Which position should be avoided in a patient who is at risk for pressure ulcers?

Supine position with heels elevated

High Fowler's position

30-degree lateral position

Prone position

Answer and Explanation

The Correct Answer is B

A. Supine position with heels elevated reduces pressure on the heels and is safe for patients at risk for pressure ulcers.

B. High Fowler’s position should be avoided because it increases pressure on the sacrum and coccyx, and the friction and shear forces from sliding down in bed elevate the risk of pressure ulcer development.

C. A 30-degree lateral position redistributes pressure and is recommended for patients at risk of pressure injuries.

D. Prone position relieves pressure from the sacrum and heels but may increase pressure on the knees or face; proper support can mitigate these risks.

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Correct Answer is A

Explanation

A. An oxygen saturation of 89% is below the normal range (typically 95–100%) and indicates hypoxemia. The nurse should immediately take action to improve oxygenation, such as increasing the oxygen flow rate as prescribed or notifying the provider if adjustments are needed.

B. Checking the client’s temperature is unrelated to acute low oxygen saturation and does not address the immediate risk of hypoxia.

C. Simply documenting the findings without intervention could allow the client’s oxygen levels to worsen, putting them at risk for organ dysfunction.

D. Assessing pain is important for overall care, but it does not address the urgent need to correct low oxygen saturation.

A. "The Patient Self-Determination Act (PSDA) will explain your rights to change lifesaving measures." B. "The case manager can make changes to the client's living will C. "The durable power of attorney for health care can cancel the client's living will." D. "The living will state the client's wishes regarding lifesaving measures."

Correct Answer is D

Explanation

A. The Patient Self-Determination Act (PSDA) informs clients of their right to make advance directives, but it does not grant family members the authority to change the client’s documented wishes once they are incapacitated.

B. A case manager does not have legal authority to alter a client’s living will; their role is to coordinate care, not to make decisions on behalf of the client.

C. The durable power of attorney for health care can make medical decisions only if the client is incapacitated and if the living will does not clearly address the situation. They cannot simply cancel the living will if it directly specifies the client’s wishes.

D. A living will legally documents the client’s preferences regarding lifesaving measures. The nurse should inform the family that the living will reflects the client’s decisions, which must be honored while the client is unable to communicate.

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Which position should be avoided in a patient who is at risk for pressure ulcers?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When taking vital signs, a nurse notes that a client's oxygen saturation is 89%. What should the nurse do next?

Correct Answer is A

Explanation

A nurse is caring for a client who is unconscious and has a living will. The client's family asks if they can make changes to lifesaving measures now that the client is unconscious. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who has a terminal diagnosis and a 3-month life expectancy. The client appears cheerful and states they are looking forward to a vacation next year. The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?

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