A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Use an air-assisted device.

Position the bed in reverse Trendelenburg.

Elevate the head of bed to a 45° angle.

Lower the bed close to the ground.

Answer and Explanation

The Correct Answer is A

A. Use an air-assisted device.

Using an air-assisted device, such as a hover mat or air mattress, is an appropriate measure when repositioning a client with a pressure ulcer. These devices help reduce friction and shear forces, minimizing the risk of further skin breakdown. It also aids in maintaining the skin's integrity during movement, making it a suitable choice for the prevention of pressure ulcers.

B. Position the bed in reverse Trendelenburg:

Positioning the bed in reverse Trendelenburg involves raising the foot of the bed higher than the head. This position is not specifically related to pressure ulcer prevention or repositioning. It may be used for other medical reasons, but it does not directly address the issue of pressure ulcer care.

C. Elevate the head of bed to a 45° angle:

While elevating the head of the bed is commonly used for various reasons, including respiratory support or preventing aspiration, it may not be directly related to the repositioning of a client with a pressure ulcer. The angle mentioned (45°) is not specifically associated with pressure ulcer care.

D. Lower the bed close to the ground:

Lowering the bed close to the ground may be a safety measure to prevent injuries from falls, but it does not address the specific needs of repositioning a client with a pressure ulcer. The focus in pressure ulcer care is typically on using appropriate devices and techniques to minimize friction and pressure on vulnerable areas of the skin.

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Correct Answer is D

Explanation

A. Initiate a 24-hr urine collection for a client who has end-stage kidney disease:

While a 24-hour urine collection is important for assessing kidney function, it is not an urgent task and can be scheduled at a later time without compromising the client's immediate well-being.

B. Change the dressing for a client who has a decubitus ulcer:

Changing the dressing for a decubitus ulcer is important for wound care, but it is not as urgent as addressing respiratory distress in a client with COPD.

C. Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus:

Administering an antibiotic for a client with a methicillin-resistant Staphylococcus aureus (MRSA) infection is important, but it is not as immediately critical as ensuring adequate oxygenation in a client with COPD. Respiratory issues take precedence in the hierarchy of priorities.

D. Initiate oxygen therapy via nasal cannula for a client who has COPD.

The priority should be given to tasks that address immediate threats to the client's well-being or safety. In this scenario, initiating oxygen therapy for a client with COPD is a priority because it addresses respiratory distress and hypoxia, which are critical concerns in individuals with COPD. Respiratory interventions take precedence to ensure adequate oxygenation.

A. Teach a client about hemodialysis. B. Create a plan of care for a client's discharge. C. Assist in checking a unit of packed RBCs to administer to a client. D. Regulate the client's infusion pump after initiating a heparin drip infusion

Correct Answer is ["C","D"]

Explanation

A. Teach a client about hemodialysis:

Educating clients about hemodialysis may require specialized knowledge that might exceed the standard nursing scope. However, nurses may provide basic information and support related to the procedure.

B. Create a plan of care for a client's discharge:

Although nurses often contribute to discharge planning by providing input, assessing needs, and communicating with the care team, the creation of a complete discharge plan may involve multidisciplinary collaboration, including social workers, case managers, and physicians.

C. Assist in checking a unit of packed RBCs to administer to a client:

Nurses are often responsible for verifying blood components (like packed red blood cells) before administration, ensuring proper patient identification, compatibility, and correct handling of the blood product.

D. Regulate the client's infusion pump after initiating a heparin drip infusion:

Nurses frequently regulate and monitor infusion pumps after starting medication infusions, ensuring the correct rate of administration according to the prescribed dosage.

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A nurse is reviewing safety precautions with an assistive personnel (AP) about repositioning a client who has a pressure ulcer. Which of the following actions suggested by the AP indicates an understanding of the procedure?

Nursing Test Bank

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Correct Answer is D

Explanation

A nurse is planning care for four clients. Which of the following tasks are within the nurse's scope of practice?

Correct Answer is ["C","D"]

Explanation

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