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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Incorrect - Requesting the client to lie still may be relevant for certain assessments, but it is not specific to the situation described in the question.
B) Incorrect - Inquiring about episodes of sundowning is more relevant for clients with cognitive impairment and is not directly related to the client's weight loss and decreased energy and appetite.
C) Correct - Questioning the client about the frequency of falls is important, as falls can contribute to weight loss, decreased energy, and appetite changes in older adults.
D) Incorrect - Assisting the client with clarifying values about end-of-life care is a valuable nursing intervention but is not the priority in this assessment scenario.

A. Height and weight of client prior to admission B. Client's pain rating on a scale of 1 to 10 C. Time of last administration of pain medication D. Eﬀectiveness of last pain medication administered E. History of pain medication use during the past year F. History of pain medication use during the past year

Correct Answer is ["B","C","D"]

Explanation

Client's pain rating on a scale of 1 to 10: This information helps assess the client's current pain level and determine the need for pain medication.

Time of the last administration of pain medication: This is important to avoid overdosing or administering pain medication too frequently. It helps ensure that pain medication is given at the appropriate time intervals.

Effectiveness of the last pain medication administered: Understanding whether the previous dose provided relief or not helps guide the choice of the next medication or dosage.

The other options are not directly related to the immediate decision of administering pain medication:

Height and weight of the client prior to admission may be part of the client's medical history but are not typically required information just before administering pain medication.

A history of pain medication use during the past year is important information but may be already documented in the client's medical records and not necessary to obtain immediately before administration.

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Immediately after log-rolling a client to a lateral position, which intervention should the practical nurse (PN) implement?

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