An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene?
The LPN and AP lower the side rails before lifting the client up in bed.
Prior to lifting the client, the LPN and AP raise the bed to waist level.
The LPN and the AP grasp the client under his arms to lift him up in bed.
The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.
The Correct Answer is C
A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.
B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.
C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.
D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- Cocaine is a powerfully addictive stimulant drug that increases the levels of dopamine in the brain, which is a chemical messenger related to movement, pleasure, and motivation.
- Cocaine's effects appear almost immediately and last for a few minutes to an hour, depending on the method of use. Some of the short-term effects of cocaine include extreme happiness and energy, mental alertness, hypersensitivity to sight, sound, and touch, and irritability.
- An elevated energy level is one of the most common and noticeable effects of cocaine use, as cocaine stimulates the central nervous system and makes the user feel more alert, active, and confident¹². This effect may also lead to increased physical activity, talkativeness, or aggression.
Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because a powerful craving for more cocaine is not a behavior that can be observed by others, but rather an internal feeling that the user may experience due to the addictive nature of the drug.
Option C is incorrect because high self-esteem is not a typical effect of cocaine use, as cocaine may cause paranoia or anxiety in some users.
Option D is incorrect because euphoria is not a behavior that can be observed by others, but rather an emotional state that the user may feel due to the increased dopamine levels in the brain
Correct Answer is B
Explanation
Choice A reason:
Discarding the first 10 mL of urine is a common practice for obtaining a urine sample for certain tests, but it is not specifically necessary for a urine culture. In a urine culture, the goal is to obtain a sample directly from the bladder to identify any bacteria present, so discarding the initial urine is not necessary.
Choice B reason
Donning sterile gloves prior to the procedure is the appropriate action for the nurse to take. When catheterizing a toddler for a urine culture, it is essential to maintain a sterile procedure to reduce the risk of infection and ensure the safety of the child. Using sterile gloves is a crucial step in preventing contamination during the catheterization process.
Choice C reason
The size of the catheter (12-French) mentioned in option C may not be appropriate for a toddler. The size of the catheter used for a toddler would generally be smaller, depending on the age and size of the child. The appropriate catheter size should be determined based on the child's age and condition.
Choice D reason
EMLA cream is a topical anaesthetic cream used to numb the skin before certain procedures. While it might be appropriate in some cases, it is not typically used for catheterization procedures in toddlers. Catheterization is a quick procedure, and using EMLA cream may not be necessary or practical in this situation.
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