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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Correct Answer is C

Explanation

- A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).

- B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45).

- C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).

- D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).

A. "I should store my personal items all together on the shelf in my bathroom.” B. "I will wear a yellow wristband so everyone knows I am at risk of falling.” C. "I should keep the overhead lights on at all times while I am here.” D. "I will have to wear a restraint around my waist when I am sitting up in a chair.”

Correct Answer is A

Explanation

Choice A rationale:

Storing personal items together on a shelf in the bathroom promotes organization and reduces the risk of tripping or falling over scattered items. Keeping the environment tidy and free of clutter is an essential fall prevention strategy, especially in areas where the client moves frequently.

Choice Brationale:

Wearing a yellow wristband to indicate a fall risk is a common practice in healthcare facilities. However, merely wearing the wristband does not demonstrate a comprehensive understanding of fall prevention strategies. While it is essential for healthcare providers to identify patients at risk of falling, educating the patient about specific strategies to prevent falls is equally important.

Choice C rationale:

Keeping the overhead lights on at all times does not necessarily indicate an understanding of fall prevention strategies. While adequate lighting is important to prevent falls, leaving lights on continuously may not be necessary during daylight hours. It is more effective to ensure there is adequate lighting in commonly used areas and during nighttime hours.

Choice Drationale:

Wearing a restraint around the waist is not a recommended fall prevention strategy. Physical restraints are generally discouraged in healthcare settings due to ethical concerns and the potential to cause harm to the patient. Restraints can lead to complications such as pressure ulcers, loss of muscle strength, and decreased mobility.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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