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 A
Explanation
A. The erythrocyte sedimentation rate (ESR) is a marker of inflammation and is used to monitor the effectiveness of anti-inflammatory treatments such as aspirin in clients with rheumatoid arthritis.
B. Antinuclear antibody (ANA) is used to diagnose autoimmune diseases but is not typically monitored for the effectiveness of aspirin therapy in RA.
C. Rheumatoid factor (RF) is used for the diagnosis of RA, but it does not change significantly with treatment.
D. White blood cell (WBC) count is not a specific marker for monitoring the effectiveness of aspirin in treating RA.
Correct Answer is D
Explanation
A. Lactated Ringer's does not provide the necessary glucose to prevent hypoglycemia in clients receiving TPN.
B. 3% sodium chloride is hypertonic and not appropriate for preventing hypoglycemia.
C. 0.9% sodium chloride does not provide the necessary glucose.
D. Dextrose 10% in water (D10W) provides a glucose source to help prevent hypoglycemia in clients when TPN is temporarily unavailable.
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