A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?

"I will twist at the waist while pulling the draw sheet."

"I will keep my legs straight to provide more power in the lift."

"I will tighten my abdominal muscles prior to moving."

"I will place the bed in the lowest position."

Answer and Explanation

The Correct Answer is C

Tightening the abdominal muscles prior to moving helps to stabilize the spine and prevent back strain. This is an important technique for caregivers to use when assisting a client who is immobile and requires repositioning in bed.

a. Twisting at the waist while pulling the draw sheet can cause strain on the back muscles and should be avoided.

b. Keeping the legs straight does not provide more power in the lift and can also cause strain on the back muscles.

d. Placing the bed in the lowest position does not necessarily prevent back strain and is not related to the proper technique for repositioning a client in bed.

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Correct Answer is ["F"]

Explanation

f) Skin surrounding the stoma is reddened and appears irritated.

The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.

Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.

A. Use a cuﬀ with a width that is about 60% of the client's arm circumference. B. Apply the cuﬀ above the client's antecubital fossa. C. Have the client sit with his arm resting above the level of his heart. D. Release the pressure on the client's arm 5 to 6 mm per second.

Correct Answer is A

Explanation

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

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A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?

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Correct Answer is ["F"]

Explanation

A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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