A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Place the client’s glasses on the bedside table.

Place the call light within the client’s reach.

Check on the client every 4 hr.

Place the client in a room near the nurses’ station.

Answer and Explanation

The Correct Answer is B

Choice A reason: Glasses on the bedside table may be inaccessible for a quadriplegic client lacking arm movement. This doesn’t ensure immediate utility or safety. Scientifically, quadriplegia limits motor function, requiring adaptive aids within reach, making this less practical than direct assistance options.

Choice B reason: Placing the call light within reach empowers the quadriplegic client to summon help, addressing their limited mobility. This aligns with scientific rehabilitation principles, enhancing independence and safety by ensuring communication access, critical for managing needs in paralysis effectively.

Choice C reason: Checking every 4 hours is insufficient for quadriplegia, where urgent needs (e.g., pressure sores) arise faster. Scientifically, frequent monitoring is standard, and this gap risks neglect, making it less proactive than enabling client-initiated contact for timely care and intervention.

Choice D reason: A room near the station aids staff response but doesn’t guarantee immediate help without client input. Scientifically, proximity alone doesn’t address quadriplegia’s dependency needs as directly as a call light, which ensures the client can signal distress promptly.

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Correct Answer is D

Explanation

Choice A reason: Fluconazole treats fungal infections, not RSV, a viral respiratory illness. Antivirals like ribavirin might apply, but antifungals don’t. Scientifically, this mismatches RSV’s etiology, as it’s a paramyxovirus, rendering fluconazole ineffective and irrelevant for managing this preschooler’s condition.

Choice B reason: Monitoring urine for protein assesses kidney function, unrelated to RSV, which affects lungs. Proteinuria isn’t a typical RSV sign. Scientifically, this lacks relevance, as RSV causes respiratory distress, not renal complications, making it an unnecessary action here.

Choice C reason: An X-ray of the neck targets croup or epiglottitis, not RSV, which affects lower airways. RSV needs chest imaging if severe. Scientifically, neck imaging misaligns with RSV’s pathophysiology, wasting resources when lung assessment is more pertinent.

Choice D reason: Droplet precautions prevent RSV spread via respiratory droplets, critical in preschoolers who aerosolize virus easily. Scientifically, this aligns with infection control, as RSV’s high contagiousness requires masks and isolation to protect others, a primary nursing action per guidelines.

A. Decreased blood pressure B. Decreased skin turgor C. Weight loss D. Crackles heard in the lungs

Correct Answer is D

Explanation

Choice A reason: Decreased blood pressure is not a direct sign of fluid overload; it may indicate hypovolemia or shock. Fluid overload increases intravascular volume, typically raising pressure initially. This finding contradicts the excess fluid state in enteral feeding complications, where the body retains too much water, affecting other systems first.

Choice B reason: Decreased skin turgor suggests dehydration, not fluid overload. In overload, excess fluid accumulates in tissues, potentially causing edema, not poor elasticity. Enteral feeding can lead to overhydration if mismanaged, making turgor an unreliable indicator here, as it reflects fluid deficit rather than the excess seen in this scenario.

Choice C reason: Weight loss occurs with fluid loss or malnutrition, not overload. Fluid overload from enteral feedings causes rapid weight gain due to water retention. This finding opposes the expected physiology of excess fluid, where the body holds onto water, increasing mass, not shedding it as in dehydration.

Choice D reason: Crackles in the lungs indicate fluid overload, as excess fluid from enteral feedings backs up into pulmonary circulation, causing pulmonary edema. This audible sign reflects fluid escaping into alveoli, impairing gas exchange, a common complication when intake exceeds the body’s ability to excrete water effectively.

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A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Nursing Test Bank

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