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

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.

Evaluate the client’s ability to help with repositioning.

Answer and Explanation

The Correct Answer is D

This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort. The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.

Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.

The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.

Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.

The nurse should use assistive devices that are appropriate for the client’s condition and weight.

Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.

The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.

The nurse should also involve the client in the care plan and respect their preferences whenever possible.

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Correct Answer is D

Explanation

This is because bleeding after a cardiac catheterization is a possible complication that can occur when a catheter is inserted into an artery in the groin or arm to examine the heart. Bleeding can drip or spurt from the puncture site, or form a lump under the skin called a hematoma. Applying continuous pressure above the site can help stop the bleeding and prevent hematoma formation.
Choice A is wrong because applying intermittent pressure 2.5 cm (1 in) above the percutaneous skin site may not be enough to control the bleeding and may increase the risk of hematoma.
Choice B is wrong because applying intermittent pressure 2.5 cm (1 in) below the percutaneous skin site may not be effective and may cause more damage to the artery.
Choice C is wrong because applying continuous pressure 2.5 cm (1 in) below the percutaneous skin site may also be ineffective and harmful to the artery.

A. Apply warm compresses to the incision site. B. Maintain bed rest for 2 days postoperatively. C. Irrigate indwelling urinary catheter with 50 mL of normal saline. D. Administer enema to relieve constipation. E. Place a blanket roll under the client’s knees while in bed.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

The correct answer is choice A. Applying warm compresses to the incision site is anticipated for the client, as it can help reduce swelling and pain.

The other choices are contraindicated for the following reasons:

Choice B: Maintaining bed rest for 2 days postoperatively is contraindicated, as it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. The client should be encouraged to ambulate as soon as possible after surgery.
Choice C: Irrigating indwelling urinary catheter with 50 mL of normal saline is contraindicated, as it can introduce bacteria into the bladder and cause infection. The catheter should be kept patent and draining without irrigation unless there is a specific order from the provider.
Choice D: Administering enema to relieve constipation is contraindicated, as it can increase the pressure in the pelvic area and cause bleeding or damage to the surgical site. The client should be given stool softeners and laxatives to prevent constipation.
Choice E: Placing a blanket roll under the client’s knees while in bed is contraindicated, as it can impair blood circulation and cause thrombophlebitis. The client should avoid flexing the knees excessively and elevate the legs slightly when lying down.

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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 school-age child who is 2 hr postoperative following cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a postoperative client following a perineal prostatectomy. Exhibits For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Potential Order:.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

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