NCLEX-PN Series: Strategies for Positioning

NCLEX-PN Series: Strategies for Positioning

Questions Leave the first rating Terms in this set (13) Science MedicineNursing Save Immediately a percutaneous liver biopsy, the LPN should place the client in which of the following positions?

a) Supine

b) Right-side lying

c) Left-side lying

d) Semi-fowler's

b

Explanation: If you lay a client on their right side to

apply pressure and prevent hemorrhage on the liver. The liver is on the right side of the abdomen under the ribs. All of the other responses will not apply pressure to the liver.

An angiogram is scheduled for a client with decreased circulation in the right leg. After the angiogram, the LPN should place the client in which of the following positions?

a) Semi-fowler's with right leg bent at

the knee

b) Side-lying with a pillow between

the knees

c) Supine with the right leg extended

d) High-Fowler's with the right leg

elevated c

Explanation: By positioning a client after an

angiogram are you trying to prevent something or promote something? You are trying to promote adequate circulation of the right leg. Keeping the leg at or below the level of the heart so blood flow is not constricted. How should the client be positioned after and angiography to prevent constriction of vessels and keep the right leg at or below the level of the heart?

• The head of the bed is elevated at 30-45

degrees in this position. The leg is lower than the heart. However if the right leg is bent at the knee this could constrict arterial blood flow.

• Use of a pillow in this position could create

pressure points in the right leg. You don't want the knees bent.

• In this position the leg is at the level of the heart.

Circulation will not be constricted because the leg is straight.

• The head of the bed is elevated 60-90 degrees

in this position. Elevating the leg promotes venous return.

Side note: The client is on bed rest for 8-12 hours in

a supine position after an angiogram.

The LPN is caring for a client after an appendectomy. The client continues to report discomfort to the nurse shortly after receiving an analgesic.Which of the following measures by the LPN would be most appropriate?

a) Notify the primary HCP

b) Place the client in Fowler's

position

c) Massage the client's abdomen

d) Provide the client with reading

material b

Explanation: Massaging the client's abdomen will

increase the client's pain. Providing client with reading materials will only distract them but not relieve the pain. Changing the client's position decrease the client's pain by relieving pressure on the client's abdomen.The LPN is caring for a client diagnosed 6 months ago with a 6th thoracic (T6) spinal cord injury. The client reports a "throbbing headache," and the client's face, neck, and upper chest are flushed and diaphoretic. Which action should the LPN take first?

a) Loosen the client's upper body

clothing

b) Check the client for fecal

impaction

c) Remove the indwelling urinary

catheter

d) Sit the client in an upright position

d

Explanation: Autonomic dysreflexia is a potential

complication when a client has a spinal cord injury of T6 or above. This is an emergency. Immediate action must be taken to prevent severe hypertension and stroke. Think about which action will decrease BP most quickly.

• this is an appropriate action but not the first

action

• Fecal impaction may be a cause of autonomic

dysreflexia The impaction should be removed. But it is not a first action.

• This is an inappropriate action. Bladder

distension may be a cause of autonomic dysreflexia. If the catheter is obstructed it should be removed. But this should not be the first action.

• If you sit the client upright the client's BP will

immediately decrease. This action will prevent a further increase in BP.

The LPN is assisting with the care of a client diagnosed 2 weeks ago with right-sided stroke. When assisting the client with meals, it is most important for the LPN to take which action?

a) Encourage the client to bite each

food 4 times.

b) Assist the client to use a straw to

drink fluids with the meal

c) Instruct the client to sit in a chair

for 30 minutes after the meal

d) Provide 8 oz. (240mL) of milk with

every meal at bedtime c

Explanation: All answers relate to swallowing and

eating. Stroke clients are at risk for aspiration.

• It is important to chew and swallow each bite

but not necessarily 4 times.

• Using a straw and drinking thin liquids both

increase the risk of choking and aspiration. Thin liquids are more difficult to swallow. The risk for choking and aspiration is increased.

• By sitting upright after a meal, gravity increases

the passage of food into the stomach.

• Milk and milk products increase production of

saliva and make swallowing more difficult.The LPN is assisting with the care of a client diagnosed with a 4th cervical (C4) complete spinal cord injury.Which observation most concerns the LPN?

a) The assistive personnel (AP)

positions the client in a 30 degree side-lying position

b) The client watches television with

the head of the bed at a 45 degree angle

c) The assistive personnel (AP) uses

warm water and gentle soap for bathing

d) The client lightly rubs the skin with

a bath towel after bathing to ensure dryness b

Explanation: