The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient?

Slide the patient into the new position

Place the patient in a 30 degree supine position.

utilize a transfer device to lift the patient.

Elevate the head of the bed 45 degrees

Answer and Explanation

The Correct Answer is C

A) Slide the patient into the new position: Sliding a patient when repositioning can create shear forces on the skin, which may contribute to skin damage. Shearing can occur when the skin sticks to the surface while the underlying tissues move, leading to increased risk of pressure ulcers. Therefore, sliding is not considered the most effective or safest way to reposition a patient at risk for skin impairment.

B) Place the patient in a 30-degree supine position: Placing the patient in a 30-degree supine position is a good method for reducing pressure on bony prominences and minimizing the risk of pressure injuries. However, while this position is helpful for preventing skin breakdown, it does not address the method of repositioning, which is what is being asked in this question.
C) Utilize a transfer device to lift the patient: Using a transfer device, such as a lift or slide sheet, to lift the patient is the best method for repositioning. This technique helps to reduce friction and shear forces on the skin, providing a safer and more effective way to move the patient without causing damage. Transfer devices also allow for a smoother repositioning, minimizing the risk of skin impairment.

D) Elevate the head of the bed 45 degrees: Elevating the head of the bed to 45 degrees can increase the risk of pressure injuries, especially if the patient is immobile and cannot relieve pressure themselves. This position can also contribute to shear forces as the patient slides downward. It may be appropriate in certain clinical situations, but it does not directly address the method of repositioning.

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Correct Answer is C

Explanation

A) Droplet: Droplet precautions are used for infections that spread through respiratory droplets when an infected person coughs, sneezes, or talks. While measles is transmitted through respiratory droplets, the virus is highly contagious and requires airborne precautions, not just droplet precautions.

B) Contact: Contact precautions are used for infections spread through direct contact with the patient or their environment, such as gastrointestinal or skin infections. Measles is primarily spread through the air and is not classified as a contact transmission infection.

C) Airborne: Measles is an airborne illness, which means that it can be transmitted through small respiratory droplets that remain suspended in the air for long periods of time. Airborne precautions are necessary to protect healthcare workers and other patients from exposure. These precautions include placing the child in a negative pressure room and requiring healthcare workers to wear N95 respirators.

D) Protective environment: Protective environment precautions are used for patients with severely weakened immune systems, such as those undergoing chemotherapy or organ transplantation. These precautions are designed to protect the patient from infections, not to prevent the spread of contagious illnesses like measles.

A. Focusing on helping patients be disease free B. Providing care that involves the whole person C. Assuring that care is strictly personal in nature D. Directing focus only on the pathological state

Correct Answer is B

Explanation

A) Focusing on helping patients be disease free: The World Health Organization (WHO) definition of health goes beyond the absence of disease. It emphasizes the complete state of physical, mental, and social well-being, rather than simply the absence of illness. Focusing solely on being disease-free does not align with this holistic view of health.

B) Providing care that involves the whole person: This is the correct approach in line with the WHO definition of health. WHO defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. Therefore, the nurse should focus on addressing all aspects of a person’s health, including emotional, social, and physical needs, to promote overall well-being.

C) Assuring that care is strictly personal in nature: While personal care is important, the WHO definition of health emphasizes a broader, more holistic approach that incorporates physical, mental, and social aspects of health, not just personal care. It’s about treating the whole person in context, including their environment and social relationships.

D) Directing focus only on the pathological state: The WHO definition moves beyond just focusing on the pathological (disease) state and emphasizes wellness in all aspects of life. While addressing medical issues is important, focusing solely on pathology ignores the broader concept of health that includes mental and social well-being.

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