A nurse on a medical-surgical unit is caring for a client.
Exhibits
Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing dropdown and dropdown
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
The client is at risk for developing pressure injury and foot drop. Given the client's history of a recent cerebrovascular accident (CVA) and the inability to reposition themselves, there is a heightened risk for pressure injuries due to prolonged periods of immobility. Additionally, the observed occasional movement of the left arm and leg with the right side without movement suggests a potential for muscle weakness or paralysis, which can lead to foot drop, characterized by difficulty in lifting the front part of the foot.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hiccups are not a common adverse effect of morphine.
B. Heartburn is not a common adverse effect of morphine.
C. Orthostatic hypotension is a known adverse effect of morphine due to its potential to cause vasodilation and lower blood pressure, especially when the client changes positions.
D. Diarrhea is not a common adverse effect of morphine; constipation is more likely.
Correct Answer is ["B","C","D"]
Explanation
A. Implementing a recorded order message is not a standard practice and may not be permissible in all healthcare settings.
B. Transcribing the order into the client's health record is essential to ensure accurate documentation.
C. Repeating the order back to the provider ensures that the nurse has correctly understood the prescription.
D. Questioning any part of the order that is unclear or inappropriate ensures patient safety and accuracy.
E. While obtaining the provider's signature is necessary, the timeframe may vary depending on facility policies and regulations. The focus should be on ensuring the accuracy and clarity of the order first.
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