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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Aspiration risk due to frequent coughing while eating is the priority as it can lead to aspiration pneumonia.
B. Blood pressure elevation may need attention but is secondary to the immediate risk of aspiration.
C. Nutritional intake is important, but immediate safety concerns like the risk of aspiration take precedence.
D. Leaning to the left side while sitting might indicate a motor deficit but doesn't present an immediate risk compared to aspiration.
Correct Answer is C
Explanation
A. Eyewear should be removed after the gown as part of the sequence to prevent exposure to potential contaminants.
B. The mask should be removed after the gown to prevent contamination of the nurse's face.
C. The nurse should follow the sequence of doffing personal protective equipment (PPE) recommended by the Centers for Disease Control and Prevention (CDC) to prevent contamination. The sequence is: gloves, gown, eyewear, and mask. Gloves are the most contaminated piece of PPE and should be removed first by grasping the outside of one glove at the wrist and peeling it off, then holding it in the gloved hand and sliding the fingers of the ungloved hand under the remaining glove at the wrist and peeling it off over the first glove. The nurse should then discard both gloves in a waste container.
D. The gown is removed after the gloves when leaving the room to prevent carrying any potential contaminants outside the patient's room and to maintain infection control measures.
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