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Silvestri Chapter 18 Ed#54E

Silvestri Chapter 18 Ed#54E

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Published by: Linda Kuglarz on Oct 14, 2008
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Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 018 (edited file)—"Positioning Clients"10/14/08, Page 1 of 6, 3 Figure(s), 0 Table(s), 0 Box(es)
18: Positioning Clients
PRACTICE QUESTIONS
1. A client returns to the nursing unit after an above-the-knee amputation of the right leg. Thenurse positions the client:1. With the stump flat on the bed2. With the foot of the bed elevated3. In reverse Trendelenburg position4. ProneAnswer: 2Rationale: During the first 24 hours after amputation, the nurse elevates the foot of bed (but notthe stump itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hipflexion contractures. The physician’s postoperative orders regarding positioning are alwaysfollowed.Test-Taking Strategy: Note the key words,
returns to the nursing unit after 
. Recalling thatedema is a concern after surgery will direct you to option 2. Review postoperative positioningafter amputation if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Fundamental SkillsReference: Linton, A., & Maebius, N. (2003) ,
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, p. 847.2. A nurse is assigned to assist in caring for a client who has had an autograft placed on thelower extremity. The nurse plans to:1. Maintain the surgical extremity in a flat position.2. Keep the surgical extremity covered with a blanket.3. Maintain the client in a prone position.4. Elevate and immobilize the surgical extremity.Answer: 4Rationale: Autografts placed over joints or on lower extremities are often elevated andimmobilized after surgery for 3 to 7 days. This period of immobilization allows the autografttime to adhere and attach to the wound bed. Options 1, 2, and 3 are incorrect positions.Test-Taking Strategy: Use the process of elimination. Options 2 and 3 can be eliminated first because both a blanket and a prone position can easily disrupt a graft. From the remainingoptions, note that option 4 specifically addresses immobilization of the extremity. Review careafter an autograft if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/PlanningContent Area: Fundamental SkillsReferences: Lewis, S., Heitkemper, M., & Dirksen, S. (2004).
Medical-surgical nursing:
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 018 (edited file)—"Positioning Clients"10/14/08, Page 2 of 6, 3 Figure(s), 0 Table(s), 0 Box(es)
 Assessment and management of clinical problems
(6th ed.). St. Louis: Mosby, p. 534.Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003).
Medical-surgical nursing: Health and illness perspectives
(7th ed.). St. Louis: Mosby, pp. 2000-2001.3. A nurse is assigned to assist in caring for a client after cardiac catheterization. The nurse plans to maintain bed rest with:1. Head elevation at 45 degrees2. Head elevation no greater than 30 degrees3. Bathroom privileges only4. In high-Fowler’s positionAnswer: 2Rationale: After cardiac catheterization, the extremity into which the catheter was inserted iskept straight for the time period as prescribed. The client may turn from side to side. The headof the bed is not elevated higher than 30 degrees to keep the affected leg straight at the groin and prevent arterial occlusion . Bathroom privileges are not allowed in the immediate postcatheterization period. In high-Fowler’s position, the head of the bed is elevated 90 degrees.Test-Taking Strategy: Use the process of elimination. Recalling that a concern after this procedure is bleeding and arterial occlusion will direct you to option 2. Review care to the clientafter cardiac catheterization if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/PlanningContent Area: Fundamental SkillsReferences: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, p. 564.Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003).
Medical-surgical nursing: Health and illness perspectives
(7th ed.). St. Louis: Mosby, p. 640.4. A nurse is reinforcing home care instructions to a client and family regarding care after righteye cataract removal. Which of the following statements, if made by the client, would indicatean understanding of the instructions?1. “I will not sleep on my right side.”2. “I will not sleep on my left side.”3. “I will take aspirin if I have any pain.”4. “I will not wear my glasses until my physician says it is OK.”Answer: 1Rationale: After cataract surgery, the client should not sleep on the side of the body that wasoperated on. Clients should be instructed not to take aspirin or medications containing aspirin.Acetaminophen (Tylenol) can be taken as needed for pain. Clients may wear their glasses.Test-Taking Strategy: Use the process of elimination. If you can remember to instruct clients tostay off the operative side, this will assist you with answering questions related to cataractsurgery. Review care after this type of surgery if you had difficulty with this question.Level of Cognitive Ability: ComprehensionClient Needs: Health Promotion and MaintenanceIntegrated Process: Teaching/Learning
 
Silvestri, 3/e, ISBN 1-1460-0052-6Chapter 018 (edited file)—"Positioning Clients"10/14/08, Page 3 of 6, 3 Figure(s), 0 Table(s), 0 Box(es)
Content Area: Fundamental SkillsReference: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, pp. 1065-1066.5. After a liver biopsy, the nurse places the client in which of the following positions?1. Supine2. Prone3. A left side-lying position with a small pillow or folded towel under the puncture site4. A right side-lying position with a small pillow or folded towel under the puncture siteAnswer: 4Rationale: After a liver biopsy, the client is assisted to assume a right side-lying position with asmall pillow or folded towel under the puncture site for at least 3 hours. Options 1, 2, and 3 areincorrect positions.Test-Taking Strategy: Knowledge regarding the anatomy of the body will assist in answeringthis question. Remember that the liver is on the right side of the body, and that the application of  pressure on the right side will minimize the escape of blood or bile through the puncture site.Review care after a liver biopsy if you had difficulty with this question.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Fundamental SkillsReferences: Linton, A., & Maebius, N. (2003).
 Introduction to medical-surgical nursing 
(3rded.). Philadelphia: W.B. Saunders, p. 720.Pagana, K., & Pagana, T. (2003).
Mosby’s diagnostic and laboratory test reference
(6th ed.). St.Louis: Mosby, p. 659.6. A nurse is administering a cleansing enema to a client with a fecal impaction. Beforeadministering the enema, the nurse assists the client to which of the following positions?1. On the left side of the body, with the head of the bed elevated 45 degrees2. On the right side of the body, with the head of the bed elevated 45 degrees3. Left Sims’ position4. Right Sims’ positionAnswer: 3Rationale: When administering an enema, the client is placed in a left Sims’ position so that theenema solution can flow by gravity in the natural direction of the colon. The head of the bed isnot elevated.Test-Taking Strategy: Recalling the anatomy of the bowel will assist in eliminating options 2and 4. Option 1 can be eliminated next because the head of the bed should be flat during enemaadministration. Review the procedure for enema administration if you had difficulty with thisquestion.Level of Cognitive Ability: ApplicationClient Needs: Physiological IntegrityIntegrated Process: Nursing Process/ImplementationContent Area: Fundamental SkillsReference: Christensen, B., & Kockrow, E. (2003).
 Foundations of nursing 
(4th ed). St. Louis:

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