The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

Picks up an item on the far side of the bed by stretching over the mattress.

Bends at the waist to hang a urinary bedside unit on the bed frame.

Pushes the lower drawer of the medication cart closed using one's hip.

Stands erect with knees bent to pull a draw sheet and move the client in bed.

Answer and Explanation

The Correct Answer is D

A.   This can strain the back and increase the risk of injury. It's important to use proper body mechanics, such as bending the knees and keeping the back straight, when reaching for objects.
B.   Bending at the waist can strain the back and increase the risk of injury. It's important to lift objects with the legs, not the back.
C.   This can strain the back and hips. It's important to use proper body mechanics, such as using the legs and core muscles to push or pull heavy objects.
D.   Standing erect with knees bent provides a strong base of support and helps to distribute weight evenly. Bending the knees allows for lifting with the legs, which is less stressful on the back and reduces the risk of injury. Pulling a draw sheet and moving a client in bed requires a combination of strength and proper body mechanics. Standing erect with knees bent helps to prevent strain on the back and muscles

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Correct Answer is A

Explanation

A. Asking the client to describe their feelings provides an opportunity to explore their symptoms in more detail, which might help in understanding their pain better. This approach respects the client's experience and opens a dialogue to assess their discomfort more accurately, especially if they are not expressing it verbally or are having difficulty quantifying it.
B. Administering medication without further assessment might be premature. The client's denial of pain and the presence of grimacing and guarding behavior suggest that there may be underlying discomfort, but it's crucial to assess the situation more thoroughly before administering medication.
C. While documenting the client’s verbal denial of pain is important, it should not be the only action taken. The client's non-verbal cues such as grimacing and guarding behavior suggest that they might be experiencing pain despite their verbal denial.
D. Confronting the client could be perceived as accusatory and might make them feel defensive or uncomfortable. It's important to approach the situation with empathy and understanding rather than confrontation.

A. Decrease the rate of the feeding by half. B. Observe for an allergic reaction to the formula. C. Hang a new bag of the enteral formula. D. Stop the tube feeding and assess the client.

Correct Answer is D

Explanation

A. Decreasing the rate of the feeding might be a consideration if the feeding was too rapid, but it is not the immediate priority if aspiration is suspected.
B. While it is important to monitor for allergic reactions to enteral formulas, this is not the immediate concern if aspiration is suspected. Allergic reactions would typically present with symptoms such as rash, itching, or gastrointestinal distress, and not immediately after aspiration.
C. Hanging a new bag of enteral formula is not an appropriate action if aspiration is suspected. The
priority is to ensure the client’s safety and address any complications that may arise from the aspiration, such as aspiration pneumonia.
D. Stopping the tube feeding and assessing the client is the most appropriate initial action if aspiration is suspected. Immediate assessment is necessary to determine if the client is experiencing signs of aspiration, such as coughing, wheezing, difficulty breathing, or changes in consciousness.

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The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

Correct Answer is A

Explanation

A client with a gastrostomy tube is receiving a continuous feeding, and the nurse suspects that the client has aspirated some of the feeding. Which action should the nurse take?

Correct Answer is D

Explanation

When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

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