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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 and

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

A. 2 mg is incorrect and significantly higher than the prescribed dose.
B. 0.20 mg is incorrect because trailing zeros after the decimal point can lead to dosage errors.
C. 2.0 mg is incorrect and significantly higher than the prescribed dose and also includes a trailing zero.
D. 0.2 mg is the correct way to transcribe two tenths of a milligram without using trailing zeros, which reduces the risk of medication errors.

Correct Answer is C

Explanation

A. Labeling the feeding bag is important for ensuring the safety and monitoring of feeding times, but it is not the first action.
B. Hanging the feeding bag at the correct height ensures proper flow of the feeding but is not the first action.
C. Aspirating the client's stomach contents is the first action to check for residuals and ensure the placement of the NG tube is correct, preventing aspiration.
D. Warming the feeding to room temperature is important for client comfort but is not the first action.

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