The nurse is assessing the body alignment of an immobilized client. Which is the best client position for the nurse to obtain an accurate assessment?

Prone.

Sims.

Supine.

Fowlers.

Answer and Explanation

The Correct Answer is C

A. Prone: Prone positioning limits assessment of spinal curvature, extremity alignment, and body symmetry because the client is lying on the abdomen, which can obscure certain postural deviations.

B. Sims: Sims position is primarily used for rectal or vaginal procedures and does not provide a full view of overall body alignment, making it less ideal for assessment purposes.

C. Supine: Supine position allows the client to lie flat on the back with the body fully supported. This position provides the best view of the head, neck, spine, shoulders, hips, and extremities for a comprehensive assessment of body alignment.

D. Fowlers: Fowlers position elevates the head and torso, which may alter natural spinal alignment and obscure an accurate assessment of posture and symmetry compared with a flat, supine position.

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Correct Answer is C

Explanation

A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment: Routine irrigation is not typically necessary unless instructed for debris removal. Over-manipulation may increase the risk of infection or injury to the healing eye.

B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: While sunglasses can protect the eyes from UV light, strict limitation of sunlight is not usually required for 2 weeks. Standard protective measures and avoiding direct glare are sufficient.

C. Avoid straining at stool, bending, or lifting heavy objects: These activities increase intraocular pressure, which can compromise the surgical site and healing process after cataract extraction. Avoiding them is critical to prevent complications such as wound dehiscence or hemorrhage.

D. Do not read without direct lighting for 6 weeks: Reading is generally safe after cataract surgery as long as the client uses appropriate lighting. There is no standard requirement to avoid reading for 6 weeks.

A. Use nasal or cough tissues followed by handwashing at all times. B. Ensure supplemental oxygen and respiratory medications are available at all times. C. Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines. D. Avoid large crowed areas during the colder months of the year.

Correct Answer is C

Explanation

A. Use nasal or cough tissues followed by handwashing at all times: Hand hygiene and respiratory etiquette are important to reduce infection risk, but they are general preventive measures and not as critical as vaccination for high-risk clients with chronic respiratory diseases.

B. Ensure supplemental oxygen and respiratory medications are available at all times: Having medications and oxygen ready is important for managing acute symptoms, but it does not prevent illness or complications; it is part of ongoing disease management not prevention.

C. Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines: Vaccination is the most important preventive measure for clients with asthma, chronic bronchitis, or emphysema. These clients are at higher risk for respiratory infections, which can cause severe exacerbations, hospitalization, and complications.

D. Avoid large crowded areas during the colder months of the year: Limiting exposure can reduce infection risk but is a situational preventive measure. Vaccination provides broader and more effective protection against common respiratory pathogens.

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The nurse is assessing the body alignment of an immobilized client. Which is the best client position for the nurse to obtain an accurate assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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