Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement?
Raise the head of the bed 30 degrees.
Measure blood pressure and pulse rate.
Flex legs and place blanket between legs.
Place pillows to maintain alignment.
The Correct Answer is D
Log-rolling is a technique of moving a client as a unit without twisting or bending the spine, which is used for clients with spinal injuries or surgeries. After log-rolling a client to a lateral position, the PN should place pillows to maintain alignment and prevent pressure ulcers or nerve damage. The pillows should be placed under the head, neck, upper arm, chest, abdomen, pelvis, and lower leg.
The other options are not correct because:
A. Raising the head of the bed 30 degrees is not necessary or appropriate after log-rolling a client to a lateral position, as it can cause shearing forces or compromise the spinal stability. The head of the bed should be kept flat or slightly elevated during log rolling.
B. Measuring blood pressure and pulse rate is not the immediate intervention after log-rolling a client to a lateral position, as it does not ensure the comfort or safety of the client. The PN should monitor the vital signs before and after log-rolling, but not during or immediately after.
C. Flexing legs and placing a blanket between legs is not the immediate intervention after log-rolling a client to a lateral position, as it does not support the spine or prevent pressure ulcers or nerve damage. The PN should keep the legs straight and aligned with the body during log-rolling, and place a pillow under the lower leg after log-rolling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- Oral hygiene is the care of the mouth, teeth, and gums. It is important to perform oral hygiene on unconscious clients to prevent infection, dryness, and discomfort.
- When performing oral hygiene on an unconscious client, the client should be placed in a **Fowler's position** or a **semi-Fowler's position**, which means the head of the bed is elevated 45 to 90 degrees or 15 to 45 degrees, respectively. This position helps to prevent aspiration of fluids or secretions into the lungs, which can cause pneumonia or other complications.
- A **side-lying position** is when the client is lying on one side, with the lower arm under the head or pillow and the upper arm resting on a pillow in front of the chest. This position may be used for comfort or to relieve pressure on certain areas of the body, but it is not suitable for oral hygiene on an unconscious client, as it does not prevent aspiration.
- An **emesis basin** is a kidney-shaped container that is used to collect vomit or other fluids from the mouth. It should be placed under the client's chin during oral hygiene to catch any excess water or debris, but it does not prevent aspiration.
- In the scenario, the unlicensed assistive personnel (UAP) is performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on the bedside table near the chin. This is an unsafe and incorrect technique, as it puts the client at risk of aspiration. The practical nurse (PN) should stop the procedure and tell the UAP to place the client in Fowler's position, which is the correct and safe position for oral hygiene on an unconscious client.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because enrolling the UAP in a hospital education class on conducting safe client care does not address the immediate problem or correct the error.
Option C is incorrect because praising the UAP for doing oral hygiene but encouraging family participation does not address the error or ensure the client's safety.
Option D is incorrect because telling the UAP to continue because the unconscious client is positioned safely is false and negligent.
Correct Answer is B
Explanation
- A bowel pattern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel pattern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
- A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patterns. It also includes inspecting and auscultating the abdomen for any abnormalities.
- When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel pattern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because administering a stool softener without assessing the client's bowel pattern may not be appropriate or effective.
Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.
Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.
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