BEST PRACTICE NCLEX QUESTION BASED ON POSITIONING CLIENTS Part -8

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Priority concepts are mobility and safety

  • Always review the primary health care provider’s (PHCP’s) or surgeon’s prescription, especially after treatments or procedures, and take note of instructions regarding positioning and mobility.
  • Positions to ensure safety and comfort are as given below:
    • Integumentary system:
      • Autograft: After surgery, the site is immobilized usually for 3 to 7 days, or as prescribed.
      • In case of Burns of the face and head, elevate the head of the bed to prevent or reduce facial, head, and tracheal edema.
      • Circumferential burns of the extremities: elevate the extremities above the heart level to prevent or reduce dependent edema.
    • Reproductive system:
      • Mastectomy: semi fowler’s positions with elevation of the bed at least 30 degrees along with affected arm elevated on a pillow to promote lymphatic fluid return after a removal of axillary lymph nodes
    • Endocrine system
      • Hypophysectomy: elevate the head of the bed to prevent increased intracranial pressure.
      • Thyroidectomy: semi-fowlers to fowler’s position to reduce swelling and edema in the neck area. support head or neck with sandbags or pillow
    • Gastrointestinal system:
      • Hemorrhoidectomy: lateral/ side lying position to prevent pain or bleeding
      • Gastroesophageal reflux disease: Reverse Trendelenburg’s position to promote gastric emptying and prevent esophageal reflux.
      • Liver biopsy: right lateral / side-lying position and place small pillow or folded towel under puncture site.
      • Paracentesis: semi- fowler position in bed or sitting upright on the side of bed or in a chair with the feet supported.
      • Nasogastric tube:
        • Insertion: high fowler’s position with the head titles forward (help close the trachea and open the esophagus)
        • Irrigation and tube feedings: Elevate the head of bed (semi fowler to fowler position) to prevent aspiration. Head elevation is maintained for 30 minutes to 1 hour after an intermittent feeding and should remain elevated for continuous feedings.
      • Rectal enema and irrigations: Left Sim’s position to allow the solution to flow by gravity in the natural direction of the colon.
      • Sengstaken-Blakemore and Minesota tubes: not commonly used, if prescribed, maintain elevation of the bed.
    • Respiratory system:
      • Chronic Obstructive Pulmonary Disease: In advance disease, place client in a sitting position, leaning forward, with the client’s arms over several pillows or an overbed table; this position will help the patient to breathe easier
      • Laryngectomy (radial neck dissection) semi-fowler or fowler position to maintain airway and minimize edema
      • Bronchoscopy post procedure: semi-fowler position to prevent choking
      • Postural drainage: Trendelenburg’s position
    • Cardiovascular system:
      • Abdominal aneurysm resection: after surgery, limit elevation of the head to 45 degrees to avoid flexion of the graft.
      • Amputation of the lower extremity: during first 24 hours after amputation, elevate the foot of the bed to reduce edema. Consult with the PHCP and, if prescribed, position the client in a prone position twice a day for 20–30-minute period to stretch muscles and prevent flexion contractures of the hip.
      • Arterial vascular grafting of an extremity: affected extremity is kept straight, limit movement and avoid flexion of the hip and knee.
      • Heart failure and pulmonary edema: position the client in upright, preferably with the legs dangling over the side of the bed, to decrease venous return and lung congestion.
      • Peripheral arterial disease: at rest, elevate feet, but not above the level of the heart.
      • Deep vein thrombosis: if the extremity is red, edematous, and painful, traditional heparin sodium therapy may be initiated. Bed rest with leg elevation may also prescribed for the client.
      • Varicose veins: Leg elevation above the heart level usually prescribed, minimized prolong sitting or standing during the daily activities.
      • Venous insufficiency and leg ulcers: Leg elevation
    • Sensory system:
      • Cataract surgery: Postoperatively, elevate the head of the bed
        (semi-fowler to fowler position) and position the client on the back or the nonoperative side to prevent the development of edema at the operative side.
      • Retinal detachment: If detachment is large, bed rest and bilateral eye patching prescribed to minimize the eye movement
    • Neurological system
      • Autonomic dysreflexia: head elevation of the bed to a high fowler’s position to assist with adequate ventilation and assist in the prevention of hypertensive stroke.
      • Cerebral aneurysm: bed rest with head of the bed elevated 30 – 40 degrees to prevent pressure on the aneurysm site.
      • Cerebral angiography: bed rest, extremity kept straight in which contrast medium was injected and immobilized for about 6-8 hours.
      • Stroke or brain attack:
        • In case of hemorrhagic strokes, bed head elevated to 30 degrees to reduce the intracranial pressure and to facilitate the venous drainage.
        • In case of ischemic strokes: the head of the bed is usually kept flat
        • Maintain head in the midline, neutral position to facilitate venous drainage from the head
        • Avoid extreme hip and neck flexion, extreme hip flexion may increase intrathoracic pressure, whereas extreme neck flexion prohibits venous drainage from the brain.
      • Craniotomy: should not positioned on the site that was operated on, especially if the bone flap has been removed, because the brain has no covering on the affected site. Elevate bed head 30-40 degrees and maintain head in a midline, neutral position to facilitate venous drainage from the head.
      • Laminectomy and other vertebral surgery: Clients are often out of the bed postoperatively with a back brace if prescribed. Back is kept straight when out of the bed.
      • Increased intracranial pressure: 30 – 40 degrees elevated head of the bed and maintain head in midline, neutral position to facilitate venous drainage from the head. Avoid extreme hip and neck flexion.
      • Lumbar puncture: During procedure: assist the client to the lateral (side-lying) position, with the back bowed at the edge of the examining table, the knees flexed up to the abdomen and the neck flexed so that the chin is resting on the chest. After the procedure, place patient in supine position for 4-12 hours, as prescribed.
      • Spinal cord injury: Immobilize the client on a spinal backboard, with the head in a neutral position, to prevent incomplete injury from the becoming complete. Prevent head flexion, rotation or extension, the head is immobilized with a firm, padded cervical collar. Logroll the client.
  • Musculoskeletal system:
    • Total hip replacement: positioning depends upon the surgery techniques used that is anterior or posterior approach, the method of the implantation, the prosthesis. and surgeon’s preference. Maintain abduction when the client is in a supine position or positioned on the nonoperative side. Place a wedge (Abduction) pillow between the client’s legs to maintain abduction; instruct the client not to cross the legs

