A nurse is instructing a client about postural drainage. The nurse should have the client lie with his head lower than his feet to mobilize secretions and understands this position to be which of the following?

Supine

Trendelenburg

Fowler's

Sims'

Answer and Explanation

The Correct Answer is B

A. Supine: The client lies flat on their back with no tilt. This position does not help mobilize secretions from the lower lungs.
B. Trendelenburg: In this position, the head is lower than the feet, using gravity to help drain secretions from the lower lobes of the lungs.
C. Fowler's: The client is in a semi-sitting position (head elevated). This is used for breathing ease but not effective for postural drainage.
D. Sims': This is a semi-prone position used for enema administration or rectal examinations, not for mobilizing lung secretions.

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Correct Answer is C

Explanation

A. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg: It is typically defined by a drop of ≥10 mm Hg diastolic or ≥20 mm Hg systolic.
B. Orthostatic hypotension increases a client's risk of a pulmonary emboli: Orthostatic hypotension does not cause PE; they are unrelated pathophysiologies.
C. Orthostatic hypotension increases a client's risk of a fall: The drop in blood pressure on standing can cause dizziness or fainting, leading to a fall risk.
D. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg: The correct threshold is ≥20 mm Hg systolic.

A. Inadequate staffing ratio between clients and health care providers B. Discipline for throwing chairs at staff C. Refusal to take medication D. Continued self-destructive behavior

Correct Answer is D

Explanation

A. Inadequate staffing ratio between clients and health care providers: Restraints should never be used for staff convenience or due to understaffing.
B. Discipline for throwing chairs at staff: Restraints must not be used for punishment.
C. Refusal to take medication: This does not justify restraints unless the client is a danger to themselves or others.
D. Continued self-destructive behavior: Restraints may be used when there is a risk of self-harm and other alternatives have failed, following institutional protocols and provider orders.

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A nurse is instructing a client about postural drainage. The nurse should have the client lie with his head lower than his feet to mobilize secretions and understands this position to be which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is discussing restraints with a newly licensed nurse. Which of the following situations should the nurse identify as an acceptable indication for using restraints for a client?

Correct Answer is D

Explanation

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