The nurse enters the room of an older adult client and observes the client positioned in a wheelchair as seen in the picture. The unlicensed assistive personnel (UAP) is preparing to push the client's wheelchair in the hallway. Which instruction should the nurse provide the UAP before the client is moved into the hallway?
Use a belt restraint to secure the client in the chair.
Empty the client's urinary drainage bag.
Reposition the client's urinary drainage bag.
Elevate the client's feet higher on the foot rests.
The Correct Answer is C
A. Using a belt restraint is generally not recommended unless specifically ordered for safety reasons, as it may not be appropriate or necessary in all cases. Restraints should only be used when absolutely needed and when all other methods of ensuring safety have been considered.
B. Emptying the urinary drainage bag before moving the client is important to prevent overflows and ensure that the bag does not become a source of discomfort or potential infection. However, this step might not always be immediately necessary unless the bag is full or the client’s comfort and hygiene are at risk.
C. Repositioning the urinary drainage bag is crucial for ensuring that the bag remains below the level of the bladder and is not subject to kinks or obstructions. This helps prevent backflow and potential infections. Proper positioning also contributes to the client’s comfort and dignity, making this a priority before moving the client.
D. Elevating the client’s feet on the footrests is important for their comfort and to prevent swelling or pressure sores, especially if the client has limited mobility or circulatory issues. Proper positioning can prevent discomfort and promote better circulation, which is essential for maintaining the client’s well- being during transport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B. The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C. The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D. The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E. The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.
Correct Answer is A
Explanation
A. This is a critical first step when a medication dose discrepancy is identified. Reporting the mismatch alerts the appropriate personnel (such as the pharmacy or healthcare provider) to investigate and resolve the issue. This ensures that the correct dose is administered and helps prevent potential medication errors.
B. While calculating the dose on hand is important to ensure accurate dosing, this action should be secondary to reporting the issue first. Calculating the dose is part of the process to verify and adjust the dose if needed, but the primary concern is to report the discrepancy to get it addressed properly and safely.
C. Asking the pharmacist for a different dose is a valid action, but it should come after reporting the discrepancy. The pharmacist can provide guidance on whether a different dose can be dispensed and help clarify any issues with the medication.
D. Withholding the medication is an appropriate precaution if there is uncertainty about the dose, but it is not the first action to take. This step should follow the initial reporting of the discrepancy to ensure that the medication is correct and safe to administer.
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