A nurse is caring for a client who had a spinal cord injury and has paraplegia. The client is alert and oriented.
The client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities are performed once each day.
On Day 5, the client’s feet are warm, pedal pulses are 2+ bilaterally, plantar flexion contractures are noted bilaterally, and the left heel has a 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, with skin intact.
Which findings require intervention by the nurse?
Passive range-of-motion exercises to lower extremities performed once each day
Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact
Plantar flexion contractures noted bilaterally
Pedal pulses 2+ bilaterally
Correct Answer : A,B,C
The correct answers are Choices A, B, and C.
Choice A rationale: Passive range-of-motion exercises should be performed more frequently than once each day to maintain joint mobility, prevent contractures, and stimulate circulation. Performing them only once daily is inadequate for a client with paraplegia who is immobile.
Choice B rationale: Nonblanchable erythema is a sign of a stage 1 pressure ulcer, indicating that the skin is at risk of further breakdown and infection. Immediate intervention is required to prevent progression to more severe pressure injuries.
Choice C rationale: Plantar flexion contractures can lead to significant long-term disability and complications, such as difficulty in ambulation and pain. These contractures require intervention through more frequent range-of-motion exercises, splinting, or physical therapy to prevent worsening.
Choice D rationale: Pedal pulses that are 2+ bilaterally are within normal limits and indicate adequate peripheral circulation. This finding does not require intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While elevating the head of the bed to 30 degrees can be helpful in some procedures, it is not the most crucial step when inserting a nasogastric (NG) tube. The primary goal is to ensure the tube enters the esophagus and not the trachea.
Choice B rationale
If a patient begins to gag or choke during the procedure, it may indicate that the tube has entered the trachea instead of the esophagus. However, removing the NG tube immediately might not always be the best course of action. It’s important to first assess the situation, reposition the patient, and attempt to advance the tube while the patient swallows.
Choice C rationale
Applying suction to the NG tube prior to insertion is not a standard practice. Suction is typically applied after the NG tube has been properly placed and secured, to remove gastric contents for therapeutic (decompression) or diagnostic (analysis) purposes.
Choice D rationale
Encouraging the patient to take sips of water can facilitate the insertion of the NG tube into the esophagus. Swallowing helps guide the tube down into the esophagus instead of the trachea.
Correct Answer is D
Explanation
Choice A rationale
Cucumbers are a good source of hydration due to their high water content, but they are not particularly high in potassium.
Choice B rationale
Corn is a versatile vegetable that provides a good source of fiber, but it is not particularly high in potassium.
Choice C rationale
Asparagus is a nutrient-rich vegetable known for its diuretic properties, but it is not particularly high in potassium.
Choice D rationale
Avocados are a nutrient-dense fruit that is high in healthy fats and also a good source of potassium. They are a great food choice for a client at risk for hypokalemia.
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