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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Reviewing the chart for number of voids over the last 24 hours is not the best action to evaluate the client for urinary retention. It may provide some information about the client's urinary pattern, but it does not indicate the amount of urine left in the bladder after voiding.
Choice B reason: Palpating the suprapubic region for distention is a useful action to assess the client for urinary retention, but it is not the most accurate or reliable method. It may be difficult to palpate the bladder if the client is obese, has abdominal pain, or has bowel distention.
Choice C reason: Evaluating the client for urinary incontinence is not relevant to the assessment of urinary retention. Urinary incontinence is the involuntary loss of urine, while urinary retention is the inability to empty the bladder completely.
Choice D reason: Scanning the client's bladder after voiding is the best action to evaluate the client for urinary retention. It is a noninvasive and precise technique that measures the post-void residual urine volume. A normal post-void residual is less than 50 mL, while a high post-void residual indicates urinary retention.
Correct Answer is C
Explanation
Choice A reason: Reviewing the advanced directive document is not the priority action. The nurse should first intervene to clear the airway and prevent aspiration of vomitus.
Choice B reason: Elevating the head of the bed 45 degrees is a good practice, but it is not sufficient to relieve the choking. The nurse should also perform suctioning to remove the vomitus from the mouth and throat.
Choice C reason: Performing oropharyngeal suctioning is the best action as it helps to clear the airway and prevent aspiration of vomitus. The nurse should use a Yankauer suction catheter and apply intermittent suction while moving the catheter around the mouth and throat.
Choice D reason: Irrigating the nasogastric tube with water is not appropriate as it may worsen the vomiting and choking. The nurse should stop the enteral feeding and clamp the tube until the client's condition is stabilized.
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