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 D
Explanation
Move the client to a room near the nurses' station.
- A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.
- B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.
- C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.
- D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.
Correct Answer is ["B","C","E","F"]
Explanation
The four findings that require follow-up are B, C, E, and F.
Rationale:
- Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
- Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
- Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
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