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 B

Explanation

If a nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr and notices that the client's IV bag is empty at 1200, the first intervention the nurse should take is to assess the client's vital signs. This will help the nurse determine if the client is experiencing any adverse eﬀects from the rapid infusion of ﬂuids.

Option a is incorrect because notifying the primary care provider is important but not the first intervention.

Option c is incorrect because calculating the infused volume is important but not the first intervention.

Option d is incorrect because completing an incident report is important but not the first intervention.

A. Encourage the client to take sips of water. B. Check for gastric residual volume. C. Flush the tube with sterile 0.9% sodium chloride irrigation. D. Encourage the client to breathe deeply and cough.

Correct Answer is B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula?

Correct Answer is B

Explanation

A nurse is monitoring a client who is receiving continuous IV ﬂuid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

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