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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Rationale: Notifying the physician may be necessary if troubleshooting the issue does not resolve the problem, but it is not the initial step.
Choice B Rationale: The nurse should first check the tubing of the indwelling urinary catheter for any kinks, twists, or obstructions that might prevent the urine flow. This is a simple and non-invasive intervention that can resolve the problem quickly and easily.
Choice C Rationale: Removing the indwelling catheter is not advisable without proper assessment and intervention, as it can lead to complications.
Choice D Rationale: Replacing the indwelling catheter is not the first step and should only be done if the problem cannot be resolved through assessment and interventions.
Correct Answer is C
Explanation
Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.
Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.
Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.
Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted
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