A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?

To prevent contractions in the hand.

To prevent skin breakdown.

To prevent decrease perfusion in the lower extremities.

To prevent pooling of blood in the hand.

Answer and Explanation

The Correct Answer is A

A. To prevent contractions in the hand:

The use of hand and wrist rolls helps prevent contractures, which are permanent shortening of muscles or joints. This is particularly important in comatose patients or those with limited mobility to maintain proper hand positioning and prevent deformities.

B. To prevent skin breakdown:

While proper positioning can contribute to preventing skin breakdown, the primary purpose of hand and wrist rolls, in this context, is to address the risk of contractures rather than skin breakdown.

C. To prevent decreased perfusion in the lower extremities:

The action described is specifically related to the hands and wrists, not the lower extremities. It is not designed to prevent decreased perfusion in the lower extremities.

D. To prevent pooling of blood in the hand:

While maintaining proper hand positioning may contribute to optimal circulation, the primary purpose is to prevent contractures rather than addressing blood pooling.

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Correct Answer is B

Explanation

A. Protect the muscles of the lower extremities from atrophy:

This statement is not the primary purpose of sequential compression devices (SCDs) and compression stockings. While these devices can help maintain muscle tone by promoting blood circulation, their primary function is to prevent blood pooling and reduce the risk of deep vein thrombosis (DVT).

B. Keep the blood from pooling in lower extremities to avoid clots:

This is the correct purpose of sequential compression devices and compression stockings. They are designed to promote venous return and prevent blood from pooling in the lower extremities, thereby reducing the risk of blood clots, especially in individuals at risk for deep vein thrombosis (DVT).

C. Keep the patient from getting sores on the skin:

Preventing sores on the skin is not the primary purpose of these devices. While improved circulation may contribute to skin health, preventing skin sores is not the primary therapeutic goal of SCDs and compression stockings.

D. Keep the patient’s joints in working order:

Maintaining joint function is not the primary purpose of sequential compression devices and compression stockings. These devices primarily focus on promoting venous circulation and preventing complications related to blood pooling and clot formation.

A. Increased, strong B. Diminished, weaker than expected C. Absent, unable to palpate D. Bounding

Correct Answer is A

Explanation

A. Increased, strong:

A pulse amplitude of +3 indicates an increased or strong pulse. This suggests a forceful and palpable pulse, potentially associated with conditions like fever, anemia, or increased cardiac output.

B. Diminished, weaker than expected:

This would typically be associated with a lower than normal pulse amplitude. It might suggest poor peripheral perfusion or decreased cardiac output.

C. Absent, unable to palpate:

If the pulse is absent or unable to be palpated, it could indicate severe conditions such as vascular occlusion or cardiac arrest.

D. Bounding:

A bounding pulse is one with a forceful and strong amplitude. It suggests a powerful expansion of the arterial wall, and it can be associated with conditions like fever, anemia, or increased cardiac output.

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A nurse is caring for a comatose patient and applies a hand and wrist roll in each hand of the patient to keep the thumb slightly adducted and correct position to the fingers. What is the primary purpose of this action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse understands that sequential compression devices and compression stockings are used for which of the following?

Correct Answer is B

Explanation

The nurse is taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?

Correct Answer is A

Explanation

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