Author Question: Which interventions would the nurse implement in order to support the unresponsive client in the ... (Read 102 times)

amal · **on:** Jun 25, 2018

Which interventions would the nurse implement in order to support the unresponsive client in the dorsal recumbent position?

Select all that apply.
1. Place several pillows under the client's head.
2. Place a pillow under the lower legs from knee to ankle.
3. Place trochanter rolls laterally against the femur.
4. Always place a rolled towel or small pillow under the lumbar curvature.
5. Elevate the upper arms on pillows.

Question 2

The nurse may delegate which tasks to the unlicensed assistive personnel (UAP)?

Select all that apply.
1. Determining the number of staff needed for safe transfer
2. Assessing the client's ability to assist with transfers
3. Use of a hydraulic lift when moving a client
4. Determining appropriate positions for the client
5. Encouraging the client to participate as much as possible in repositioning

ecabral0 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2,3

Usually, only one pillow of adequate thickness would be placed under the client's head and shoulders to prevent hyperextension of the neck. Placing a pillow under the lower leg prevents hyperextension of the knees, keeps the heels off the bed, and reduces lumbar lordosis. Placing pillows against the femur prevents external rotation of the hips. A pillow should be placed under the lumbar curvature only if a space is found between the lumbar area and the bed. The nurse would elevate the forearms and hands, not the upper arms, on pillows if the client is unconscious or has paralysis of the upper extremities.

Answer to Question 2

Correct Answer: 3,5
The nurse can safely delegate use of a hydraulic lift to the UAP as long as the nurse assesses the UAP's competence to use the equipment. The UAP should be instructed always to encourage client participation in the provision of care in order to foster autonomy for the client. Determining the number of staff needed to safely transfer a client, assessing the client's ability to assist, and determining the best position for the client are the nurse's responsibility because they take advanced education, and should not be delegated to the UAP.