A nurse and an assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions?
Lower the client's bed to the lowest position.
Stand next to the client's shoulders.
Place a small pillow under the client's head.
Flex his hips while pulling the client.
The Correct Answer is D
The correct answer is D.
Flex his hips while pulling the client. The nurse and AP should use proper body mechanics when repositioning a client to prevent injury and promote comfort. Flexing the hips while pulling the client reduces strain on the back muscles and allows for greater leverage.
The nurse and AP should raise the bed to a comfortable working height, not lower it to the lowest position. The nurse and AP should stand on opposite sides of the bed near the client's hips, not shoulders. The nurse and AP should remove any pillows under or around the client before repositioning him.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Neonatal Infant Pain Scale (NIPS): The NIPS is a widely used and validated pain assessment tool specifically designed for newborns, including full-term infants like the 38-week gestation newborn in this case. It evaluates behavioral indicators such as facial expressions, crying, arm and leg movement, and physiological indicators like breathing patterns.
B. FACES pain rating scaleis designed for older children who can self-report pain by selecting a facial expression corresponding to their level of discomfort. It is not suitable for newborns who cannot self-report their pain.
C. Premature Infant Pain Profile (PIPP):The PIPP is specifically designed for preterm infants (less than 37 weeks of gestation) and assesses pain based on behavioral and physiological indicators.
D. Visual Analog Scale (VAS): The VAS requires a client to self-report their pain by indicating a point along a continuum, which is not appropriate for newborns.
Correct Answer is B
Explanation
Answer: B. Location of the identification tag on the client's body
Rationale: The nurse should document the location of the identification tag on the client's body to ensure proper identification and prevent errors or mix-ups during transport or autopsy. The last set of vital signs, the copy of advance directives, and the cause of death are not part of the postmortem documentation but rather part of the medical record or death certificate.
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