Author Question: What should the nurse do first when assisting the client to a lateral position for placement of a ... (Read 81 times)

meagbuch · **on:** Jul 23, 2018

What should the nurse do first when assisting the client to a lateral position for placement of a bedpan?

1. Perform hand hygiene.
2. Move the client to the side of the bed.
3. Place the client's arm over the chest.
4. Raise the opposite side rail.

Question 2

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should:

1. Include what mobility is impaired.
2. Use Level 1, 2, 3, or 4 to describe immobility.
3. Describe what happens when the client attempts mobility.
4. Add strength assessment data.

recede · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1
Rationale 1: Even though the intervention being performed is placing the client on a bedpan, the nurse should first perform hand hygiene. This prevents cross-transmission of infection from one client to another. Performing this hygiene in front of the client also increases the client's perception of the quality of care being provided and the nurse's concern about infection control.
Rationale 2: This action is done later in the procedure.
Rationale 3: This action is done later in the procedure.
Rationale 4: This action is done later in the procedure.

Answer to Question 2

Correct Answer: 1
Rationale 1: In order to make this broad nursing diagnosis more specific to the client, the nurse should include what mobility is impaired. For example, if the client cannot transfer from bed to chair, a more specific nursing diagnosis is Impaired Transfer Mobility.
Rationale 2: There are NANDA levels of activity intolerance, but not of immobility.
Rationale 3: Describing what happens when the client attempts mobility might be used in the as manifested by section of the nursing diagnosis, but not in the problem statement section.
Rationale 4: Strength assessment data might be used in the as manifested by section of the nursing diagnosis, but not in the problem statement section.