A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

A measure the calves for symmetry

B palpate the bladder

C Place a pillow between the knees and ankles

D Check the gag reflex

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.

Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.

Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.

Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.

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Correct Answer is C

Explanation

Choice A Rationale: Educating about the importance of proper food handling is important for preventing foodborne illnesses but is not specific to the care of a client with tetanus.

Choice B Rationale: Offering food at least 4 times a day may be necessary for maintaining nutritional support, but it does not address the specific care needs of a client with tetanus.

Choice C Rationale: Anticipating administration of opioids is an important component of the care plan for tetanus. Opioids can help manage muscle spasms and severe pain associated with tetanus.

Choice D Rationale: Providing distraction activities may be beneficial for clients with tetanus to help divert their attention from muscle spasms and discomfort, but it is not the primary intervention.

A. A Urinary output B. B Blood Pressure C. C Counting respirations D. D Bowel sounds

Correct Answer is C

Explanation

Choice A Rationale: Urinary output is also an important assessment in clients with a C3 spinal cord injury because it helps monitor for urinary retention and potential complications but it is not a priority compared to assessing the respiratory function of this client.

Choice B Rationale: Blood pressure is important to monitor but may not be the top priority assessment in this context.

Choice C Rationale: The nurse should prioritize counting respirations for a client with a C3 spinal cord injury, as this level of injury affects the phrenic nerve that innervates the diaphragm. The client may have difficulty breathing and require mechanical ventilation.

Choice D Rationale: Bowel sounds are important but may not be the priority assessment in this case.

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A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for the client hospitalized with tetanus, which of the following will the nurse include in the care plan?

Correct Answer is C

Explanation

When planning care for a client with a C3 spinal cord injury, which of the following will the nurse identify as the priority ongoing assessment?

Correct Answer is C

Explanation

A client has sustained a T4-T5 injury and the nurse suspects he is in neurogenic shock. Which of the following manifestations are consistent with neurogenic shock? Select All that Apply

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A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize which of the following as confabulation?

A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?

After performing an assessment on a client with a spinal cord injury, which intervention will the nurse employ to prevent cardiovascular complications?

When caring for the client hospitalized with tetanus, which of the following will the nurse include in the care plan?

After assessing a client with deficits from a spinal cord injury, the nurse identifies the client's 02 saturation is 92%. Which of the following is the best first action by the nurse?