A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Instruct the client to sit on a rubber ring when seated in a chair.

Raise the head of the client's bed to a 90° angle.

Use moisturizing lotion while massaging the client's bony prominences.

Place pillows between the client's knees when in a side-lying position.

Answer and Explanation

The Correct Answer is D

A)   Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B)   Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C)   Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D)   Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.

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Correct Answer is B

Explanation

A) While wearing an N95 respirator may be necessary for certain infections, it is not a routine precaution for clients in protective isolation.
B) Ensuring the client's room has positive-pressure airflow helps prevent the entry of airborne pathogens into the room, reducing the risk of infection for the immunocompromised client.
C) Using disposable plates and utensils helps reduce the risk of cross-contamination and infection transmission but is not directly related to airborne infection control.
D) Monitoring the client's temperature is important for assessing for signs of infection, but it does not directly prevent infection transmission in the same way as positive-pressure airflow.

A. Alert and orientated x4 B. Heart and lung sounds clear C. Client urinating 100 mL/hour D. Client is tolerating soft diet and oral fluids E. Bilateral pedal pulses 2+ F. Temperature 36.8° C (98.2° F) G. Pulse rate 84/min H. Respiratory rate 16/min I. Blood pressure 106/76 mm Hg J. Oxygen saturation 96% on room air

Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

Explanation

The client's condition shows signs of improvement as indicated by several findings. The blood glucose level has decreased from 468 mg/dL to 310 mg/dL, which, although still above the normal range, is a significant improvement. The pulse rate has normalized from 110/min to 84/min, and the blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, indicating better cardiovascular stability. The

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A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

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