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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Place the client in a quiet environment.

A. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.
B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate.Therefore, this choice is incorrect.
C. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.
D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.

A. Weight gain B. Decrease in anteroposterior diameter of the chest C. HCO3 24 mEq/L D. pH 7.31

Correct Answer is D

Explanation

pH 7.31

Rationale:

A - This is incorrect because weight gain is not expected in clients who have COPD, as they often have difficulty eating and digesting food due to dyspnea and fatigue.

B - This is incorrect because a decrease in anteroposterior diameter of the chest is not typical of COPD, as the condition causes hyperinflation and air trapping in the lungs, leading to an increase in chest size and a barrel-shaped appearance.

C - This is incorrect because HCO3 24 mEq/L is within the normal range for blood bicarbonate levels, which are 22 to 26 mEq/L. Clients who have COPD often have chronic respiratory acidosis, which stimulates the kidneys to retain bicarbonate and increase its levels in the blood to compensate for the low pH.

D - This is correct because pH 7.31 indicates acidosis, which is common in clients who have COPD due to impaired gas exchange and accumulation of carbon dioxide in the blood.

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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?

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