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 C
Explanation
Choice A rationale
Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.
Choice B rationale
Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.
Choice C rationale
Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.
Choice D rationale
Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
The nurse should stop the IV infusion. The client has manifestations of IV infiltration, which occurs when IV fluid enters the surrounding tissue. Stopping the IV infusion and removing the IV catheter can reduce the risk for further tissue damage.
Choice B rationale
The nurse should elevate the client’s left arm. Elevation can help decrease swelling and reduce the risk for tissue damage.
Choice C rationale
The nurse should apply heat to the client’s left hand. Heat can help reduce swelling and promote comfort.
Choice D rationale
Starting a new IV in the client’s left hand is not recommended at this point. The nurse should first manage the infiltration and then assess the need for a new IV3.
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