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A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home education plan information relative to: (Select all that apply.)

using the spreader bar to turn the patient.

protecting the cast from soiling.

grasping the cast over the leg to help in turning.

easing itching under the cast by scratching with a bent coat hanger.

turning frequently to the prone position.

Answer and Explanation

Correct Answer : B,E

A. Using the spreader bar to turn the patient.

The spreader bar is not designed for lifting or turning; it maintains cast shape and stability.

B. Protecting the cast from soiling.

Soiling the cast can lead to skin irritation and infection, especially in the perineal area.

C. Grasping the cast over the leg to help in turning.

This can cause pressure points or cast damage; turning should be done using proper support techniques.

D. Easing itching under the cast by scratching with a bent coat hanger.

This is unsafe and can cause skin injury or infection under the cast.

E. Turning frequently to the prone position.

Frequent position changes, including prone if tolerated, help prevent pressure sores and promote circulation.

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Correct Answer is B

Explanation

A. Ask the client if she has been out of bed today:

This gives some insight into activity level but doesn't objectively measure strength.

B. Ask the client to push her legs and feet against the nurse's palms:

This provides a direct, physical assessment of the client's lower extremity strength, which is essential before ambulation.

C. Check the client's pedal pulses and feet for edema:

These assessments are related to circulation, not muscular strength.

D. Ask the client how strong she feels today:

This is subjective and may not reflect actual muscle strength or ability to ambulate safely.

A. Move body parts rapidly through the movements. B. Support extremities above and below joints. C. Stretch the body part just beyond the existing range of motion. D. Continue moving body parts if muscle spasticity occurs.

Correct Answer is B

Explanation

A. Move body parts rapidly through the movements.

Rapid movement can cause injury and discomfort. Movements should be slow and smooth.

B. Support extremities above and below joints.

Supporting both above and below the joint ensures joint stability and prevents strain or injury during passive ROM.

C. Stretch the body part just beyond the existing range of motion.

Passive ROM should stay within the current range. Forcing motion can cause pain or injury.

D. Continue moving body parts if muscle spasticity occurs.

If spasticity occurs, movement should stop. Forcing motion through spasms can increase injury risk.

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A patient has a hip spica cast and will be discharged home to family. The nurse would include in the home education plan information relative to: (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Correct Answer is B

Explanation

A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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