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 ["C"]
Explanation
The correct answer is choice C. Initiation of changes in infection control measures.
Choice A rationale:
Limiting the client’s fluid intake to avoid hemodilution is not relevant to managing a decreased ANC. Hemodilution is not a concern in this context, and fluid intake should generally be maintained to support overall health.
Choice B rationale:
Avoiding exposure to cold temperatures is not directly related to managing a decreased ANC. While keeping the client comfortable is important, it does not address the increased risk of infection associated with neutropenia.
Choice C rationale:
Initiation of changes in infection control measures is crucial when a client’s ANC decreases. Neutropenia increases the risk of infections, so enhanced infection control practices, such as strict hand hygiene, use of protective isolation, and monitoring for signs of infection, are essential to protect the client.
Choice D rationale:
Increasing the client’s dietary servings of fruits and vegetables is generally beneficial for overall health but does not specifically address the immediate risks associated with a decreased ANC. In fact, certain fresh fruits and vegetables might need to be avoided if they pose a risk of introducing pathogens.
Correct Answer is D
Explanation
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
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