A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse positions the client in the orthopneic position. What is the primary reason for the use of this position for this client?
Prevents pressure ulcers.
Supports hip extension.
Facilitates breathing.
Promotes urinary elimination.
The Correct Answer is C
Choice A Reason:
“Prevents pressure ulcers” is incorrect. While positioning can help prevent pressure ulcers, the orthopneic position is specifically used to aid in breathing rather than to prevent pressure ulcers. Pressure ulcers are typically managed by regularly repositioning the client and using pressure-relieving devices.
Choice B Reason:
“Supports hip extension” is incorrect. The orthopneic position does not primarily support hip extension. This position involves sitting up and leaning forward, which does not significantly affect the hips.
Choice C Reason:
“Facilitates breathing” is correct. The orthopneic position, also known as the tripod position, helps to improve breathing in clients with COPD. By leaning forward and resting the arms on a table or knees, the diaphragm can move more freely, and accessory muscles of respiration are better utilized, reducing the work of breathing.
Choice D Reason:
“Promotes urinary elimination” is incorrect. The orthopneic position is not intended to promote urinary elimination. Urinary elimination is typically managed through other interventions such as ensuring adequate hydration and, if necessary, using a catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Cardiac monitoring involves the continuous observation of the heart’s electrical activity, typically using an electrocardiogram (ECG). While cardiac monitoring is essential for detecting arrhythmias and other cardiac events, it does not directly measure fluid retention. Fluid retention in CHF patients can lead to symptoms such as edema and weight gain, which are not directly assessed through cardiac monitoring.
Choice B Reason:
Daily weight measurement is a reliable and practical method for assessing fluid retention in clients with congestive heart failure. Fluid retention leads to an increase in body weight, and monitoring daily weight changes can help detect fluid accumulation early. A sudden weight gain of more than 2-3 pounds in a day or 5 pounds in a week is a significant indicator of fluid retention and worsening heart failure. This method is non-invasive, easy to perform, and provides valuable information for managing CHF.
Choice C Reason:
Blood pressure monitoring is crucial for managing clients with CHF, as hypertension can exacerbate heart failure. However, blood pressure readings alone do not provide a direct measure of fluid retention. While fluid overload can affect blood pressure, it is not a specific or sensitive indicator of fluid status. Blood pressure monitoring should be used in conjunction with other assessment tools to manage CHF effectively.
Choice D Reason:
Urine output measurement is an important parameter for assessing kidney function and fluid balance. In clients with CHF, reduced urine output can indicate worsening heart failure and fluid retention. However, urine output alone may not provide a complete picture of fluid status, especially if the client is on diuretic therapy. Daily weight measurement remains a more direct and reliable method for assessing fluid retention in CHF patients.
Correct Answer is A
Explanation
Choice A Reason:
Use good body mechanics is correct. Good body mechanics involve using the body in an efficient and careful way to prevent injury. This includes bending at the knees instead of the waist, keeping the back straight, and using the legs to lift heavy objects. Proper body mechanics reduce the strain on the back and joints, preventing injuries.
Choice B Reason:
Maintain proper posture is also important but is part of using good body mechanics. Proper posture involves keeping the spine in a neutral position, avoiding slouching, and ensuring that the head is aligned with the spine. This helps distribute weight evenly and reduces the risk of injury.
Choice C Reason:
Use assistive devices is correct. Assistive devices such as transfer boards, mechanical lifts, and gait belts can help reduce the physical strain on nurses when moving or lifting patients. These devices are designed to make tasks safer and easier, thereby minimizing the risk of back and joint injuries.
Choice D Reason:
Stay physically fit is also important. Physical fitness helps maintain muscle strength, flexibility, and endurance, which are crucial for performing physically demanding tasks. Regular exercise can help prevent injuries by improving overall body mechanics and reducing fatigue.
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