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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: The purpose of a halo fixation device is to immobilize the cervical spine and prevent movement, which is crucial for healing and preventing further spinal cord injury.
Choice B Rationale: A halo fixation device does not allow for neck movement during the healing process.
Choice C Rationale: Applying talcum powder under the vest may increase the risk of skin irritation or infection.
Choice D Rationale: Turning the screws on the device should only be done by qualified healthcare professionals, not by the family.
Correct Answer is C
Explanation
Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.
Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.
Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.
Choice D Rationale: Documenting the incident is important but should follow
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