A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
Reposition the client without the use of assistive devices.
Raise the side rails on both sides of the client’s bed during repositioning.
Discuss the client’s preferences for determining a repositioning schedule.
Evaluate the client’s ability to help with repositioning.
The Correct Answer is D
This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.
Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.
The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.
Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.
The nurse should use assistive devices that are appropriate for the client’s condition and weight.
Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.
The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.
The nurse should also involve the client in the care plan and respect their preferences whenever possible.
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Related Questions
Correct Answer is D
Explanation
This action helps the client feel more comfortable and less intimidated by the nurse. It also allows the nurse to observe the client’s swallowing and signs of aspiration more easily.
Choice A is wrong because talking with the client during her feeding can distract her from swallowing properly and increase the risk of aspiration.
The nurse should encourage the client to focus on eating and avoid conversation until the feeding is over.
Choice B is wrong because discouraging the client from coughing during feedings can prevent her from clearing her airway and expelling any food particles that might have entered the trachea.
The nurse should monitor the client for coughing, choking, or changes in voice quality, which are indicators of aspiration.
Choice C is wrong because instructing the client to lift her chin when swallowing can actually make swallowing more difficult and increase the risk of aspiration.
The nurse should instruct the client to tuck her chin when swallowing, which helps close off the trachea and direct food into the esophagus.
Correct Answer is B
Explanation
This is because epiglottitis is a life-threatening condition that can cause severe airway obstruction and respiratory distress in children. The nurse should monitor the child for signs of worsening breathing, such as stridor, cyanosis, restlessness, or drooling. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice A is wrong because assessing the child for frequent swallowing may increase the risk of vomiting and aspiration. Swallowing may also be difficult and painful for the child due to the inflammation of the epiglottis.
Choice C is wrong because suctioning the child’s oropharynx may cause more swelling and irritation of the epiglottis, or trigger a spasm that can close off the airway. The nurse should avoid any stimulation of the throat or mouth that may worsen the condition.
Choice D is wrong because administering pancreatic enzymes with meals is not relevant to epiglottitis. Pancreatic enzymes are used to treat cystic fibrosis, a genetic disorder that affects the lungs and digestive system. Epiglottitis is caused by a bacterial infection or an injury to the throat.
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