A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?
Massage bony prominences on the client's left side.
Support the client's left arm on a pillow while sitting.
Position the bedside table on the client's left side.
Place the client's cane on their left side while ambulating.
The Correct Answer is B
A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.
B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.
C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.
D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
"Repeat the dose if your child vomits within 1 hour after taking the medication." This statement is incorrect. If a child vomits within 1 hour after taking digoxin, the parents should not repeat the dose. The reason is that the child may have already absorbed a sufficient amount of the medication before vomiting, and an additional dose could lead to digoxin toxicity.
Choice B reason:
"You can add the medication to a half-cup of your child's favourite juice." This statement is incorrect. Adding digoxin to juice or any other food or drink is not recommended. Digoxin should be administered separately and not mixed with food or liquids to ensure accurate dosing and prevent potential interactions with other substances.
Choice C reason:
"Have your child drink a small glass of water after swallowing the medication." This statement is correct. Giving a small glass of water after administering digoxin helps ensure that the medication is fully swallowed and goes into the stomach, reducing the risk of it being retained in the mouth or throat.
Choice D reason:
"Limit your child's potassium intake while she is taking this medication." This statement is not accurate. Digoxin is often prescribed in conjunction with other heart failure medications, some of which may impact potassium levels. However, the parents should not arbitrarily limit the child's potassium intake without specific instructions from the healthcare provider. The healthcare provider will monitor the child's potassium levels and adjust the treatment plan as necessary.
Correct Answer is D
Explanation
Choice A reason
Re-evaluate the client for an ET cuff leak is not appropriate. While an ET cuff leak could contribute to respiratory distress, the immediate concern is the high-pressure alarm, which indicates increased resistance to airflow. The nurse should address the alarm first and then assess for other potential causes, including an ET cuff leak.
Choice B reason:
Option B: Assess for disconnected tubing is not appropriate. A disconnected tubing is also a potential cause of the high-pressure alarm. However, before checking for disconnected tubing, the nurse should first deliver manual breaths with a resuscitation bag to provide the client with adequate ventilation.
Choice C reason:
Decrease the ventilator flow rate is not appropriate. Decreasing the ventilator flow rate might not be the appropriate action in this situation, as the high-pressure alarm indicates increased resistance, which might require increased flow to overcome. Additionally, the nurse should not delay taking immediate action by adjusting ventilator settings without knowing the specific cause of the high-pressure alarm.
Choice D reason:
When the high-pressure alarm is beeping, and the client is experiencing respiratory distress, it indicates that there is an increased resistance to airflow within the ventilator circuit or the client's airway. This can be a life-threatening situation, and immediate action is required.
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