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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Free Nursing Study Resources

Correct Answer is ["0.8"]

Explanation

Volume= dose/concentration

= 12/15

= 0.8 mL

A. The patient may have paralytic ileus that could last 3-5 days B. It is normal for all post-op patients not to have bowel sounds C. The absence of bowel sounds is an abnormal finding D. Document absent bowel sounds and notify the physician

Correct Answer is A

Explanation

Choice A rationale: The absence of bowel sounds on post-operative day 2 may indicate paralytic ileus, which is a temporary impairment of bowel motility. Paralytic ileus can last for 3-5 days postoperatively and is considered a normal response to surgery.
Choice B rationale: It is not normal for all post-op patients to have absent bowel sounds on day 2. Bowel sounds should typically return within the first 24 hours after surgery.
Choice C rationale: The absence of bowel sounds can be a normal finding in the immediate postoperative period, especially within the first 24 hours. However, it becomes abnormal if prolonged.
Choice D rationale: Documenting absent bowel sounds is appropriate, but notifying the physician should be based on the overall clinical picture and other symptoms.

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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

Ordered: Morphine sulfate 12 mg IM Available: Morphine sulfate 15 mg/mL How many mL will you administer?

Correct Answer is ["0.8"]

Explanation

A nurse is assessing bowel sounds on post-operative day 2 abdominal surgery patients. He does not hear bowel sounds. What should the nurse conclude about his findings?

Correct Answer is A

Explanation

5 fl oz = ____mL

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