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 C
Explanation
A. Positions the wrapped package on the bedside table so the outer flap is away from her: This action is correct because opening the flap away from the body minimizes the risk of contaminating the sterile field.
B. Holds gauze packages 15 cm (6 in) above the sterile field: This action is correct. Dropping sterile items from a height of 6 inches or more prevents contamination by ensuring they do not touch the edges or outside surfaces of the sterile field.
C. Holds a bottle of solution with the label away from the palm of the hand: When pouring a solution, the label should be held toward the palm of the hand to protect it from damage caused by spills. A damaged label could make it difficult to identify the solution, increasing the risk of error.
D. Wears sterile gloves when moving sterile items on the sterile field: This action is appropriate. Sterile gloves help maintain the sterility of the field and are required when manipulating sterile items.
Correct Answer is D
Explanation
A. Pernicious anemia is a condition related to vitamin B12 deficiency and does not typically cause blood-tinged urine.
B. Prostate enlargement (benign prostatic hyperplasia) can cause urinary symptoms like hesitancy and frequency but does not directly cause blood-tinged urine.
C. Dehydration can lead to concentrated urine and urinary tract irritation but does not typically cause blood-tinged urine.
D. Blood-tinged urine in a client with an indwelling urinary catheter is concerning for a bladder infection, especially if accompanied by other signs like fever or foul odor.
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