A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Rolls the client to one side of the bed

Reaches over the bed to straighten the fitted sheet

Lowers the side rail on the side of the bed closest to the AP

Raises the bed to waist level

Answer and Explanation

The Correct Answer is B

A. Rolling the client to one side of the bed is an appropriate action to change the linens.
B. Reaching over the bed to straighten the fitted sheet can cause strain and potential injury to the AP's back and should be corrected.
C. Lowering the side rail on the side of the bed closest to the AP is necessary for changing the linens safely.
D. Raising the bed to waist level is an appropriate action to ensure proper body mechanics and prevent injury.

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Correct Answer is D

Explanation

A. Notifying the provider is necessary but not the first action.
B. Applying a cold pack may help with swelling but is not the first action to take.
C. Removing the PICC line should only be done after assessing the situation and consulting with the provider.
D. Measuring the circumference of both upper arms is the first action to assess the extent of the swelling and compare it to the other arm, which will help determine the severity of the issue.

A. "My partner should cough while swallowing food." B. "My partner should tilt their head forward when swallowing." C. "My partner should place their food on the weaker side of their mouth when eating." D. "My partner should sit at a 30° angle while eating their meals."

Correct Answer is B

Explanation

A. Coughing while swallowing food can help clear the airway but is not a primary technique for managing dysphagia.
B. Tilting the head forward when swallowing helps to close the airway and reduce the risk of aspiration, indicating effective teaching.
C. Food should be placed on the stronger side of the mouth to aid in effective chewing and swallowing.
D. A 30° angle is insufficient; the client should be in an upright position (90°) to reduce the risk of aspiration.

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A nurse is observing an assistive personnel (AP) changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective?

Correct Answer is B

Explanation

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