Chapter 19: Positioning Clients

The nurse is providing instructions to a client and the family regarding 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."

1 Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient. Test-Taking Strategy: Focus on the subject, right cataract surgery. Use of the principles of gravity and edema formation will assist in answering this question. Remember to instruct the cli- ent to remain off the operative side and to rest with the head elevated to minimize edema formation. This will assist you when answering questions related to cataract surgery. Review: Positioning following cataract surgery

The nurse is caring for a client following a craniotomy, in which a large tumor was removed from the left side. In which position can thenursesafelyplacetheclient? Refer to the figures in options 1 to 4.

1 Rationale: Clients who have undergone crainotomy should have the head of the bed elevated 30 to 45 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline neutral position. The client should not be positioned on the site that was operated on, especially if the bone flap was removed, because the brain has no bony covering on the affected site. A flat position or Trendelenburg's position would increase intracranial pressure. Areverse Trendelenburg's position would not be helpful and may be uncomfortable for the client. Test-Taking Strategy: Focus on the subject, positioning fol- lowing craniotomy. Remember that a primary concern is the risk for increased intracranial pressure. Therefore, use concepts related to gravity and preventing edema and increased intracranial pressure to answer this question. Review: Positioning following craniotomy

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 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 bed elevated 45 degrees

1 Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position. Test-Taking Strategy: Focus on the subject, positioning for enema administration. Use knowledge regarding the anatomy of the bowel to answer the question. The descending colon is located on the lower left side of the body. The head of the bed should be flat during enema administration. Review: Enema administration

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 posto- perative 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.

2 Rationale: Autografts placed over joints or on lower extremi- ties are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site. Test-Taking Strategy: Focus on the subject, positioning fol- lowing autograft. Use general postoperative principles; elevating the graft site will decrease edema to the graft. The client should not be placed in a prone position or have it covered after surgery since it can disrupt a graft easily. Review: Positioning following autograft

The nurse is caring for a client who is 1 day postop- erative for a total hip replacement. Which is the best position in which the nurse should place the client? 1. Side-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

2 Rationale: Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the health care provider's (HCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the HCP) is avoided to prevent displacement of the prosthesis. Test-Taking Strategy: Focus on the strategic word, best. Use knowledge regarding care of clients following total hip replace- ment to answer this question. After a total hip replacement, the client should never have the extremity internally or externally rotated. Lying on the surgical side can cause damage to the surgical replacement site. Review: Positioning after total hip replacement

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. Sims' position with the head of the bed flat 4. Prone with the head turned to the side and supported by a pillow

2 Rationale: To facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with the feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims' positions are inappropriate positions for this procedure. Test-Taking Strategy: Focus on the subject, positioning for thoracentesis. To perform a thoracentesis safely, the site must be visible to the health care provider (HCP) performing the procedure. The client should be placed in a position where he or she is as comfortable as possible with access to the affected side. A prone position would not give the HCP access to the chest. Lying on the affected side would prevent access to the site. Review: Positioning for thoracentesis

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1.Rightside 2. Low Fowler's 3. High Fowler's 4. Supine with the head flat

3 Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube. Test-Taking Strategy: Focus on the subject, insertion of a nasogastric tube. Visualize each position and think about how it may facilitate insertion of the tube. Also, recall that a concern with insertion of a nasogastric tube is pulmonary aspiration. Placing the client in a high Fowler's position with his or her chin to the chest will decrease the risk of aspiration. Review: Positioning for nasogastric tube insertion

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-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3 Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Aflat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking. Test-Taking Strategy: Focus on the subject, the safe position or activity for the client with deep vein thrombosis. Think about the pathophysiology associated with this disorder and the principles related to gravity flow and edema to answer the question. Review: Positioning for a venous disorder

The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the health care provider's (HCP's) prescription and plans to allow which cli- ent position or activity following 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

4 Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP's preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCPs prefer a lower position or the flat position) until hemostasis is adequately achieved. Test-Taking Strategy: Focus on the subject, positioning fol- lowing cardiac catheterization. Think about this diagnostic procedure and what it entails. Understanding that the head of the bed is never elevated more than 30 degrees and bathroom privileges are restricted in the immediate post catheterization period will assist in answering this question. Review: Positioning following cardiac catheterization

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

4 Rationale: The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check health care provider prescriptions regarding positioning following amputation. Test-Taking Strategy: Focus on the subject, positioning following amputation, and note that the client has just returned from surgery. Using basic principles related to immediate post- operative care and preventing edema will assist in directing you to the correct option. Review: Positioning following amputation