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
Aspiration is when food or liquid enters the airway and causes choking or infection. Speech therapists can teach clients exercises to strengthen the muscles involved in swallowing, as well as strategies to prevent aspiration, such as changing the position of the head or the texture of the food.
Choice B is wrong because respiratory therapists help clients with breathing problems, not swallowing problems.
They may provide oxygen therapy, chest physiotherapy, or mechanical ventilation.
Choice C is wrong because physical therapists help clients with mobility problems, not swallowing problems.
They may provide exercises, massage, or assistive devices to improve movement and function.
Choice D is wrong because occupational therapists help clients with daily living activities, not swallowing problems.
They may provide training, adaptive equipment, or environmental modifications to enhance independence and quality of life.
Dysphagia is a medical term for swallowing difficulties.
It can be caused by various conditions that affect the nerves or muscles involved in swallowing, such as stroke, head injury, Parkinson’s disease, or esophageal cancer.
Dysphagia can lead to complications such as malnutrition, dehydration, or aspiration pneumonia.
Correct Answer is D
Explanation
It's common practice to check blood pressure in both arms when there is a significant discrepancy in blood pressure readings between the arms. This discrepancy could be due to factors like arterial blockages or other conditions. By measuring the blood pressure in the other arm, the nurse can confirm whether the high blood pressure is consistent on both sides or if there was an issue with the initial measurement. This step helps provide a more accurate assessment of the client's blood pressure.
- The other options are not appropriate at this stage:
Deflating the cuff faster may not resolve the issue and could lead to inaccurate measurements.
Requesting a prescription for an antihypertensive medication should only be done after confirming the blood pressure is consistently elevated and under the direction of a healthcare provider.
Using a narrower cuff is not indicated in this situation. It's more important to assess the other arm's blood pressure to identify any discrepancies.
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