A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Use an air-assisted device.

Position the bed in reverse Trendelenburg.

Elevate the head of bed to a 45° angle.

Lower the bed close to the ground.

Answer and Explanation

The Correct Answer is A

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

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Correct Answer is C

Explanation

A. "Maybe you should wait to have the procedure."

This response may come across as directive and could potentially influence the client's decision. It does not encourage the client to express their feelings or concerns but suggests a specific course of action.

B. "This is a common feeling for clients to have before the procedure."

While it's true that many clients may experience conflicted feelings before undergoing certain procedures, this response is somewhat dismissive. It does not invite the client to explore their specific concerns and may not address the individual nature of the client's feelings.

C. Share more with me about your concerns related to the procedure.

This response encourages the client to express their concerns and provides an opportunity for the nurse to understand the specific issues causing the conflict. It demonstrates empathy and openness, fostering a therapeutic nurse-client relationship. By inviting the client to share more, the nurse can gain insight into the client's emotional and psychological concerns about the tubal ligation.

D. "Why are you concerned about the procedure?"

While this question is an attempt to understand the client's concerns, it may be perceived as too direct or confrontational. The wording might make the client feel defensive or pressured to justify their feelings. The more open-ended phrasing in option C is generally more conducive to therapeutic communication.

A. Hot tea B. Soft-serve ice cream C. Raisin toast D. String cheese

Correct Answer is C

Explanation

Hot tea:

Hot tea may not be well-tolerated by individuals experiencing chemotherapy-induced nausea, as hot or strong-smelling foods and beverages can be triggers. It is generally recommended to choose foods at room temperature.

Soft-serve ice cream:

Soft-serve ice cream may be too cold and could exacerbate nausea or discomfort. Cold foods might not be well-tolerated during or after chemotherapy.

Raisin toast:

This is the correct answer. Raisin toast is a good choice as it is a bland and easily digestible carbohydrate. It can be a suitable option for individuals experiencing nausea, providing some calories without strong odors or flavors.

String cheese:

While cheese can be a good source of protein, string cheese might not be the best choice if the individual is experiencing nausea, as the smell or taste of certain cheeses can be strong and trigger nausea.

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A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who expresses conflicted feelings about undergoing a tubal ligation. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about chemotherapy-induced nausea. Which of the following food selections indicates the newly licensed nurse understands the teaching?

Correct Answer is C

Explanation

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