A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?
Supine in low-Fowler's position
Side-lying with the right side of the chest elevated
Right lateral in Trendelenburg position
Prone with pillows under the lower extremities
The Correct Answer is C
a. Supine in low-Fowler's position - This position is not effective for draining the left lower lobe.
b. Side-lying with the right side of the chest elevated - This position would not effectively drain the left lower lobe.
c. Right lateral in Trendelenburg position - This is correct. Placing the client on their right side with the chest lower than the hips (Trendelenburg position) helps gravity assist in draining secretions from the left lower lobe.
d. Prone with pillows under the lower extremities - This position would not be effective for draining the left lower lobe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use trochanter rolls beside the client's legs:
Trochanter rolls are positioning devices placed alongside the thighs to prevent external rotation of the hips when a client is lying supine. This helps maintain proper alignment and prevents hip contractures, especially in clients who are immobile.
B. Logroll the client every 4 hr:
Logrolling is a technique used to turn a client with spinal precautions, such as after spinal surgery or injury. It involves turning the entire body as a unit to avoid twisting the spine. However, in a general plan of care for an immobile client, logrolling every 4 hours may not be necessary unless there are specific medical indications.
C. Place the client's arms at their side when turning them:
Placing the client's arms at their side may not be the most optimal positioning during turns, as it can contribute to joint contractures. The nurse should consider positioning the arms in a manner that maintains joint flexibility and prevents contractures.
D. Cross the client's ankles when lying supine:
Crossing the client's ankles when lying supine is not a recommended practice. It can lead to pressure on the lateral aspect of the knees and ankles, potentially causing discomfort and impairing circulation. It is important to maintain proper alignment and support for the client's lower extremities.
Correct Answer is B
Explanation
A. "I will move your joints to the point of mild pain":
This statement is incorrect. Passive range-of-motion exercises should not cause pain. The goal is to move the joints within their natural range of motion without causing discomfort or harm to the client. If pain occurs, the nurse should stop the movement and assess for any underlying issues.
B. "I will repeat these movements 3 to 5 times":
This is the correct statement. Passive range-of-motion exercises involve moving the client's joints through their range of motion without the client actively participating. Repeating the movements 3 to 5 times helps prevent joint stiffness and maintain flexibility without causing excessive strain or fatigue.
C. "These movements will be performed once per day":
This statement is less optimal. While performing passive range-of-motion exercises once a day may be beneficial, incorporating them into the client's routine more frequently, such as several times a day, can provide additional benefits in preventing joint contractures and maintaining joint function.
D. "I will move your joints quickly":
This statement is incorrect. Passive range-of-motion exercises should be performed slowly and gently. Moving the joints too quickly may cause discomfort or injury. The emphasis is on smooth, controlled movements to promote joint flexibility without causing harm.
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