A nurse is caring for a client who is immobile and is requesting assistance with a bedpan. Identify the sequence of actions the nurse should take to position the client on the bedpan. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Apply a small amount of powder to the buttocks.

Position the client on the bedpan.

Roll the client onto their side.

Elevate the head of the bed.

Answer and Explanation

The Correct Answer is C,A,B,D

Positioning an immobile client on a bedpan requires a safe, step-by-step approach that promotes dignity, prevents injury, and maintains spinal alignment. The nurse must use proper body mechanics and patient positioning techniques to avoid shearing forces, skin breakdown, and musculoskeletal strain. The sequence ensures the client is properly aligned before placement of the bedpan and that comfort measures are implemented to reduce friction and pressure. Safe bedpan placement is a fundamental skill in basic nursing care for dependent clients.

Rationale:

A. Dusting a small amount of powder (if not contraindicated) or ensuring the skin is dry reduces friction, making it easier for the client's skin to slide smoothly against the surface of the bedpan.

B. Place the bedpan firmly against the client's buttocks and roll the client back down onto it. For a standard bedpan, the wider, curved rim goes under the buttocks toward the lower back, and the narrower end points toward the feet.

C. Turn the client to the side away from you. This allows you to inspect the skin and easily access the sacral area while positioning the bedpan without causing friction or skin tearing.

D. Once the client is securely on the pan, raise the head of the bed to a semi-Fowler's position (30 to 60 degrees). This mimics a natural sitting position for elimination, uses gravity to assist, and prevents fluid from traveling backward up the back.

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Correct Answer is C

Explanation

Neonatal hyperbilirubinemia occurs when there is an excess buildup of bilirubin due to increased red blood cell breakdown and immature liver conjugation. Phototherapy is used to convert bilirubin into water-soluble isomers that can be excreted through urine and stool. Effective treatment requires maximizing skin exposure to light and ensuring even distribution of phototherapy. Nursing care focuses on hydration, thermoregulation, eye protection, and frequent repositioning.

Rationale:
A. Applying lotion to the newborn’s skin every 2 hours is contraindicated during phototherapy because it can increase skin absorption of heat and potentially interfere with light penetration. Lotions and oils may also cause overheating or skin irritation when exposed to phototherapy lights. Skin should remain clean and dry to allow effective bilirubin breakdown.

B. Obtaining a blood glucose level every 4 hours is not a routine requirement for newborns receiving phototherapy unless there is a specific risk factor for hypoglycemia. Phototherapy primarily affects bilirubin metabolism and fluid balance rather than glucose regulation. Monitoring should focus on bilirubin levels, hydration status, and temperature.

C. Repositioning the newborn every 2 to 3 hours is appropriate because it ensures maximum skin exposure to phototherapy light. Changing the infant’s position helps expose different body surfaces, improving the effectiveness of bilirubin breakdown. This intervention also promotes even treatment and prevents pressure-related complications.

D. Offering glucose water every 1 to 2 hours is not recommended because it can interfere with adequate nutritional intake and is not effective in treating hyperbilirubinemia. Breast milk or formula feeding is preferred to promote bowel movements and bilirubin excretion. Frequent feeding helps reduce enterohepatic circulation of bilirubin more effectively than glucose water.

A. "I will rub my hands together until they are dry when using an alcohol-based hand rub." B. "I will use a nail brush to clean under my artificial nails." C. "I should adjust the water temperature so that it is as hot as I can tolerate it when rinsing my hands." D. "I should wash my hands for 10 seconds."

Correct Answer is A

Explanation

Hand hygiene is the most effective method for preventing healthcare-associated infections and reducing transmission of microorganisms. Proper technique depends on whether soap and water or an alcohol-based hand rub is used. Alcohol-based hand rubs are preferred when hands are not visibly soiled because they rapidly reduce microbial load through protein denaturation. Correct technique requires adequate contact time and friction until the product fully evaporates.

Rationale:
A. Rubbing hands together until dry when using an alcohol-based hand rub demonstrates correct technique because adequate friction and contact time are required for effective microbial destruction. The solution must cover all hand surfaces and be allowed to air dry completely to ensure maximum antiseptic effect. This indicates understanding of proper hand hygiene with alcohol-based sanitizers.

B. Using a nail brush to clean under artificial nails is incorrect because artificial nails are discouraged in healthcare settings due to their association with increased microbial harboring. Nail brushes are not recommended as they can cause skin microabrasions that increase infection risk. Proper hand hygiene focuses on removing artificial nails rather than cleaning beneath them.

C. Adjusting water temperature to the hottest tolerable level is incorrect because excessively hot water can cause skin irritation and damage. Damaged skin increases the risk of microbial colonization and transmission. Effective handwashing depends on technique and duration rather than water temperature.

D. Washing hands for 10 seconds is incorrect because effective handwashing requires a minimum of 20 seconds of scrubbing with soap and water. Shorter durations are insufficient to remove transient microorganisms from the hands. Proper timing is essential to achieve adequate mechanical removal of pathogens.

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A nurse is caring for a client who is immobile and is requesting assistance with a bedpan. Identify the sequence of actions the nurse should take to position the client on the bedpan. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is discussing hand hygiene with an assistive personnel (AP). Which of the following statements by the AP indicates an understanding of the teaching?

Correct Answer is A

Explanation

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