A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?
Have the client hold a pillow over the abdomen to cough and deep breathe.
Encourage the client to eat all of the meals that are sent.
Offer fruit juice at least twice during both the day and evening shifts.
Lower the bed prior to helping the client to move up in bed.
The Correct Answer is D
Choice A: Have the client hold a pillow over the abdomen to cough and deep breathe is not the most important instruction because it is not related to repositioning. This is a good practice to prevent respiratory complications after surgery, but it can be done at any time.
Choice B: Encourage the client to eat all of the meals that are sent is not the most important instruction because it is not related to repositioning. This is a good practice to promote nutrition and healing after surgery, but it can be done at any time.
Choice C: Offer fruit juice at least twice during both the day and evening shifts is not the most important instruction because it is not related to repositioning. This is a good practice to prevent dehydration and constipation after surgery, but it can be done at any time.
Choice D: Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because positioning the head with the chin tilted slightly downward can help prevent aspiration by closing the airway and directing food to the back of the throat.
Choice B Reason: This is incorrect because raising the head of the bed to 60 degrees can help prevent aspiration by using gravity to keep food in the stomach and away from the lungs.
Choice C Reason: This is incorrect because placing food on the unaffected side of the mouth can help prevent aspiration by stimulating the intact nerves and muscles that control swallowing.
Choice D Reason: This is correct because allowing 30 minutes of rest before feeding can increase the risk of aspiration by reducing the client's alertness and coordination. The UAP should feed the client when he or she is awake and responsive.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.
Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.
Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.
Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.
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