DEVICES USED FOR THE PERFECT POSITIONING:

  1. Bed boards: place under mattress, useful for increasing back support
  2. Foot boots: made of rigid plastic or heavy foam, keep foot flexed at the proper angle
  3. Hand rolls: maintain the fingers in a slightly flexed and functional position, keep thumb slightly adducted in opposition to fingers
  4. Hand-waist splints: maintain proper alignment of the thumb in slight adduction and the wrist in slight dorsiflexion.
  5. Pillows: provide support, reduce pain, coughing or deep breathing
  6. Sandbags: immobilize extremities and maintain specific body alignment
  7. Side-rails: safety, provide assistance
  8. Trapeze bar: assists in transfer from the bed to a wheelchair, help to perform upper arm- strengthening exercises.
  9. Trochanter rolls: prevent external rotation of the legs when the client is in supine position.
  10. Wedge pillow: maintain legs in abduction after total hip replacement surgery.

PRACTICE NCLEX QUESTIONS:

  1. A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?
    1. Lying in bed on the affected side
    2. Lying in bed on the unaffected side
    3. Sim’s position with the head of the bed flat
    4. Prone with the head turned to the side and supported by a pillow
  2. The nurse is caring for a client following a craniotomy in which a large cancerous tumor was removed from the left side. In which position can the nurse safely place the client?
    1. Head of the bed elevated 30-40 degrees
    2. Flat position
    3. Reverse Trendelenburg’s position
    4. Position on the side that was operated on
  3. The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?
    1. Out of the bed activities as desired
    2. Bed rest with affected extremity kept flat
    3. Bed rest with elevation of the affected extremity
    4. Bed rest with the affected extremity in a dependent position
  4. The nurse is caring for client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?
    1. Head elevated lying on the operative side
    2. On the nonoperative side with the legs abducted
    3. Side-lying with the affected leg internally rotated
    4. Side-lying with the affected leg externally rotated
  5. The nurse is providing instructions to a client and the family regarding the home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?
    1. I should sleep on my left side
    2. I should sleep on my right side
    3. I should sleep with my head flat
    4. I should not wear my glasses at any time
  6. The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?
    1. Left’s Sims ‘position
    2. Right Sims ‘position
    3. On the left side of the body, with the head of the bed elevated 45 degrees
    4. On the right side of the body, with the head of the body elevated 45 degrees
  7. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?
    1. Prone
    2. Reverse Trendelenburg’s
    3. Supine, with the residual limb flat on the bed
    4. Supine, with the residual limb supported with pillows
  8. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?
    1. Maintain the client in a prone position
    2. Elevate and immobilize the grafted extremity
    3. Maintain the grafted extremity in a flat position
    4. Keep the grafted extremity covered with a blanket.
  9. The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the PHCP’s prescription and plans to allow which client position or activity after the procedure?
    1. Bed rest in high fowler’s position
    2. Bed rest with bathroom privileges only
    3. Bed rest with head elevation at 60 degrees.
    4. Bed rest with head elevation no greater than 30 degrees
  10. The nurse is preparing to insert a nasogastric tube into the client. The nurse should place the client in which position for insertion?
    1. Right side
    2. Low fowler’s
    3. High fowler’s
    4. Supine with the head flat

ANSWERS

  1. 2
  2. 1
  3. 3
  4. 2
  5. 1
  6. 1
  7. 4
  8. 2
  9. 4
  10. 3

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