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 D
Explanation
A normal state of awareness is characterized by being aware of oneself and one's surroundings. In this case, a nurse would document the client's condition as being "aware of self and environment" to indicate that the client has a normal state of awareness.
Correct Answer is C
Explanation
Subjective data refers to information that is reported by the client and cannot be directly observed or measured by the healthcare provider. In this case, the statement "leave me alone" is an example of subjective data that the nurse should document. This information provides insight into the client's feelings and emotions and can help guide the nurse's care and interventions.
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