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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
"Antiembolism stockings on, leg exercises performed hourly" indicates that activities to prevent postoperative venous stasis were performed correctly. This combination ensures both mechanical prophylaxis (antiembolism stockings) and physical activity (leg exercises) to prevent blood clots in postoperative patients.
Choice A rationale:
"Leg exercises not performed because of placement of antiembolism hose" is not the correct approach. Leg exercises should be encouraged even when antiembolism stockings are worn, as they have complementary benefits in preventing venous stasis.
Choice B rationale:
"Antiembolism stockings removed hourly during leg exercises" is not recommended. Antiembolism stockings should be worn continuously to be effective in preventing venous stasis.
Choice C rationale:
"Client demonstrates the ability to move all extremities well" is a good sign of the client's mobility but does not confirm that the specific activities to prevent postoperative venous stasis were performed correctly. The combination of stockings and leg exercises is more comprehensive.
Correct Answer is C
Explanation
Choice A rationale:
Procuring platelet products from the blood bank is a task that should be performed by a licensed nurse, not an unlicensed assistive personnel (UAP). It involves assessing the client's needs, verifying orders, and administering the product, which require nursing judgment and skills.
Choice B rationale:
Titrating oxygen to prescribed parameters is a nursing task that requires clinical judgment, especially if the client's condition changes. UAPs do not have the training or scope of practice to adjust oxygen levels. This task should be assigned to a licensed nurse.
Choice D rationale:
Inserting a urinary catheter, even for an uncomplicated client, is a task that should be performed by a licensed nurse. It involves the potential risk of infection and injury, and it requires sterile technique and assessment of the client's condition. UAPs do not have the training or scope of practice to insert urinary catheters.
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