The practical nurse (PN) tells the unlicensed assistive personnel (UAP) that an immobile client is at risk for the development of contractures. The UAP replies that compression stockings have been applied to the client's lower extremities. Which action should the PN take next?
Instruct the UAP to remove the stockings until the client is more mobile.
Demonstrate how to pivot the client from the bed to a bedside chair.
Teach the UAP that the client needs to begin range of motion exercises.
Reinforce the benefits of these stockings in preventing contractures.
The Correct Answer is C
Rationale:
A. This option is incorrect because removing compression stockings will not prevent contractures and could increase the client’s risk for venous pooling or deep vein thrombosis (DVT). Stockings address circulatory issues, not joint mobility.
B. This option is incorrect because pivoting the client to a chair helps with mobility and pressure relief but does not directly prevent contractures in immobile joints. While ambulation is beneficial, the client may not yet be able to participate safely in transfers.
C. This option is correct because range of motion (ROM) exercises are the primary intervention to prevent contractures in immobile clients. The PN should teach the UAP how to safely perform passive or assisted ROM exercises to maintain joint flexibility and prevent shortening of muscles and tendons. This directly addresses the risk for contracture development.
D. This option is incorrect because compression stockings help prevent venous stasis and DVT, not contractures. Reinforcing their benefits does not address the client’s joint mobility needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. This option is incorrect because using a plastic barrier can trap excessive heat and moisture, increasing the risk of burns and skin breakdown. A cloth or towel barrier is recommended instead.
B. This option is incorrect because heat therapy for comfort and pain relief is a noninvasive nursing intervention and does not require a provider’s prescription when used safely and appropriately.
C. This option is incorrect because skin should be assessed more frequently than every 30 minutes, especially during the initial application. Waiting 30 minutes may delay detection of redness, burns, or irritation.
D. This option is correct because demonstrating the use of temperature control helps ensure the client applies heat safely, reducing the risk of burns or injury. Client education on safe temperature settings is a key nursing responsibility when implementing heat therapy.
Correct Answer is C
Explanation
Rationale:
A. Healthcare provider (HCP) notified, client refuses to have blood glucose taken is partially correct but does not include the client’s statement, which is important for accurate and objective documentation.
B. Blood glucose not obtained because client no longer wants to have finger stick is incorrect because it is subjective and does not include notification of the HCP or the client’s exact words.
C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider (HCP) notified is correct because it objectively documents the client’s refusal, includes the exact words in quotation marks for accuracy, and notes that the HCP was notified, which is required for continuity of care and legal purposes.
D. Healthcare provider (HCP) notified that client is uncooperative and irritable, glucose level not assessed is incorrect because it uses judgmental and subjective language (“uncooperative and irritable”), which is inappropriate for professional documentation.
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