Which nursing action should be implemented first when assisting the patient to a lateral position for placement of a bedpan?

Move the patient to the side of the bed.

Place the patient's arm over the chest.

Raise the bed to a proper working height.

Turn the patient using the draw sheet.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Moving the patient to the side of the bed is the first nursing action that should be implemented when assisting the patient to a lateral position for placement of a bedpan. This step ensures proper body mechanics and patient safety during the transfer. The nurse should assist the patient to the edge of the bed, farthest from them, and then help the patient turn onto their side, facing away from the nurse. This position facilitates the placement of the bedpan and maintains the patient's dignity and comfort.

Choice B rationale:

Placing the patient's arm over the chest is a subsequent step after moving the patient to the side of the bed. After the patient is in the lateral position, the nurse should assist in placing the uppermost arm comfortably over the chest to maintain balance and stability during the bedpan placement.

Choice C rationale:

Raising the bed to a proper working height is essential for the nurse's ergonomic safety and comfort during the procedure. However, it is not the first step in assisting the patient to a lateral position. The bed should be at a height that allows the nurse to work comfortably without straining their back, but this step comes after the patient has been safely positioned on their side.

Choice D rationale:

Turning the patient using the draw sheet is another appropriate technique for repositioning patients, especially when they are unable to assist with the movement. However, in this scenario, the nurse needs to assist the patient to a lateral position for the bedpan placement, which involves different techniques. Using a draw sheet might be necessary in other situations, such as when turning a bedridden patient in bed, but it is not the first action for placing a bedpan.

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Correct Answer is C

Explanation

Choice A rationale:

During inhalation, carbon dioxide levels are lower in the alveoli due to the exchange of gases. The higher concentration of carbon dioxide is found in the blood, which diffuses into the alveoli for elimination during exhalation.

Choice B rationale:

Alveoli do not collapse during the inhalation cycle. Surfactant, a substance produced by type II alveolar cells, reduces surface tension and prevents alveoli from collapsing, ensuring efficient gas exchange.

Choice C rationale:

Oxygen moves from the alveoli to the capillaries, while carbon dioxide moves from the capillaries to the alveoli. This exchange of gases occurs due to differences in partial pressures, facilitating the uptake of oxygen by red blood cells and the removal of carbon dioxide from the body.

Choice D rationale:

Exhaling carbon dioxide is a passive process that does not require significant effort. The respiratory muscles relax during exhalation, allowing the lungs to passively expel carbon dioxide from the body as a waste product of metabolism.

A. Maintain the patient in a supine position during rest. B. Monitor the client's oxygen saturation hourly. C. Ambulate the client in the hall four times daily. D. Encourage high protein foods during mealtime.

Correct Answer is B

Explanation

Choice A rationale:

Maintaining the patient in a supine position during rest would not be appropriate for a client with shortness of breath. This position can worsen breathing difficulties, especially in clients with respiratory issues. It reduces lung expansion and can lead to increased work of breathing.

Choice B rationale:

Monitoring the client's oxygen saturation hourly is the appropriate intervention for a client with shortness of breath. Oxygen saturation (SpO2) levels indicate the percentage of oxygen bound to hemoglobin in the blood. Monitoring SpO2 levels helps assess the client's oxygenation status and provides crucial information about the effectiveness of respiratory interventions. Normal oxygen saturation levels typically range between 95% to 100%. Monitoring allows timely recognition of hypoxemia, enabling prompt intervention to improve oxygenation and prevent complications.

Choice C rationale:

Ambulating the client in the hall four times daily may not be suitable for a client experiencing shortness of breath, as it can exacerbate respiratory distress. Ambulation increases oxygen demand and can further compromise oxygenation in individuals struggling to breathe.

Choice D rationale:

Encouraging high protein foods during mealtime is unrelated to the immediate management of shortness of breath. While proper nutrition is essential for overall health and healing, it does not directly address the acute issue of respiratory distress.

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Which nursing action should be implemented first when assisting the patient to a lateral position for placement of a bedpan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement regarding the anatomy and physiology of the respiratory system is correct?

Correct Answer is C

Explanation

Which intervention would be appropriate for a client with shortness of breath?

Correct Answer is B

Explanation

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