A nurse is assisting a coworker with moving a client up in bed using a draw sheet. Which of the following actions should the nurse take?

Place both feet apart and shift from the back to the front leg when moving the client up in bed.

Position the client's arms at their sides prior to moving them up in bed.

Elevate the head of the client's bed 30° prior to moving the client.

Bend at the waist when grasping the draw sheet when moving the client up in bed.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This choice reflects the correct technique for maintaining balance and using proper body mechanics when assisting with moving a client up in bed. Shifting weight from the back to the front leg while keeping the feet apart provides a stable base and reduces the risk of injury to the nurse.

Choice B rationale:

Positioning the client's arms at their sides before moving them up in bed is not a necessary step and may not contribute significantly to the process. The primary focus should be on proper body mechanics and the use of assistive devices, such as a draw sheet, to ensure safe patient handling.

Choice C rationale:

Elevating the head of the client's bed 30° is not directly related to the task of moving the client up in bed using a draw sheet. While head elevation might have other clinical indications, it does not impact the technique of assisting with repositioning.

Choice D rationale:

Bending at the waist when grasping the draw sheet is incorrect body mechanics and can lead to strain on the nurse's back. Proper technique involves using the legs to bend and lift while keeping the back straight, reducing the risk of injury.

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Correct Answer is D

Explanation

The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Choice A rationale:

Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.

Choice B rationale:

Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.

Choice C rationale:

Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.

Choice D rationale:

Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.

A. Request additional information about the caller's relationship to the client. B. Provide a general update about the client's condition over the telephone. C. Refer the family member to the client's provider for the update. D. Encourage the family member to contact the client directly for information.

Correct Answer is C

Explanation

Choice A rationale:

Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.

Choice B rationale:

Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.

Choice C rationale:

Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.

Choice D rationale:

Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.

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A nurse is assisting a coworker with moving a client up in bed using a draw sheet. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

Correct Answer is D

Explanation

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

Correct Answer is C

Explanation

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A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

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