A nurse is planning to place a client into the Sims’ position.
Which of the following actions should the nurse plan to take?

Elevate the client’s feet with two pillows.

Raise the head of the client’s bed to a 30° angle.

Raise the head of the client’s bed to a 60° angle.

Place a pillow under the client’s flexed leg.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D. Placing a pillow under the client’s flexed leg is part of the Sims’ position, which is a way of lying on the left side, with the right hip and knee bent and the left arm behind the back.

It is used for vaginal and colonic examinations and natural childbirth.

Choice A is wrong because positioning the client’s arms at his sides is not part of the Sims’ position.

The left arm should be behind the back.

Choice B is wrong because elevating the client’s feet with two pillows is not part of the Sims’ position.

The lower leg should be straightened and the upper leg should be bent.

Choice C is wrong because raising the head of the client’s bed to a 30° angle is not part of the Sims’ position.

The bed should be flat or slightly tilted.

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Correct Answer is A

Explanation

This is because a frayed electrical cord can pose a serious risk of electric shock or fire to the client and the nurse.

The nurse should act quickly to eliminate the hazard and ensure the safety of the client and others.

Choice B is wrong because accessing the facility’s maintenance protocol is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before following any protocol.

Choice C is wrong because reporting defective equipment is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before reporting it to the appropriate authority.

Choice D is wrong because requesting a replacement device is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before requesting a new one.

A. Measure the intake and output of a client who has received furosemide. B. Check a client’s peripheral IV site for redness or swelling. C. Assess the pain level of a client who has received acetaminophen. D. Reinforcing teaching with a client about crutch-gait walking E. None F. None

Correct Answer is C

Explanation

- When coordinating the care of a group of clients with assistive personnel (AP), it's important to delegate tasks appropriately based on the AP's scope of practice and training. Here are the tasks that can be assigned to the AP:

Measure the intake and output of a client who has received furosemide: This task involves recording fluid intake and output, which is typically within the scope of practice for an AP, as long as they have been trained in the proper procedure and documentation.

Check a client’s peripheral IV site for redness or swelling: This task involves basic assessment and can be assigned to an AP, as long as they are familiar with the signs of potential complications related to IV sites and have been trained in the facility's protocol for reporting any issues.

Reinforcing teaching with a client about crutch-gait walking: Education and reinforcement of information provided by healthcare professionals can often be delegated to APs, especially if they have received training on the specific topic. However, it's important to ensure that the AP is knowledgeable about crutch-gait walking and the information they are reinforcing.

The task related to assessing pain (e.g., assessing the pain level of a client who has received acetaminophen) should generally be performed by a licensed healthcare provider, such as a nurse. Assessment of pain requires a deeper understanding of the client's pain experience and may involve making clinical decisions related to pain management.

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A nurse is planning to place a client into the Sims’ position. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing hygiene care for a client, a nurse notices a frayed electrical cord on the client’s electronic blood pressure monitor. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A nurse is planning to place a client into the Sims’ position.
Which of the following actions should the nurse plan to take?