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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice a reason: A 3 mL syringe is the most accurate device for measuring a 2 mL dose of a viscous liquid solution due to its design and gradation precision. Syringes provide clearly marked measurement lines, allowing for highly accurate dosing, especially for amounts as small as 2 mL. For viscous liquids, the controlled plunger mechanism of a syringe ensures smooth and consistent measurement and delivery. This is critical in nursing practice, as even slight deviations in medication dosing can lead to therapeutic failures or adverse effects. Additionally, syringes are designed to handle a variety of liquid viscosities, reducing the likelihood of measurement errors caused by sticking or uneven flow. By eliminating the need for visual estimation common with other tools, the syringe minimizes user error and enhances patient safety. The 3 mL capacity ensures the nurse can measure the exact dose without overloading or underutilizing the equipment, maintaining both precision and ease of use.

Choice b reason: A one-ounce medicine cup is less accurate for measuring a 2 mL dose due to its relatively larger size and less precise measurement gradations. Medicine cups are typically designed for measuring larger volumes, such as 5 mL, 15 mL, or more, and are not ideal for small doses. The wide surface area and less detailed markings make it difficult to accurately align the liquid level to the desired measurement, especially for small amounts like 2 mL. This can result in over- or under-dosing, which is particularly problematic when administering potent medications. Additionally, the open design of medicine cups may make pouring viscous liquids challenging, as the liquid may stick to the sides of the cup, leading to further inaccuracies. While convenient for larger doses or liquid mixtures, the medicine cup does not offer the precision required for small, specific dosages in clinical practice.

Choice c reason: A tuberculin syringe, which has a capacity of 1 mL, is specifically designed for administering very small doses, such as subcutaneous or intradermal injections. Using it for a 2 mL dose is impractical and could lead to dosing errors. The nurse would need to fill the syringe twice to administer the full 2 mL, increasing the risk of cumulative measurement inaccuracies. This approach is also time-consuming and may lead to wastage of the medication, as viscous liquids can leave residue inside the syringe, further complicating the dose calculation. Additionally, the markings on a tuberculin syringe are optimized for fractions of a milliliter, not for whole milliliter increments, making it unsuitable for measuring a 2 mL dose. Using this tool for a dose beyond its designed capacity contradicts best practices in nursing, which emphasize using equipment tailored to the specific requirements of the medication and patient.

Choice d reason: Using a 3 mL syringe with a sterile needle is unnecessary and not recommended for administering an oral medication. While the 3 mL syringe itself is suitable for measuring a 2 mL dose, the inclusion of a sterile needle is irrelevant and introduces an additional risk of improper administration. Oral medications are not meant to be injected, and the presence of a needle could lead to accidental use or injury. Furthermore, sterile needles are specifically intended for invasive procedures, such as intramuscular or intravenous injections, and their inclusion in an oral medication protocol is not only superfluous but also contraindicated. The presence of the needle complicates the preparation process without providing any benefit, detracting from the simplicity and efficiency of administering the medication orally. In nursing practice, ensuring that the equipment matches the route of administration is crucial to patient safety and protocol adherence.

A. "Tell me about the visit with your significant other." B. "Would you like to talk for a little while?" C. "What did you enjoy about your visit tonight?" D. "I can see that you are feeling lonely." E. None F. None

Correct Answer is A

Explanation

Choice A reason: This is the most therapeutic response as it invites the client to share her feelings and thoughts about the visit. It also shows the nurse's interest and empathy for the client.

Choice B reason: This is a less therapeutic response as it is vague and non-specific. It does not address the client's behavior or mood. It also puts the burden on the client to initiate the conversation.

Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.

Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 equipment should the nurse use to most accurately measure a 2 mL dose of viscous liquid solution to be administered orally?

Correct Answer is A

Explanation

A female client assigned to a mental health unit visits with her significant other during the evening. After the significant other leaves, the nurse notices that the client is more isolative and refuses to attend the evening group. Which response by the nurse is most therapeutic?

Correct Answer is A

Explanation

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

The nurse is entering prescriptions for lab work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

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)?

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?