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 B
Explanation
Choice A Reason: This is incorrect because hematocrit is a measure of the percentage of red blood cells in the blood, which can indicate anemia or polycythemia, but not infection.
Choice B Reason: This is correct because neutrophil count is a measure of the number of neutrophils, which are white blood cells that fight infection and inflammation. A high neutrophil count can indicate a bacterial infection, such as in the wound.
Choice C Reason: This is incorrect because serum potassium and sodium levels are measures of the electrolyte balance in the blood, which can indicate dehydration, fluid overload, or kidney dysfunction, but not infection.
Choice D Reason: This is incorrect because blood pH level is a measure of the acidity or alkalinity of the blood, which can indicate acidosis or alkalosis, but not infection.
Correct Answer is A
Explanation
Choice A: Notify the healthcare provider is the correct action because it is the nurse's responsibility to report any medication errors or adverse reactions to the prescriber as soon as possible.
Choice B: Document the event on the chart is not the next action because it should be done after notifying the healthcare provider and completing an incident report.
Choice C: Complete an incident report is not the next action because it should be done after notifying the healthcare provider and before documenting the event on the chart.
Choice D: Inform the nurse on the next shift is not the next action because it should be done after documenting the event on the chart and during handoff.
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