An adolescent client who recently lost most sight in both eyes has been admitted for evaluation. The nurse observes an unlicensed assistive personnel (UAP) who is assisting the client to walk in the hallway for the first time since admission, as seen in the picture. Which action should the nurse take?

Encourage the UAP to continue to assist the client down the hallway.

Demonstrate to the UAP how to assist the client with ambulation more safely.

Instruct the UAP to guide the client back to his room right away.

Advise the UAP to stay nearby but allow the client to ambulate independently.

Answer and Explanation

The Correct Answer is B

A.   While it is important to support the UAP's efforts, simply encouraging them to continue without
assessing the method used may not ensure the safety of the client. The UAP’s approach to assisting the
client could potentially involve unsafe practices, especially given the client's significant vision loss.
B.   Demonstrating safe ambulation techniques to the UAP ensures that the client is guided effectively and safely. For clients with significant vision loss, it is essential to use specific techniques, such as providing clear verbal cues, using a sighted guide method (e.g., having the client hold the guide's arm), and ensuring a clear and safe path.
C.   This choice may be premature without evaluating the current situation. It assumes the UAP is providing unsafe assistance, but it does not provide a solution to how the UAP should assist the client in a more effective manner.
D.   Allowing the client to ambulate independently, especially after significant vision loss, might not be safe. Clients who have recently lost their vision may require assistance to navigate their environment safely. While staying nearby can offer some level of safety, it is not sufficient if the client needs hands- on guidance and support to avoid hazards.

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Correct Answer is B

Explanation

A. While it is true that using proper techniques can reduce the risk of back injuries for healthcare providers, this is not the primary purpose of the log rolling technique. The main goal of log rolling is to protect the client’s spinal alignment rather than focusing on the safety of the staff.
B. This is the best explanation for the purpose of using the log rolling technique. Log rolling is designed to keep the client’s spine in a straight, aligned position while turning. This technique is particularly important for clients with spinal injuries or conditions where maintaining spinal alignment is crucial to prevent further injury or complications.
C. While it is true that turning a client is generally better for skin integrity than pulling, this explanation does not specifically address the purpose of log rolling. Log rolling is more focused on maintaining spinal alignment rather than solely on reducing skin damage.
D. Using two or three people can indeed increase safety during the turning process and help in managing the client more effectively, but this explanation does not capture the primary purpose of the log rolling technique itself.

A. Notify the healthcare provider of the client's concerns. B. Ask an unlicensed assistive personnel to stay with the client. C. Obtain a bedside commode for the client to use. D. Place the bedpan within the reach of the client.

Correct Answer is C

Explanation

A. While notifying the healthcare provider may be necessary in some cases, it's not the most immediate or appropriate action in this situation. The nurse can address the client's concerns directly by providing a bedside commode.
B. While having a UAP available for assistance can be helpful, providing a bedside commode is a more practical and efficient solution.
C. A bedside commode can help prevent accidents and spills, which can be embarrassing and contribute to a negative experience. Offering a bedside commode demonstrates respect for the client's concerns and preferences, which can help to build trust and improve the overall care experience.
D. A bedpan may not be as comfortable or convenient for the client as a bedside commode, especially if they have mobility limitations.

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Naxlex Comprehensive Predictor Exams

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

Correct Answer is B

Explanation

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

An older adult client is admitted to a long term care facility. Upon admission, the client is oriented but fatigued, is incontinent of urine, and has a stage II pressure ulcer on the left heel. Which additional finding requires further assessment?

A male client tells the nurse that he is taking large doses of a fish oil supplement to lower his triglyceride level. Which action should the nurse take?

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?