What is the most appropriate action for a nurse to take when a patient reports discomfort while being repositioned?
Ask the patient to tolerate the discomfort until repositioning is complete.
Continue repositioning quickly to reduce time in discomfort.
Apply more force to complete the repositioning.
Stop the repositioning process and assess the cause of discomfort.
The Correct Answer is D
A. Asking the patient to tolerate discomfort ignores their immediate needs and can cause pain, injury, or loss of trust.
B. Continuing quickly does not address the underlying cause of discomfort and may increase the risk of harm.
C. Applying more force is unsafe, can cause injury, and disregards the patient’s reported discomfort.
D. The most appropriate action is to stop the repositioning process and assess the cause of discomfort. This ensures patient safety, identifies potential issues such as pressure points, contractures, or pain from medical conditions, and allows the nurse to adjust the technique or provide pain management before continuing. Patient-centered care prioritizes comfort and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The length of time spent washing hands is the most important factor in effective hand hygiene. Proper technique with adequate duration (at least 20 seconds with soap and water or until hand rub dries) ensures removal of pathogens and reduces the risk of infection transmission.
B. While the type of soap or hand rub matters, standard non-antibacterial soap is generally sufficient if proper technique and time are used; the duration and thoroughness are more critical.
C. Using antibacterial soap is not required for routine hand hygiene and does not significantly improve effectiveness over regular soap with proper technique.
D. Water temperature does not significantly impact the removal of pathogens; it mainly affects comfort. Effective hand hygiene relies on mechanical friction and adequate washing time, not water temperature.
Correct Answer is D
Explanation
A. A post-operative day one client requires close monitoring by licensed nursing staff due to the risk of complications; vital signs in this situation are not appropriate to delegate.
B. A client experiencing chest pain requires immediate assessment and intervention by a nurse; delegating vital signs could delay recognition of life-threatening changes.
C. A client receiving a blood transfusion needs continuous monitoring by a nurse to detect adverse reactions; vital signs should not be delegated.
D. A stable client in a long-term care facility has predictable and low-risk needs, making it appropriate to delegate vital signs to assistive personnel.
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