Difficulty: Medium
Average Score: 93%
Full-length
The nurse is making rounds and observes a client who is unconscious (see fi gure). The nursing assistant has just turned the client from lying on her back. Before raising the side rail, the nurse should:
Correct answer
C
Rationale
The client is positioned correctly in the side-lying position. The pillows support the clientÔÇÖs joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the clientÔÇÖs skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.