The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

Lateral heels offloaded with pillows

Supine heels offloaded with pillows

Fowler's heels offloaded with pillows

Prone ankles offloaded with pillows.

Answer and Explanation

The Correct Answer is A

A. Lateral heels offloaded with pillows: Positioning the patient laterally with heels offloaded helps reduce pressure on the heels and prevent pressure sores.

B. Supine heels offloaded with pillows: Although offloading the heels is important, the supine position may still exert pressure on the heels and does not provide as effective offloading as the lateral position.

C. Fowler's heels offloaded with pillows: Fowler’s position may still place some pressure on the heels, even with pillows for offloading.

D. Prone ankles offloaded with pillows: The prone position is generally not recommended for patients with spinal injuries, and it does not effectively address heel pressure.

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Correct Answer is C

Explanation

A. Small muscle twitching. Small muscle twitching is more common during REM sleep, not Stage IV NREM sleep.

B. An increase in temperature. Stage IV NREM sleep is associated with stable body temperature rather than an increase.

C. Difficult to arouse. Stage IV NREM sleep is known as deep sleep, and individuals are indeed difficult to arouse during this stage.

D. An increase in pulse rate. Stage IV NREM sleep typically features a stable or decreased pulse rate, not an increase.

A. The client with a left lower extremity fracture. B. The client with a bowel obstruction. C. The client with a skin tear to the upper extremity. D. The client with pneumonia.

Correct Answer is A

Explanation

A. The client with a left lower extremity fracture. Somatic pain is related to damage to body tissues, such as fractures. This type of pain is typically localized and can be acute or chronic.

B. The client with a bowel obstruction. Pain from a bowel obstruction is typically visceral rather than somatic, as it involves internal organs.

C. The client with a skin tear to the upper extremity. While this involves the skin, it is typically considered superficial somatic pain, but the context of the question suggests a deeper musculoskeletal issue.

D. The client with pneumonia. Pain from pneumonia is usually visceral due to inflammation in the lungs.

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The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing the vital signs of a sleeping patient at 0400 a.m. and notes the patient is experiencing stage IV non-rapid eye movement (NREM) sleep. The nurse should expect which of the following findings?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

The nurse is repositioning a patient who has a spinal injury and notes reddened areas on the heels of both feet. The nurse should place the patient in which of the following positions?

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