The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure?
An abduction pillow is placed between the client's legs when positioned.
The client is told to keep both legs straight and together while turning.
A turning sheet is used under the client for turning and repositioning.
The UAPs keep their backs straight and knees bent when moving the client.
The Correct Answer is B
This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the affected leg slightly abducted and supported with pillows or an abduction device.
A. An abduction pillow is placed between the client's legs when positioned correctly and does not indicate a need for additional information. This helps to maintain proper alignment and prevent dislocation of the prosthesis.
C. A turning sheet is used under the client for turning and repositioning is correct and does not indicate a need for additional information. This helps to reduce friction and shear forces on the skin and prevent pressure ulcers.
D. The UAPs keep their backs straight and knees bent when moving the client is correct and does not indicate a need for additional information. This helps to protect their own musculoskeletal health and prevent injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiceD. Contact information for a women’s shelter.
Choice A rationale:
While providing a safety plan is important, it may not be the most immediate or practical resource for a client in an abusive situation. A safety plan is a detailed strategy for leaving an abusive relationship safely, but it requires time and preparation, which may not be feasible in an urgent situation.
Choice B rationale:
Paperwork for a restraining order is a legal step that can help protect the client, but it may not provide immediate safety. The process of obtaining a restraining order can take time, and the client may need immediate shelter and support.
Choice C rationale:
Documenting the report of abuse in the visit summary is important for medical and legal records, but it does not directly provide the client with immediate resources or safety. This documentation can be useful for future legal actions but does not address the client’s immediate need for safety and support.
Choice D rationale:
Providing contact information for a women’s shelter is the most appropriate response because it offers immediate safety and support. Women’s shelters provide a safe haven, counseling, legal support, and other resources necessary for individuals experiencing domestic violence.This option prioritizes the client’s immediate safety and well-being.
Correct Answer is B
Explanation
Choice A rationale:
The risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
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