A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

decubitus ulcers.

foot drop.

pooling of blood.

blood pressure changes.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Decubitus ulcers (pressure ulcers) are not directly prevented by applying padded boots for dorsiflexion.
Choice B rationale: Applying padded boots for dorsiflexion helps prevent foot drop, a condition where the foot is permanently in a plantar-flexed position, which can lead to contractures.
Choice C rationale: Pooling of blood is not a primary concern addressed by applying padded boots for dorsiflexion.
Choice D rationale: Blood pressure changes are not directly addressed by applying padded boots for dorsiflexion.

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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale: Contractures are a common complication of immobility due to the shortening of muscles and connective tissues.
Choice B rationale: Diarrhea is not typically associated with complications of immobility.
Choice C rationale: Polyuria is not typically associated with complications of immobility.
Choice D rationale: Atelectasis, the collapse of lung tissue, can occur in immobile clients due to reduced lung expansion and ventilation.
Choice E rationale: Pressure ulcers are a significant risk in immobile clients due to prolonged pressure on specific areas of the body.

A. Anemia B. Infection C. Wound healing D. Necrosis

Correct Answer is B

Explanation

Choice A rationale: Redness, warmth, swelling, and green drainage are not typically signs of anemia.
Choice B rationale: These symptoms are indicative of infection. Infections can cause localized redness, warmth, swelling, and the drainage of discolored material.
Choice C rationale: While wound healing may involve some inflammation, the described symptoms are more consistent with infection than normal wound healing.
Choice D rationale: Necrosis involves tissue death and is not typically associated with redness, warmth, and swelling.

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A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

The nurse is caring for a client with a wound from a biking accident. She assesses the wound and notices that the surrounding skin is very red and warm. The wound looks swollen and is draining a green like drainage. The nurse would recognize these symptoms would be a sign of what?

Correct Answer is B

Explanation

A wound care nurse has been consulted on a patient with multiple pressure wounds. The nurse comes across this heal wound. How should she document the following wound?

A nurse is teaching a client about the nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

A nurse is completing her physical assessment on her newly admitted patient. She is assessing the patient's skin and documenting her findings. How should she document the following wound?

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The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which reasoning?

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