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 B

Explanation

Choice A reason: Consulting with the dietitian to learn if the client is allowed to drink coffee is not the best action to take. The nurse should already know the components of a clear liquid diet, which do not include coffee. Coffee is a stimulant that can irritate the gastrointestinal tract and interfere with the healing process.

Choice B reason:This is the correct action. A clear liquid diet allows for transparent liquids that leave no residue, such as black coffee. Adding milk or creamer would render the coffee opaque, making it unsuitable for a clear liquid diet. Therefore, it's appropriate to remind the client to consume the coffee without any additives.

Choice C reason: Determining which member of the nursing staff brought the cup of coffee to the client is not a priority action to take. The nurse should focus on the client's safety and well-being, not on assigning blame or finding fault. The nurse can address the issue with the staff later, after ensuring the client's needs are met.

Choice D reason: Removing the coffee is unnecessary, as black coffee is permitted on a clear liquid diet. Instead, the nurse should ensure the client understands not to add any prohibited substances like milk or creamer.

A. Neuropathic pain B. Visceral pain C. Acute pain D. Nociceptive pain

Correct Answer is A

Explanation

Choice A reason: Neuropathic pain is caused by damage or dysfunction of the nervous system. It is often described as burning, shooting, or tingling sensations. The client's symptoms are consistent with neuropathic pain.

Choice B reason: Visceral pain is caused by stimulation of pain receptors in the internal organs. It is often described as deep, dull, or cramping sensations. The client's symptoms are not consistent with visceral pain.

Choice C reason: Acute pain is caused by a sudden or short-term injury or illness. It is often described as sharp, throbbing, or stabbing sensations. The client's symptoms are not consistent with acute pain.

Choice D reason: Nociceptive pain is caused by stimulation of pain receptors in the skin, muscles, bones, or joints. It is often described as aching, sore, or pressure sensations. The client's symptoms are not consistent with nociceptive pain.

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

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is B

Explanation

A client reports pain, numbness, and tingling sensations in the lower legs. How should the nurse document this finding?

Correct Answer is A

Explanation

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

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?

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?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?