too small can cause a falsely high reading.
B: It is important to recheck the BP in the other arm to compare readings. Differences in blood pressure between arms can indicate vascular issues and provide valuable diagnostic information. Consistency in readings is crucial for accurate diagnosis and treatment.
C: While it may be necessary to monitor the client's BP over time, immediately requesting another nurse to check the BP does not address the immediate concern of the accuracy of the initial reading.
D: Repositioning the client supine may be appropriate if orthostatic hypotension is suspected, but it is not the first action to take. The initial step should be to confirm the accuracy of the reading by checking the other arm.

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A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

Correct Answer is A

Explanation

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Correct Answer is B

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