Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement?
Raise the head of the bed 30 degrees.
Measure blood pressure and pulse rate.
Flex legs and place blanket between legs.
Place pillows to maintain alignment.
The Correct Answer is D
Log-rolling is a technique of moving a client as a unit without twisting or bending the spine, which is used for clients with spinal injuries or surgeries. After log-rolling a client to a lateral position, the PN should place pillows to maintain alignment and prevent pressure ulcers or nerve damage. The pillows should be placed under the head, neck, upper arm, chest, abdomen, pelvis, and lower leg.
The other options are not correct because:
A. Raising the head of the bed 30 degrees is not necessary or appropriate after log-rolling a client to a lateral position, as it can cause shearing forces or compromise the spinal stability. The head of the bed should be kept flat or slightly elevated during log rolling.
B. Measuring blood pressure and pulse rate is not the immediate intervention after log-rolling a client to a lateral position, as it does not ensure the comfort or safety of the client. The PN should monitor the vital signs before and after log-rolling, but not during or immediately after.
C. Flexing legs and placing a blanket between legs is not the immediate intervention after log-rolling a client to a lateral position, as it does not support the spine or prevent pressure ulcers or nerve damage. The PN should keep the legs straight and aligned with the body during log-rolling, and place a pillow under the lower leg after log-rolling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D
Explanation
This client has the highest priority, as he or she may be experiencing an acute asthma attack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.
B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.
This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.
C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground.
This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inflammation.
D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.
Correct Answer is ["A","B","D","E"]
Explanation
A) Correct - Demonstrating the technique used to monitor blood glucose levels is crucial.
Incorrect technique can lead to inaccurate readings, impacting insulin dosing decisions and blood sugar control.
B) Correct - Some asthma medications, like corticosteroids, can elevate blood glucose levels.
Evaluating the client's asthma medications is essential as they can contribute to fluctuations in blood sugar levels.
C) Incorrect- Asking the client if they want a different manufacturer's glucose monitoring device is not helpful, because it does not address the underlying causes of the poor glycemic control. The client may also perceive this as a lack of confidence in their ability to manage their diabetes or as a criticism of their choice of device. The nurse should focus on educating the client on how to use their current device correctly and consistently, rather than suggesting a change that may not be necessary or feasible.
D) Correct - Understanding the client's daily routine helps identify factors influencing blood glucose control, such as meal timing, activity level, and stress. This information aids in creating a personalized diabetes management plan.
E) Correct - Ensuring the client uses a new insulin needle for each administration is important for preventing infection and complications. Reusing needles can affect injection site health and insulin absorption.
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