When moving a client up in bed with the assistance of another caregiver, the nurse should:

elevate the head of the bed.

have the client fold the arms across the chest.

ask another nurse about the plan of care.

maintain a pillow under the client's head.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Elevating the head of the bed is not the recommended action when moving a client up in bed.
Choice B rationale: Having the client fold the arms across the chest is not the primary action when moving a client up in bed.
Choice C rationale: Asking another nurse about the plan of care is not necessary in this situation and does not directly address the action needed when moving the client.
Choice D rationale: Maintaining a pillow under the client's head helps provide comfort and support during the movement.

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Correct Answer is B

Explanation

Choice A rationale: Extension is the movement of a body part away from the midline.
Choice B rationale: Adduction is the movement of a body part toward the midline.
Choice C rationale: Circumduction is the circular movement at the joint.
Choice D rationale: Abduction is the movement of a body part away from the midline.

A. Deep Tissue Injury B. Stage III Pressure Ulcer C. Unstageable Ulcer D. Stage IV Pressure Ulcer

Correct Answer is A

Explanation

Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.

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When moving a client up in bed with the assistance of another caregiver, the nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse moves a client's arm from an outstretched position to a position at the side of his body. What is the term used to describe this type of body movement?

Correct Answer is B

Explanation

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

Correct Answer is A

Explanation

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

A client at a healthcare facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

When moving a client up in bed with the assistance of another caregiver, the nurse should:

The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?