A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

30° lateral.

Lateral semi-prone recumbent.

Supine.

45° supported Fowler's.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. 30° lateral.

Choice A rationale:

The 30° lateral position is recommended to reduce pressure on the client’s bony prominences. This position helps distribute the client’s weight more evenly and reduces the risk of pressure injury formation.

Choice B rationale:

The lateral semi-prone recumbent position may not be as effective in reducing pressure on bony prominences as the 30° lateral position. It could potentially increase pressure on certain areas, depending on the client’s body shape and condition.

Choice C rationale:

The supine position can increase pressure on the sacrum and heels, which are common sites for pressure injuries. Therefore, it is not the best position for a client at risk for pressure injury formation.

Choice D rationale:

The 45° supported Fowler’s position can increase pressure on the sacrum and ischial tuberosities, another common site for pressure injuries. Therefore, it is not the most effective position for reducing pressure on bony prominences for a client at risk for pressure injury formation.

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Correct Answer is C

Explanation

Choice A rationale:

Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.

Choice B rationale:

Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.

Choice C rationale:

Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.

Choice D rationale:

Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.

A. Send the unused portion to the pharmacy. B. Have a second nurse verify disposal of the unused portion. C. Keep the unused portion in the client's medication drawer. D. Return the unused portion to the locked narcotics storage location.

Correct Answer is D

Explanation

When handling an unused portion of an oral opioid analgesic after administration, the nurse should take the following action:

D) Return the unused portion to the locked narcotics storage location.

Returning the unused portion to the locked narcotics storage location is a crucial step to ensure proper control and documentation of controlled substances like opioids. It helps prevent diversion and ensures the security and accountability of these medications.

Options A, B, and C are not appropriate:

A) Sending the unused portion to the pharmacy is not typically the responsibility of the nurse, and it may not be a practical or safe option for controlled substances.

B) Having a second nurse verify disposal of the unused portion is not a standard practice for oral medication administration.

C) Keeping the unused portion in the client's medication drawer is not an appropriate method of handling unused controlled substances, as it lacks the necessary security and accountability measures.

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A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is preparing to administer an oral opioid analgesic to a client. Which of the following actions should the nurse take when handling an unused portion of the medication after administration?

Correct Answer is D

Explanation

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