A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which position would the nurse place the client?
Sims’ position
Dorsal recumbent position
Supine position
High Fowler’s position
The Correct Answer is B
Choice A rationale:
Sims' position is a side-lying position with the lower leg flexed and the upper leg extended. It is not ideal for bladder scanning because it can compress the bladder and make it difficult to obtain an accurate reading.
Additionally, in Sims' position, the bladder may not be fully accessible to the scanner, as it may be partially obscured by the upper thigh.
Choice B rationale:
Dorsal recumbent position is the optimal position for bladder scanning. In this position, the client lies flat on their back with their knees bent and their feet flat on the bed. This position allows for:
Full exposure of the bladder, making it easily accessible to the scanner.
Relaxation of the abdominal muscles, which can help to ensure an accurate reading.
A comfortable position for the client, promoting cooperation and reducing the likelihood of movement that could interfere with the scan.
Choice C rationale:
Supine position is a similar position to dorsal recumbent, but with the legs fully extended. While it is possible to perform a bladder scan in this position, it is not as ideal as dorsal recumbent because:
The extended legs can place some tension on the abdominal muscles, potentially affecting bladder position and the scan's accuracy.
The client may find this position less comfortable, leading to restlessness and potential movement that could interfere with the scan.
Choice D rationale:
High Fowler's position is a semi-sitting position with the head of the bed elevated at a 45- to 60-degree angle. This position is not suitable for bladder scanning because:
Gravity can pull the bladder downwards, making it difficult to visualize and measure accurately.
It can be challenging to maintain proper positioning of the scanner on the abdomen in this position, potentially leading to inaccurate readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
While adequate supervision is essential for safe delegation, it's not the primary question the nurse should ask. The nurse must first determine if delegation is legally and organizationally permissible.
If the nurse practice act or facility policy prohibits delegation of medication administration to UAPs, no amount of supervision can override those regulations.
Ensuring compliance with legal and professional standards is paramount to protect patient safety and the nurse's license.
Choice B rationale:
The client's response and approval are important considerations, but they don't supersede legal and organizational guidelines. If delegation isn't permitted, the client's preferences cannot justify a violation of these standards. Obtaining client consent is a crucial aspect of ethical care, but it must align with established regulations.
Choice C rationale:
UAP training is crucial for safe delegation, but it's again not the primary question.
If delegation itself isn't allowed, the UAP's level of training becomes irrelevant.
It's essential to verify the UAP's competency only after confirming the legality and organizational acceptability of delegation.
Choice D rationale:
This is the primary question because it addresses the fundamental legality and appropriateness of delegation within the specific context of the nurse's practice and workplace.
Nurse practice acts outline the scope of nursing practice and define which tasks can be delegated to unlicensed personnel.
Healthcare facility policies further delineate delegation guidelines within the institution, ensuring consistency and adherence to best practices.
By consulting these regulations first, the nurse can make an informed decision that aligns with professional standards and protects patient safety.
Correct Answer is A
Explanation
Choice A rationale:
Anticoagulant medications are the mainstay of treatment for thrombophlebitis. They work by preventing the formation of new blood clots and allowing the body's natural clot-dissolving mechanisms to break down existing clots. This helps to reduce the risk of the clot growing larger, breaking off, and traveling to the lungs (pulmonary embolism), which is a potentially life threatening complication.
Here is a detailed explanation of how anticoagulants work:
Blood clotting process: Blood clotting, also known as coagulation, is a complex process that involves multiple steps and factors. When a blood vessel is injured, a series of reactions occur to form a blood clot, which helps to stop bleeding.
Role of thrombin: Thrombin is a crucial enzyme in the clotting process. It converts fibrinogen, a soluble protein in the blood, into fibrin, which forms the mesh-like structure of blood clots.
Anticoagulants target thrombin: Anticoagulant medications work by inhibiting thrombin activity, thereby preventing the formation of fibrin and subsequent clot formation.
Different types of anticoagulants: There are several types of anticoagulant medications, each with different mechanisms of action. Some common types include:
Heparin: Heparin binds to antithrombin III, a natural anticoagulant in the body, and enhances its ability to inactivate thrombin and other clotting factors.
Warfarin: Warfarin blocks the production of vitamin K-dependent clotting factors in the liver.
Direct oral anticoagulants (DOACs): DOACs directly inhibit specific clotting factors, such as factor Xa or thrombin.
Choice B rationale:
Antibiotic medications are used to treat bacterial infections. Thrombophlebitis is not a bacterial infection, so antibiotics would not be effective in treating it.
Choice C rationale:
Antigen medications are not a category of medications. Antigens are substances that trigger an immune response in the body.
Choice D rationale:
Antihistamine medications are used to treat allergic reactions. They block the effects of histamine, a chemical released by the body during an allergic reaction. Antihistamines would not be effective in treating thrombophlebitis.
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