A nurse is evaluating a nursing student's understanding of positioning clients. Which of the following statements indicates a need for further teaching?
Positioning a client in good body alignment and changing the position regularly (every 3 hours) and systematically are essential aspects of nursing practice.
"Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures."
"Any position, correct or incorrect, can be detrimental if maintained for a prolonged period."
"For all clients, it is important to assess the skin and provide skin care before and after a position change.
The Correct Answer is A
This statement indicates a need for further teaching because it is not accurate. Positioning a client in good body alignment and changing the position regularly are essential aspects of nursing practice, but the position should be changed more frequently than every 3 hours. It is generally recommended to reposition clients at least every 2 hours to prevent pressure ulcers and other complications. The other options (Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures; Any position, correct or incorrect, can be detrimental if maintained for a prolonged period; and For all clients, it is important to assess the skin and provide skin care before and after a position change) are accurate statements and do not indicate a need for further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
According to Kubler-Ross's stages of grieving, denial is the first stage. It is a defense mechanism that helps individuals cope with the overwhelming emotions associated with loss. In this case, the client is refusing to believe that the loss of her husband is happening and is likely experiencing denial as a way to cope with her grief
Correct Answer is A
Explanation
When providing education to a postoperative client on how to use an incentive spirometer, an accurate step that should be included in the education plan is to instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose ¹⁴. This helps the client to take deep breaths and fully expand their lungs. The other options (Instruct the client to inhale normally and then place the lips securely around the mouthpiece, Encourage the client to perform incentive spirometry 2 to 3 times every 1 to 2 hours, if possible, and When the client cannot inhale anymore, the client should hold his breath and count to 10) are not accurate steps that should be included in the education plan.
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