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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client’s oxygen saturation is 88% on 2 L/min of oxygen via nasal cannula, which is below the normal range of 95% to 100%.
This could indicate that the client is not receiving enough oxygen or that the pulse oximeter is not working properly.
The nurse should first check the sensor probe for any problems, such as poor attachment, nail polish, cold extremities, or motion artifact.
Repositioning the sensor probe may improve the accuracy of the reading and help the nurse determine the next course of action.
Choice B. Apply a cooling blanket to the client is wrong because a cooling blanket is used to lower the body temperature of a client with fever or hyperthermia.
It has no effect on the oxygen saturation level.
Choice C. Place the client in a side-lying position is wrong because a side-lying position may not improve the oxygenation of the client.
A more appropriate position would be a high Fowler’s position, which allows for maximum lung expansion and gas exchange.
Choice D. Ambulate the client is wrong because ambulating the client may worsen the oxygen saturation level if the client has a respiratory condition that causes hypoxemia.
The nurse should assess the client’s respiratory status and oxygen therapy before ambulating the client.
Correct Answer is D
Explanation
The correct answer is choice D. This type of device is useful for a client who cannot assist.
A mechanical lift is used to transfer residents who cannot support their own weight.
It does not require the client to use upper body strength, as choice A suggests.
The lower end of the sling should go under the client’s thighs, not below the calves, as choice B states.
The sides of the sling are not for the client to hold on to, but for the caregiver to attach to the hooks on the lift, as choice C implies.
Therefore, choices A, B and C are wrong because they do not reflect the proper use of a mechanical lift.
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