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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who is coughing only is still able to clear the airway by themselves.
B. Inability to make any sounds indicates a complete airway obstruction, requiring the Heimlich maneuver.
C. A client who can whisper has a partial airway obstruction and should be encouraged to continue coughing.
D. A high-pitched inspiratory stridor indicates a partial obstruction, not requiring the Heimlich maneuver but close monitoring.
Correct Answer is B
Explanation
A. Emphasizing the significance of the information may not address the cultural behavior of avoiding direct eye contact.
B. Continuing with the discussion respects the client's cultural behavior, as some cultures view direct eye contact as disrespectful.
C. Stopping the instructions to see what is on the floor may misunderstand the client's cultural behavior.
D. Moving closer for eye contact may make the client uncomfortable if their culture views direct eye contact as inappropriate.
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