A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Evaluate the client's ability to help with repositioning

Reposition the client without the use of assistive devices.

Raise the side rails on both sides of the client's bed during repositioning

Discuss the client's preferences for determining a repositioning schedule

Answer and Explanation

The Correct Answer is A

Rationale:

A. Evaluate the client's ability to help with repositioning: Assessing the client's motor function and ability to assist is essential for planning a safe and effective repositioning strategy. It helps prevent injury to both the client and staff and allows for appropriate use of equipment or assistance.

B. Reposition the client without the use of assistive devices: Clients with impaired mobility due to stroke are at increased risk for injury during movement. Assistive devices should be used as needed to ensure safe and proper repositioning.

C. Raise the side rails on both sides of the client's bed during repositioning: Raising both side rails can create a restraint-like situation and may increase fall risk. Only the side rail on the opposite side of movement should be raised for safety during repositioning.

D. Discuss the client's preferences for determining a repositioning schedule: While involving the client in care decisions is important, repositioning schedules are primarily based on clinical needs (e.g., immobility, pressure ulcer prevention), not solely on preference.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. Trochanter roll: A trochanter roll is used to prevent external rotation of the hips in clients who are immobile. It does not support the feet or ankles and therefore does not prevent plantar flexion contractures.

B. Footboard: A footboard helps maintain the foot in a dorsiflexed, neutral position by providing firm support against the soles. This prevents foot drop, a common plantar flexion contracture in clients with limited mobility.

C. Sheepskin heel pad: Sheepskin heel pads protect the heels from pressure ulcers by reducing friction and shear but do not maintain ankle alignment or prevent plantar flexion of the feet.

D. Abduction pillow: An abduction pillow is placed between the legs to maintain hip alignment after procedures like hip replacement. It offers no support to the feet and does not prevent plantar flexion.

A. Rise slowly when getting out of bed B. Taking furosemide can cause your potassium levels to be high C. Taking furosemide can cause you to be overhydrated D. Eat foods that are high in sodium

Correct Answer is A

Explanation

Rationale:

A. Rise slowly when getting out of bed: Furosemide can cause orthostatic hypotension due to fluid volume depletion. Instructing the client to rise slowly helps prevent dizziness, lightheadedness, and falls when changing positions.

B. Taking furosemide can cause your potassium levels to be high: Furosemide is a loop diuretic that promotes potassium loss through the urine. Hypokalemia is a common side effect, not hyperkalemia, and potassium levels should be monitored regularly.

C. Taking furosemide can cause you to be overhydrated: Furosemide works by removing excess fluid, which reduces the risk of fluid overload. However, overdiuresis can lead to dehydration, not overhydration, if fluid losses exceed intake.

D. Eat foods that are high in sodium: Clients with heart failure are typically advised to restrict sodium intake to prevent fluid retention and worsening of symptoms. High sodium intake can counteract the therapeutic effects of diuretics like furosemide.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?

Correct Answer is A

Explanation

A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

A nurse is assessing a client who has endometritis. Which of the following findings should the nurse expect?

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus about administering NPH insulin and regular insulin together in one injection. Which of the following instructions should the nurse include?

A nurse is caring for a client who has hearing loss. While communicating with the client, which of the following actions should the nurse take?

A nurse on a mental health unit is teaching a newly licensed nurse about the use of mechanical restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is caring for a newly-admitted client. Exhibits The nurse is providing teaching about self-care to the client. Select the 4 statements the nurse should include in the teaching.

Exhibits The nurse is preparing to discharge the client. Which of the following statements by the client indicates an understanding of the discharge teaching? Select all that apply.

A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is therapeutic?