A nurse is caring for a client who has a closed head injury. In which of the following positions should the nurse place the client?
Sims
Modified Trendelenburg
Semi-Fowler's
Prone
The Correct Answer is C
Choice A: This is incorrect because Sims position is used for clients who have lower back pain, abdominal surgery, or enemas. It is not appropriate for clients who have a closed head injury.
Choice B: This is incorrect because modified Trendelenburg position is used for clients who have hypovolemic shock or poor venous return. It is not appropriate for clients who have a closed head injury.
Choice C: This is correct because semi-Fowler's position is used for clients who have increased intracranial pressure, respiratory distress, or head trauma. It elevates the head and chest to reduce cerebral edema and facilitate breathing.
Choice D: This is incorrect because prone position is used for clients who have acute respiratory distress syndrome, spinal cord injury, or pressure ulcers. It is not appropriate for clients who have a closed head injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Passing of flatus is not a reliable indicator of colostomy function, as it can occur even when there is an obstruction or ischemia in the bowel.
Choice B reason: Stoma is pinkish-red is a sign of a healthy and well-perfused colostomy, as it indicates that the blood supply to the bowel segment is adequate and there is no necrosis or infection.
Choice C reason: Tolerating a clear liquid diet is not a specific indicator of colostomy function, as it does not reflect the amount or consistency of the stool output.
Choice D reason: Absent bowel sounds are not a normal finding for a colostomy, as they can indicate a paralytic ileus or a bowel obstruction, which can cause complications such as distension, pain, or perforation.
Correct Answer is D
Explanation
Choice A reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room is not an appropriate action. The nurse should dispose of contaminated materials in a biohazard container inside the client's room to prevent the spread of infection.
Choice B reason: Administering antibiotic therapy before culturing the client's wound is not an appropriate action. The nurse should obtain a wound culture before starting antibiotic therapy to ensure accurate results and avoid altering the microorganisms present in the wound.
Choice C reason: Instructing visitors to perform hand hygiene for 15 seconds after leaving the client's room is not an appropriate action. The nurse should instruct visitors to perform hand hygiene for at least 20 seconds before and after entering the client's room to reduce the risk of transmitting infection.
Choice D reason: Placing the client in a private room with a private bathroom is an appropriate action. The nurse should implement contact precautions for a client who has an infectious wound with foul-smelling drainage to prevent cross-contamination and protect other clients and staff from exposure.
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