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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Lying down while practicing pursed-lip breathing is not the correct instruction. Pursed-lip breathing is usually performed in a sitting or standing position. Lying down can restrict lung expansion and may not effectively support the purpose of this breathing technique, which is to improve airway pressure and reduce air trapping.
Choice B rationale:
"Exhale slowly through your mouth" is the correct instruction for pursed-lip breathing. This technique involves inhaling through the nose for a count of two and exhaling slowly and steadily through pursed lips for a count of four. The goal is to promote better exhalation, prevent airway collapse, and improve oxygen exchange. The rationale behind this choice is grounded in the mechanics of pursed-lip breathing, which helps create backpressure in the airways, maintaining them open and aiding in proper exhalation.

Choice C rationale:
Inhaling through pursed lips contradicts the proper sequence of pursed-lip breathing. The technique involves inhaling through the nose and exhaling through pursed lips. Inhaling through pursed lips would not provide the intended benefits of the technique.
Choice D rationale:
"Puff your cheeks when exhaling" is not the correct instruction. Puffing the cheeks during exhalation does not contribute to the effectiveness of pursed-lip breathing. This action could potentially impede proper exhalation and defeat the purpose of the technique, which is to control airflow and improve breathing efficiency.
Correct Answer is A
Explanation
Choice A rationale:
Instructing the client to remain supine for 10 minutes after inserting a vaginal suppository helps ensure proper absorption of the medication. This position allows the suppository to stay in contact with the vaginal mucosa, promoting optimal drug absorption. This is an essential nursing action to maximize the therapeutic effect of the medication.
Choice B rationale:
Applying sterile gloves after cleansing the perineal area is not necessary when administering a vaginal suppository. While maintaining cleanliness is important, the use of sterile gloves is not typically required for this procedure. Clean, non-sterile gloves are sufficient to maintain aseptic technique during the administration.
Choice C rationale:
Inserting the suppository 3 to 4 cm (1 to 1.5 in) into the vagina is an appropriate depth for vaginal suppository insertion. The nurse should follow this guideline to ensure that the medication reaches the appropriate location within the vaginal canal, optimizing absorption and effectiveness.
Choice D rationale:
Placing the client in the lateral semi-prone recumbent position is not a standard position for administering a vaginal suppository. The suppository is typically administered with the client lying on their back (supine) to facilitate insertion and medication absorption. Placing the client in the position described would not provide the optimal angle for insertion.
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