A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

A measure the calves for symmetry

B palpate the bladder

C Place a pillow between the knees and ankles

D Check the gag reflex

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Measuring the calves for symmetry is not directly related to preventing complications after repositioning.

Choice B Rationale: Palpating the bladder is important for assessing urinary retention but is not the immediate action to prevent complications after repositioning.

Choice C Rationale: Placing a pillow between the knees and ankles is the correct action to prevent complications such as pressure ulcers and skin breakdown when a client is in a side-lying position.

Choice D Rationale: Checking the gag reflex is unrelated to repositioning and preventing complications.

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Correct Answer is B

Explanation

Choice A Rationale: Notifying the physician may be necessary if troubleshooting the issue does not resolve the problem, but it is not the initial step.

Choice B Rationale: The nurse should first check the tubing of the indwelling urinary catheter for any kinks, twists, or obstructions that might prevent the urine flow. This is a simple and non-invasive intervention that can resolve the problem quickly and easily.

Choice C Rationale: Removing the indwelling catheter is not advisable without proper assessment and intervention, as it can lead to complications.

Choice D Rationale: Replacing the indwelling catheter is not the first step and should only be done if the problem cannot be resolved through assessment and interventions.

A. Check the patient's orientation to time and date. B. Obtain a list of the patient's prescribed medications. C. Determine the patient's ability to recognize a common object. D. Ask the patient to draw a clock with a specific time

Correct Answer is D

Explanation

Choice A Rationale: Checking the patient's orientation to time and date is a part of assessing cognitive function but is not specific to the Mini-Cog exam.

Choice B Rationale: Obtaining a list of the patient's prescribed medications is important for the overall assessment but is not specific to the Mini-Cog exam.

Choice C Rationale: Determining the patient's ability to recognize a common object is not a component of the Mini-Cog exam.

Choice D Rationale: Asking the patient to draw a clock with a specific time is a key component of the Mini-Cog exam, which assesses cognitive impairment and is commonly used to screen for Alzheimer's disease.

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A client who suffered partial paralysis is repositioned by the nurse every 2 hours. After placing the client in a side-lying position, what action will nurse take to prevent complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client with a new spinal cord injury notices that the indwelling urinary catheter has stopped flowing. What is the nurses best first action?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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