Which explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

The technique is intended to maintain straight spinal alignment.

Using two or three people increases client safety.

Working together can decrease the risk of back injury to the nurses.

Turning instead of pulling reduces the likelihood of skin damage.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the best explanation as it describes the main goal of the log-rolling technique, which is to prevent twisting or bending of the spine. This is especially important for clients who have spinal injuries, surgeries, or disorders.

Choice B reason: Using two or three people is a part of the log-rolling technique, but it is not the purpose of it. It is a means to achieve the purpose of maintaining spinal alignment. It also ensures that the client is moved smoothly and gently.

Choice C reason: Working together can decrease the risk of back injury to the nurses, but it is not the purpose of the log-rolling technique. It is a benefit for the nurses, but not for the client. The nurse should focus on the client's needs and outcomes.

Choice D reason: Turning instead of pulling reduces the likelihood of skin damage, but it is not the purpose of the log-rolling technique. It is an advantage for the client, but not the main reason for using the technique. The nurse should explain how the technique affects the spine, not the skin.

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Correct Answer is A

Explanation

Choice A reason:This option is the most therapeutic because it is open-ended and invites the client to express feelings and experiences about the visit. By encouraging the client to talk, the nurse provides an opportunity for the client to explore emotions, which could explain why they became isolative afterward. Open-ended questions also demonstrate interest and support, which fosters trust and promotes communication in therapeutic relationships.

Choice B reason:Asking if the client would like to talk is supportive, but it is too vague and closed-ended. The client may simply answer “yes” or “no,” which does not facilitate deeper exploration of feelings. While it offers availability, it is not as therapeutic as directly encouraging discussion about the observed event, the visit.

Choice C reason: This is a less therapeutic response as it assumes that the client enjoyed the visit. It may not reflect the client's true feelings or experiences. It also limits the client's expression to positive aspects only.

Choice D reason: This is a non-therapeutic response as it labels the client's emotion without validation. It may not accurately describe the client's feeling or situation. It also closes the communication by making a statement instead of asking a question.

A. Provide oral sponge toothettes so the client can cleanse and moisten his mouth. B. Teach the client that the oral mucosa must remain dry to prevent aspiration. C. Turn the suction off while allowing the client to rinse his mouth with cool water. D. Instill 50 ml of normal saline solution into the tube and clamp the tube for one hour.

Correct Answer is A

Explanation

Choice A reason: Providing oral sponge toothettes is the best action to take. It helps the client to maintain oral hygiene and comfort, and prevents dryness and cracking of the oral mucosa.

Choice B reason: Teaching the client that the oral mucosa must remain dry to prevent aspiration is not a correct action. The oral mucosa needs to be moist to protect it from infection and irritation. Aspiration is prevented by checking the placement of the nasogastric tube and keeping the head of the bed elevated.

Choice C reason: Turning the suction off while allowing the client to rinse his mouth with cool water is not a safe action. It may increase the risk of aspiration and interfere with the function of the nasogastric tube. The suction should only be turned off when necessary, such as during medication administration or tube feeding.

Choice D reason: Instilling 50 ml of normal saline solution into the tube and clamping the tube for one hour is not an appropriate action. It may cause fluid overload, electrolyte imbalance, and abdominal distension. The nasogastric tube should be flushed with 30 ml of water every 4 to 6 hours to maintain patency and prevent clogging.

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Which explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

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