A nurse is caring for a client who has a thoracic spine injury. Which of the following actions should the nurse take when turning the client?
Place a pillow under the client's knees when changing positions.
Use a sheet when repositioning the client onto his side.
Apply an immobilizing collar on the client prior to movement.
Instruct the client to keep his arms at his side when altering positions.
The Correct Answer is B
Rationale:
A. Place a pillow under the client's knees when changing positions: Elevating the knees with a pillow may be appropriate for comfort, but in a client with a thoracic spine injury, this can alter spinal alignment and increase the risk of further injury. Maintaining proper spinal alignment during all movements is more important than knee elevation.
B. Use a sheet when repositioning the client onto his side: Using a sheet for logrolling or turning helps maintain spinal alignment and allows multiple caregivers to move the client safely as a unit. This technique minimizes rotation or flexion of the spine, which is critical in preventing further spinal cord injury in clients with thoracic spine trauma.
C. Apply an immobilizing collar on the client prior to movement: Cervical collars are used for cervical spine injuries, not thoracic spine injuries. Applying a collar would not stabilize the thoracic spine and could give a false sense of security while performing repositioning.
D. Instruct the client to keep his arms at his side when altering positions: The client may need to assist in turning if possible, and keeping the arms rigidly at the side is not necessary. Restricting arm movement does not ensure spinal safety and may limit the client’s ability to participate safely in repositioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Slow down the oxytocin infusion: Contractions occurring every 50 seconds and lasting 2 minutes indicate severe uterine hyperstimulation, which reduces placental blood flow and contributes to late decelerations. Slowing or stopping the oxytocin helps decrease contraction intensity and frequency, improving fetal oxygenation.
B. Administer oxygen at 2 L/min per nasal cannula: Oxygen administration can support fetal oxygenation, but 2 L/min via nasal cannula delivers minimal benefit in an acute distress situation. Oxygen would be used as a supportive measure after correcting the cause of the late decelerations. The first action is reducing uterine activity by adjusting the oxytocin infusion.
C. Place the client in a lithotomy position for delivery: Lithotomy positioning is used during the second stage of labor but is inappropriate when the fetus shows signs of distress. It does not relieve uterine hyperstimulation or improve placental blood flow. Positioning that enhances perfusion, such as side-lying, would be more beneficial after reducing the oxytocin.
D. Increase the rate of IV fluid infusion of lactated Ringers: Increasing IV fluids may help improve maternal circulation, but it does not directly resolve contractions that are too frequent or prolonged. Fluids can be an adjunct intervention but should not occur before decreasing oxytocin in the presence of late decelerations.
Correct Answer is ["A","B","C","D","F"]
Explanation
Rationale:
A. WBC count: The client’s WBC decreased from 33,000/mm³ on postpartum day 3 to 10,000/mm³ on day 5, indicating resolution of the infection and an appropriate response to antibiotic therapy. This reflects improvement in the client’s inflammatory and immune status.
B. Fundal height: The fundus has descended from 1 cm above the umbilicus to 4 cm below the umbilicus and remains firm and midline, demonstrating normal uterine involution and a return toward pre-pregnancy size, indicating recovery from postpartum changes.
C. Temperature: The client’s temperature decreased from 38.6° C on day 3 to 37.1° C on day 5, showing resolution of the febrile response associated with infection and stabilization of her overall condition.
D. Lochia: The lochia changed from moderate, dark brown, foul-smelling on day 3 to a small amount of brownish-red, odorless lochia on day 5, reflecting improvement in uterine healing and the absence of ongoing infection.
E. Hgb: The client’s hemoglobin decreased slightly from 11.1 g/dL to 10 g/dL. While slightly lower, it remains above critical levels and is not an indicator of improvement; in fact, it shows a mild drop, likely from blood loss during delivery, so it is not considered a sign of recovery.
F. Heart rate: The client’s heart rate decreased from 110/min on day 3 to 78/min on day 5, indicating resolution of tachycardia associated with infection, pain, or stress, and reflecting stabilization of cardiovascular status.
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