A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?

The pads will keep the staff from workplace injuries such as a pulled muscle.

The pads will absorb any urinary incontinence and contain stool.

The pads will help prevent friction and shearing when repositioning the client.

The pads will prevent the client from being diaphoretic.

Answer and Explanation

The Correct Answer is C

Choice A reason: While lift pads can help reduce the risk of workplace injuries for staff, such as pulled muscles, this is not their primary purpose. The main goal of using lift pads is to protect the client from injury during repositioning. Lift pads distribute the client’s weight more evenly, making it easier for staff to move them without straining themselves.

Choice B reason: Lift pads are not designed to absorb urinary incontinence or contain stool. There are specific products like incontinence pads and briefs for managing urinary and fecal incontinence. Lift pads are primarily used to assist with the safe repositioning of immobile clients.

Choice C reason: The primary purpose of lift pads is to help prevent friction and shearing when repositioning the client. Friction and shearing can cause skin damage and pressure ulcers, especially in immobile clients. Lift pads reduce the risk of these injuries by allowing smoother and safer movements.

Choice D reason: Lift pads do not prevent clients from being diaphoretic (sweating excessively). Diaphoresis can be managed through other means, such as adjusting room temperature, using fans, or providing appropriate clothing and bedding. Lift pads are not intended for this purpose.

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Correct Answer is C

Explanation

Choice A Reason:

Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI

Choice B Reason:

Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.

Choice C Reason:

Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.

Choice D Reason:

Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.

Correct Answer is ["260"]

Explanation

Calculation
Enteral nutrition: 200 mL
Water flush before feed: 30 mL
Water flush after feed: 30 mL

Total intake = 200 mL + 30 mL + 30 mL = 260 mL

The nurse should document 260 mL as intake in the I&O.

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A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assess a client. Which action should the nurse take to check cranial nerve VI?

Correct Answer is C

Explanation

Correct Answer is ["260"]

Explanation

A nurse is auscultating a client’s lung sounds and identifies crackles in the left lower lobe. Which intervention should the nurse take first?

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A nurse is assessing a client’s cranial nerves. Which methods should the nurse use to assess cranial nerve V?

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