The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

Make sure the bed is low, locked, and call light in reach of patient

Ask the client if they have ordered their dinner

Educate the client on the surgical procedure they are scheduled for in the morning

Check that the client is wearing non-skid socks while in bed

Answer and Explanation

The Correct Answer is A

A. Make sure the bed is low, locked, and the call light is in reach of the patient:

This action is crucial for preventing falls. A low bed reduces the risk of injury if the client were to accidentally fall. Locking the bed prevents unintended movement, and ensuring the call light is within reach allows the client to call for assistance if needed.

B. Ask the client if they have ordered their dinner:

While nutrition is important, it is not the immediate priority after assisting the client back to bed. Safety measures should be addressed first.

C. Educate the client on the surgical procedure they are scheduled for in the morning:

While pre-operative education is important, it is not the immediate concern after assisting the client back to bed. Safety measures for the current situation take precedence.

D. Check that the client is wearing non-skid socks while in bed:

While wearing non-skid socks is a safety measure, ensuring the bed is low, locked, and the call light is accessible is a more immediate and critical action after assisting the client back to bed.

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Correct Answer is D

Explanation

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.

A. To prevent contractions in the hand. B. To prevent skin breakdown. C. To prevent decrease perfusion in the lower extremities. D. To prevent pooling of blood in the hand.

Correct Answer is A

Explanation

A. To prevent contractions in the hand:

The use of hand and wrist rolls helps prevent contractures, which are permanent shortening of muscles or joints. This is particularly important in comatose patients or those with limited mobility to maintain proper hand positioning and prevent deformities.

B. To prevent skin breakdown:

While proper positioning can contribute to preventing skin breakdown, the primary purpose of hand and wrist rolls, in this context, is to address the risk of contractures rather than skin breakdown.

C. To prevent decreased perfusion in the lower extremities:

The action described is specifically related to the hands and wrists, not the lower extremities. It is not designed to prevent decreased perfusion in the lower extremities.

D. To prevent pooling of blood in the hand:

While maintaining proper hand positioning may contribute to optimal circulation, the primary purpose is to prevent contractures rather than addressing blood pooling.

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The nurse assists the client back to bed from the bedside commode. What is the most important action the nurse can take to assure client safety prior to leaving the room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?

Correct Answer is A

Explanation

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