A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?

Roll the client as one unit in a smooth, continuous motion.

Flex the client's knees.

Place the client's arms at their sides.

Place the client on the side of the bed nearest the direction they will be turned.

Answer and Explanation

The Correct Answer is A

- Rationale for A: Rolling the client as one unit helps maintain spinal alignment and prevents further injury. It ensures that no additional strain is placed on the injured area, which could exacerbate pain or cause further damage. This method distributes the client's weight evenly and avoids twisting movements that could be harmful.

- Rationale for B: While flexing the client's knees may be part of the process to prepare for repositioning, it is not the most critical action to take. Flexing the knees alone does not ensure the safety of the client's lower back and could potentially lead to discomfort or injury if not done in conjunction with other measures.

- Rationale for C: Placing the client's arms at their sides is not advisable as it does not provide any support or stability during the repositioning process. Arms should be positioned in a way that they do not bear weight or interfere with the movement, ensuring the client's comfort and safety.

- Rationale for D: While placing the client on the side of the bed nearest the direction they will be turned may seem practical, it is not the primary action to ensure the client's safety. This position does not address the need for maintaining proper spinal alignment or the smooth, controlled movement required to protect the lower back injury.

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Correct Answer is B

Explanation

A. Respiratory rate is part of vital signs assessment but is not typically included in anthropometric measurements.
B. Weight is a key component of anthropometric assessment, measuring body mass or body weight.
C. Level of orientation pertains to the client's mental status and cognitive functioning, not part of anthropometric measurements.
D. Current pain level is important but not directly related to anthropometric measurements.

A. There is an area rug covering a tile floor. B. Grab bars are installed in the shower. C. Prescriptions are stored in a medication organizer. D. The hot water heater is set to 47°C (117°F).

Correct Answer is A

Explanation

Rationale for A: Area rugs pose a significant tripping hazard for older adults, especially for those with osteoporosis who are at an increased risk for fractures if they fall. The nurse should intervene by advising the client to remove the area rug to prevent falls.

Rationale for B: Grab bars installed in the shower are a safety feature that helps prevent falls, especially for clients with mobility issues. This is a positive finding and does not require intervention.

Rationale for C: Storing prescriptions in a medication organizer helps the client keep track of their medications and prevents confusion, especially in older adults. This is an effective way to manage medications and does not need intervention.

Rationale for D: The hot water heater set to 47°C (117°F) is within the safe range to prevent burns while still providing sufficient warmth for bathing. This does not pose a risk to the client, and no intervention is needed.

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A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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