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 A

Explanation

A. Urine output of 175 mL in the past 8 hours is significantly low and indicates potential acute kidney injury or worsening renal function, requiring immediate notification to the provider.
B. Urine output of 2,200 mL in the past 24 hours is within normal limits.
C. Strong odor in the first-voided urine in the morning is common and not necessarily indicative of a problem.
D. Cloudy urine after sitting in the urinal for several hours can occur due to crystallization or bacterial growth and is not a critical finding.

A. A Allergies B. B Circulation C. C Neurological status D. D Ventilation E. E Current medications F. F Exposure

Correct Answer is ["B","D","E"]

Explanation

A. Allergies
Allergies are important to know but are not part of the primary survey. The primary survey focuses on immediate life threats, such as airway, breathing, and circulation, rather than detailed background information.
B. Circulation
Assessment of circulation is critical in the primary survey to identify and manage life-threatening conditions such as shock or severe bleeding. It includes evaluating blood pressure, heart rate, and peripheral pulses to assess the effectiveness of the cardiovascular system.
C. Neurological status
While neurological status is important, it is part of a secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions, while the neurological status is assessed more thoroughly in the secondary survey.
D. Ventilation
Assessing ventilation is a crucial part of the primary survey. This involves checking the client's breathing rate, depth, and effectiveness to ensure adequate oxygenation and addressing any immediate respiratory distress.
E. Current medications
Knowing current medications is important for overall care but is not part of the primary survey. The primary survey addresses life-threatening conditions rather than details of medication history.
F. Exposure
Exposure is part of the primary survey, ensuring that the client is completely exposed for a thorough assessment while protecting their privacy and warmth. It involves checking for hidden injuries and ensuring the client’s environment is safe.

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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 has impaired renal function. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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