In caring for a quadriplegic client which action would the nurse implement to prevent skin breakdown?
Reposition the client every 2 hours.
Apply compression stockings.
Ambulate the client at least once per shift.
Perform hourly skin checks.
The Correct Answer is A
A. Repositioning every 2 hours is a standard intervention to prevent pressure ulcers and promote circulation.
B. Compression stockings are used for preventing DVTs but do not directly prevent skin breakdown.
C. Ambulation is not feasible for a quadriplegic client.
D. Hourly skin checks can be beneficial but are secondary to preventive measures like repositioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clubbing is a sign of chronic hypoxia, not acute hypoxemia.
B. Cyanosis, a bluish discoloration of the skin and mucous membranes, is an indicator of acute hypoxemia.
C. Palpating for decreased tactile fremitus is related to fluid or air in the lungs, not specifically hypoxemia.
D. Auscultation for adventitious breath sounds can reveal respiratory issues but does not directly confirm hypoxemia.
Correct Answer is D
Explanation
A. Asking the client to swallow assesses the glossopharyngeal and vagus nerves.
B. Eliciting the gag reflex also assesses the glossopharyngeal and vagus nerves.
C. Testing visual acuity assesses the optic nerve.
D. The oculomotor nerve (cranial nerve III) controls pupillary response and eye movement, so the nurse should assess the pupillary response to light.
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