Saunders Review: 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."
Answer: 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.
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? Refer to the figures in options 1 to 4.
Answer: 1 Rationale: Clients who have undergone craniotomy 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. A reverse Trendelenburg's position would not be helpful and may be uncomfortable for the client
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
Answer: 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
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
Answer: 2 Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized after 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.
The nurse is caring for a 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
Answer: 2 Rationale: Positioning after a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the primary health care provider's (PHCP'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 lying on the operative side (unless specifically prescribed by the PHCP) is avoided to prevent displacement of the prosthesis
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
Answer: 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.
The nurse is preparing to insert a nasogastric tube into a 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
Answer: 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.
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
Answer: 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. A flat 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.
. 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 primary health care provider's (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
Answer: 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 primary health care provider's (PHCPs) 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 PHCPs prefer a lower position or the flat position) until hemostasis is adequately achieved.
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
Answer: 4 Rationale: The residual limb is usually supported on pillows for the first 24 hours after 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 the primary health care provider's or surgeon's prescriptions regarding positioning after amputation, because there are often differences in preference in terms of positioning after the procedure related to risks associated with hip and knee contracture.