A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

Every four hours.

Every hour.

Every shift.

Every two hours

Answer and Explanation

The Correct Answer is D

A. Every four hours:

Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.

B. Every hour:

Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.

C. Every shift:

Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.

D. Every two hours:

Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.

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Correct Answer is A

Explanation

A. Increased, strong:

A pulse amplitude of +3 indicates an increased or strong pulse. This suggests a forceful and palpable pulse, potentially associated with conditions like fever, anemia, or increased cardiac output.

B. Diminished, weaker than expected:

This would typically be associated with a lower than normal pulse amplitude. It might suggest poor peripheral perfusion or decreased cardiac output.

C. Absent, unable to palpate:

If the pulse is absent or unable to be palpated, it could indicate severe conditions such as vascular occlusion or cardiac arrest.

D. Bounding:

A bounding pulse is one with a forceful and strong amplitude. It suggests a powerful expansion of the arterial wall, and it can be associated with conditions like fever, anemia, or increased cardiac output.

A. 30 degrees. B. 15 to 20 degrees. C. 90 degrees. D. 45-60 degrees

Correct Answer is C

Explanation

A. 30 degrees:

This angle does not meet the criteria for a High Fowler's position, which requires a more upright position.

B. 15 to 20 degrees:

This angle is lower than what is generally considered as High Fowler's position. High Fowler's is a more upright position.

C. 90 degrees:

High Fowler's position involves elevating the head of the bed to 90 degrees. This position is often used for better lung expansion and respiratory function.

D. 45-60 degrees:

While this range is higher than a semi-Fowler's position, it is not as upright as the 90-degree elevation in a High Fowler's position.

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A nurse is repositioning a client who has physical limitations due to recent back surgery. How often would the nurse turn the client in bed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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