A client who had surgery 3 days ago is sitting with the head of the 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)?

Lower the bed prior to helping the client to move up in bed.

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.

Have the client hold a pillow over the abdomen to cough and deep breathe.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important instruction because lowering the bed reduces the risk of injury to both the client and the UAP. It also makes it easier for the UAP to use proper body mechanics and leverage when assisting the client to move up in bed.

Choice B reason: This is not the most important instruction because encouraging the client to eat all of the meals that are sent is not directly related to repositioning the client. While adequate nutrition is important for wound healing and recovery, the nurse should assess the client's appetite, dietary needs, and preferences before instructing the UAP to encourage the client to eat.

Choice C reason: This is also not the most important instruction because offering fruit juice at least twice during both the day and evening shifts is not directly related to repositioning the client. While adequate hydration is important for preventing constipation and promoting circulation, the nurse should consider the client's fluid status, blood sugar levels, and potential interactions with medications before instructing the UAP to offer fruit juice.

Choice D reason: This is another incorrect instruction because having the client hold a pillow over the abdomen to cough and deep breathe is not directly related to repositioning the client. While coughing and deep breathing are important for preventing respiratory complications and promoting oxygenation, the nurse should instruct the client to perform these exercises at regular intervals, not only when repositioning.

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Correct Answer is A

Explanation

Choice A reason: This is the best explanation as it describes the main goal of the log-rolling technique, which is to prevent twisting or bending of the spine. This is especially important for clients who have spinal injuries, surgeries, or disorders.

Choice B reason: Using two or three people is a part of the log-rolling technique, but it is not the purpose of it. It is a means to achieve the purpose of maintaining spinal alignment. It also ensures that the client is moved smoothly and gently.

Choice C reason: Working together can decrease the risk of back injury to the nurses, but it is not the purpose of the log-rolling technique. It is a benefit for the nurses, but not for the client. The nurse should focus on the client's needs and outcomes.

Choice D reason: Turning instead of pulling reduces the likelihood of skin damage, but it is not the purpose of the log-rolling technique. It is an advantage for the client, but not the main reason for using the technique. The nurse should explain how the technique affects the spine, not the skin.

A. Placing a client in restraints without having a healthcare provider's order. B. Informing a client that the medication being administered is a vitamin. C. Enlisting security personnel to assist with restraining the client. D. Administering the medication to a client behind a closed curtain.

Correct Answer is B

Explanation

Choice A reason: Placing a client in restraints without having a healthcare provider's order is not a tort, but a violation of the client's rights. The nurse should obtain an order for restraints as soon as possible and follow the facility's policy and procedure.

Choice B reason: Informing a client that the medication being administered is a vitamin is a tort, specifically a fraud. The nurse is deceiving the client and violating the principle of informed consent. The nurse should explain the purpose, benefits, and risks of the medication to the client and obtain the client's consent.

Choice C reason: Enlisting security personnel to assist with restraining the client is not a tort, but a prudent action. The nurse is ensuring the safety of the client and others by seeking help from trained staff. The nurse should document the incident and the rationale for the intervention.

Choice D reason: Administering the medication to a client behind a closed curtain is not a tort, but a respectful action. The nurse is maintaining the client's privacy and dignity by providing a quiet and secluded environment. The nurse should monitor the client's response and report any adverse effects.

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A client who had surgery 3 days ago is sitting with the head of the 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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

Correct Answer is A

Explanation

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Correct Answer is B

Explanation

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