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 C
Explanation
A) Incorrect- Pupillary response is not relevant to the assessment of mesalamine's effectiveness.
Pupillary response is often assessed in neurological or ophthalmic evaluations and is not a direct measure of gastrointestinal function or the response to mesalamine therapy.
B) Incorrect- Peripheral pulses are not directly affected by mesalamine therapy, and monitoring them would not provide insight into the medication's effectiveness. Peripheral pulses are typically assessed to evaluate circulatory status and are not specific to the evaluation of gastrointestinal conditions.
C) Correct- Mesalamine is a medication commonly used to treat inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. It helps to reduce inflammation in the gastrointestinal tract. Monitoring bowel patterns is important to assess the effectiveness of mesalamine in managing the symptoms of these conditions.
D) Incorrect- Oxygen saturation is a measure of the amount of oxygen in the blood and is used to assess respiratory function. While oxygen saturation is important for overall patient assessment, it is not directly related to mesalamine's effectiveness in treating inflammatory bowel disease.
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.
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