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 A

Explanation

A. Anaphylactic reactions can cause a sudden and severe drop in blood pressure, which is a potentially life-threatening symptom. It's a hallmark sign of anaphylaxis.
B. A feeling of swelling in the feet might indicate a localized reaction but is less specific to anaphylaxis.
C. Pain at the injection site might occur due to local irritation but isn't typically a primary sign of an anaphylactic reaction.
D. A sudden decrease in heart rate is not a typical sign of an anaphylactic reaction.

A. Side-lying with the right side of the chest elevated B. Right lateral in Trendelenburg position C. Prone with pillows under the lower extremities D. Supine in low-Fowler's position

Correct Answer is B

Explanation

Rationale for A: Side-lying with the right side of the chest elevated does not provide the necessary gravitational effect to drain the left lower lobe. The Trendelenburg position is more effective for lower lobe drainage.

Rationale for B: Right lateral in Trendelenburg position is the appropriate position for postural drainage of the left lower lobe. The combination of gravity and positioning helps drain secretions from the lower lobe effectively.

Rationale for C: Prone with pillows under the lower extremities does not facilitate proper drainage of the left lower lobe. This position might be more useful for posterior lobe drainage, not the lower lobes.

Rationale for D: Supine in low-Fowler's position is not ideal for draining secretions from the lower lobes of the lungs. Postural drainage requires specific positions that use gravity to promote secretion clearance from the affected lobe.

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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?

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