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 ["A","C","D"]
Explanation
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of fluid volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance systems that may indicate fluid overloads, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.
The other options are not correct because:
B. Checking fingernails for the presence of clubbing is not relevant for assessing fluid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.
E. Comparing muscle strength of both arms is not relevant for assessing fluid volume excess, as muscle weakness is not a specific sign of fluid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.
Correct Answer is B
Explanation
Gravida: The client has been pregnant five times: three times she gave birth to term babies, once she gave birth to preterm twins, and once she had a spontaneous abortion.
Term births: She has given birth three times: at 38 weeks, 41 weeks, and 35 weeks (twins). These are all considered term births. Term pregnancies are 37 weeks and beyond. So, the number of term births is 2.
Preterm births: She had one birth at 35 weeks, which is considered preterm. So, the number of preterm births is 1.
Abortions: She had one spontaneous abortion at 10 weeks' gestation. So, the number of abortions is 1.
Living children: All of her children are alive and well. So, the number of living children is 4.
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