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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Laterally on the left side with a pillow under the head and the right arm and hand hyperextended

Supine with a pillow under the head, and elevate the right hand and arm on a pillow

Semi-Fowler's position without a pillow under the head, and the right arm and hand elevated on a pillow

Prone without a pillow, and with the right arm and hand flexed in a position of comfort and elevated on a pillow

Answer and Explanation

The Correct Answer is C

A. Laterally on the left side

Lateral positioning may not fully prevent contractures.

B. Supine with a pillow under the head

A pillow under the head can cause neck contractures.

C. Semi-Fowler’s without a pillow, right arm & hand elevated

Prevents contractures and promotes drainage of edema.

D. Prone without a pillow

Prone position increases discomfort and risk of respiratory complications.

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Correct Answer is C

Explanation

A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.

B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.

C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.

D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.

A. diphenhydramine 50mg PO. B. famotidine 40mg PO. C. epinephrine 1mg IM. D. a fluid bolus of normal saline.

Correct Answer is C

Explanation

A. Diphenhydramine 50 mg PO
Diphenhydramine (Benadryl) treats mild allergic reactions but is not sufficient for anaphylaxis. The presence of SOB and angioedema suggests airway compromise, requiring epinephrine.

B. Famotidine 40 mg PO
Famotidine (H2 blocker) can help with allergic reactions but is not the priority in an emergency.

C. Epinephrine 1 mg IM
Epinephrine is the first-line treatment for anaphylaxis. It reverses airway swelling, hypotension, and bronchoconstriction. The standard IM dose is 0.3-0.5 mg, not 1 mg, but epinephrine remains the priority drug.

D. A fluid bolus of normal saline
IV fluids help treat hypotension in anaphylaxis, but epinephrine is the priority intervention.

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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Nursing Test Bank

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