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
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Correct Answer is A
Explanation
In this situation, the nurse is performing the role of an educator. The nurse is explaining the procedures for preventing infection in a central venous access device to the spouse and demonstrating how to hook the client to the medication infusion.
Correct Answer is ["A","D"]
Explanation
A test to determine the amount of residual urine is used to measure the amount of urine that remains in the bladder after voiding. This assessment can be used for several reasons, including to determine the need for medications that can help improve bladder emptying and to evaluate the amount of retained urine after voiding. Retained urine can increase the risk of urinary tract infections and other complications. This test is not typically used to evaluate fluid volume status, glomerular filtration rate, or the extent of renal failure.
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