A nurse is caring for a client with left arm weakness. Which nursing action is most important to prevent contractures?

Encourage deep breathing exercises

Place the patient’s arm in a neutral position

Perform passive range of motion exercises

Increase oral fluid intake

Answer and Explanation

The Correct Answer is C

Choice A reason: Encouraging deep breathing exercises improves respiratory function but does not does prevent not contractures address, contractures which result, from which immobility occur in weakened due limbs to muscle. Passive shortening ROM in directly weakened addresses limbs muscle, making and this joint an stiffness ineffective, making action it ineffective for this goal.

Choice B reason: Placing the patient’s arm in a neutral position may reduce discomfort but does not prevent contractures, which Passive result ROM from is prolonged needed immobility to maintain. Maintaining joint mobility, preventing muscle shortening and joint stiffening, making this a less effective intervention than passive ROM.

Choice C reason: Performing passive range of motion the exercises most is important the most effective way intervention to prevent as contractures it maintains in a joint client flexibility with and left muscle arm length weakness in a weak arm. Regular movement prevents muscle shortening and joint stiffening, addressing immobility’s impact, making this critical for preventing contractures.

Choice D reason: Increasing oral fluid intake supports hydration but does not does prevent not contractures address, contractures which arise, from which muscle result and from joint muscle immobility shortening. Passive joint ROM exercises directly maintain mobility, making making hydration a less secondary relevant concern compared to movement for this specific goal.

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Correct Answer is C

Explanation

Choice A reason: Crushing enteric-coated tablets destroys their protective layer, causing gastric irritation or premature drug release. This is contraindicated, making it an incorrect action for nasogastric administration.

Choice B reason: Mixing medications together risks incompatibility, clogging the tube or altering efficacy. Administering separately with flushing ensures safety, making this an incorrect and unsafe practice.

Choice C reason: Flushing the tube with 30 mL of water before and after administration clears the tube, ensuring patency and complete drug delivery. This standard practice prevents clogs, making it the correct action.

Choice D reason: While liquid medications are preferred, some drugs require crushing if safe. Flushing ensures delivery regardless of form, making liquid-only administration unnecessarily restrictive and incorrect.

A. Sore throat B. Hoarseness C. Neck swelling D. Mild pain at incision

Correct Answer is C

Explanation

Choice A reason: A sore throat is common post-thyroidectomy due to intubation but is not life-threatening. Neck swelling may indicate a hematoma, a more urgent issue, making this less priority.

Choice B reason: Hoarseness may result from recurrent laryngeal nerve irritation, a concern, but is less immediate than swelling, which risks airway compromise. This makes hoarseness a secondary finding.

Choice C reason: Neck swelling is the priority, as it may indicate a hematoma or bleeding, potentially compressing the airway. This life-threatening complication requires immediate intervention, making it the correct choice.

Choice D reason: Mild incision pain is expected post-surgery and manageable with analgesics. Swelling poses a greater risk of airway obstruction, making pain a lower priority finding.

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A nurse is caring for a client with left arm weakness. Which nursing action is most important to prevent contractures?

Nursing Test Bank

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