A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:
decubitus ulcers.
foot drop.
pooling of blood.
blood pressure changes.
The Correct Answer is B
Choice A rationale: Decubitus ulcers (pressure ulcers) are not directly prevented by applying padded boots for dorsiflexion.
Choice B rationale: Applying padded boots for dorsiflexion helps prevent foot drop, a condition where the foot is permanently in a plantar-flexed position, which can lead to contractures.
Choice C rationale: Pooling of blood is not a primary concern addressed by applying padded boots for dorsiflexion.
Choice D rationale: Blood pressure changes are not directly addressed by applying padded boots for dorsiflexion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Dark yellow urine may indicate concentrated urine, and encouraging fluid intake helps dilute the urine, promoting kidney function and preventing dehydration.
Choice B rationale: Reducing fluid intake is not appropriate based solely on the color of the urine. It is essential to assess overall hydration status.
Choice C rationale: Dark yellow urine alone does not necessarily indicate infection. Other symptoms and laboratory tests would be needed for a diagnosis.
Choice D rationale: Taking no action is not appropriate when the color of urine suggests dehydration. Assessing and addressing hydration status are important.
Correct Answer is B
Explanation
Choice A rationale: A client who is confined to bedrest may not need a gait belt as they are not ambulating.
Choice B rationale: A client with leg strength who can cooperate with movement is a likely candidate for a gait belt. This device provides support and stability during ambulation.
Choice C rationale: A client with a thoracic incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
Choice D rationale: A client with an abdominal incision may not necessarily need a gait belt for ambulation unless there are specific mobility concerns.
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