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 A

Explanation

Ask the APs to discontinue the conversation:

This is the most appropriate immediate action. Discussing a client's care in a public area violates the principle of patient confidentiality. The nurse should intervene promptly and ask the assistive personnel to stop the conversation.

Inform the client what has occurred:

While transparency with the client is important, it may not be the first action to take in this situation. The priority is to address the breach of confidentiality by stopping the conversation.

Notify the client's provider:

Notifying the client's provider is not the initial action to take in this situation. First, the nurse should address the immediate issue by stopping the inappropriate conversation. The provider may be informed later, if necessary.

Schedule a disciplinary conference for the APs:

Scheduling a disciplinary conference is a step that may be taken after addressing the immediate issue. The priority is to stop the inappropriate conversation and address confidentiality concerns before considering disciplinary actions.

A. Report the fire details to the facility emergency extension. B. Close the door to the client's room. C. Activate the fire alarm. D. Turn off electrical equipment.

Correct Answer is C

Explanation

A. Report the fire details to the facility emergency extension:

While reporting the fire details is important, activating the fire alarm takes precedence. The alarm initiates a quicker and broader response to the emergency.

B. Close the door to the client's room:

Closing the door may be a subsequent action to contain smoke and fire, but it is not the immediate priority. Activating the fire alarm ensures a faster response and is crucial for alerting others.

C. Activate the fire alarm.

Activating the fire alarm is the most immediate action to take in the event of a fire. The fire alarm alerts others in the facility, including staff and emergency services, about the potential danger. This rapid notification initiates the emergency response, ensuring a quick and coordinated effort to address the fire situation and safeguard everyone in the vicinity.

D. Turn off electrical equipment:

Turning off electrical equipment is a valid action to prevent further hazards, but it is not the immediate priority. Activating the fire alarm comes first to ensure the safety of everyone in the facility.

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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?

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