A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Place the client’s glasses on the bedside table.

Place the call light within the client’s reach.

Check on the client every 4 hr.

Place the client in a room near the nurses’ station.

Answer and Explanation

The Correct Answer is B

Choice A reason: Glasses on the bedside table may be inaccessible for a quadriplegic client lacking arm movement. This doesn’t ensure immediate utility or safety. Scientifically, quadriplegia limits motor function, requiring adaptive aids within reach, making this less practical than direct assistance options.

Choice B reason: Placing the call light within reach empowers the quadriplegic client to summon help, addressing their limited mobility. This aligns with scientific rehabilitation principles, enhancing independence and safety by ensuring communication access, critical for managing needs in paralysis effectively.

Choice C reason: Checking every 4 hours is insufficient for quadriplegia, where urgent needs (e.g., pressure sores) arise faster. Scientifically, frequent monitoring is standard, and this gap risks neglect, making it less proactive than enabling client-initiated contact for timely care and intervention.

Choice D reason: A room near the station aids staff response but doesn’t guarantee immediate help without client input. Scientifically, proximity alone doesn’t address quadriplegia’s dependency needs as directly as a call light, which ensures the client can signal distress promptly.

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Correct Answer is B

Explanation

Choice A reason: Mouthing objects is normal at 4 months, aiding exploration and teething. It’s developmentally appropriate, not requiring provider notification at this stage.

Choice B reason: Anterior fontanel closure before 9-18 months may signal craniosynostosis, affecting brain growth. This premature finding warrants urgent provider evaluation.

Choice C reason: Rolling back to abdomen is a 4-6-month milestone, expected here. It’s a healthy motor development sign, not needing provider attention.

Choice D reason: Posterior fontanel often closes by 2-3 months, normal at 4 months. This aligns with typical infant skull development, not a concern.

A. Place the client in Sims' position for catheter insertion. B. Verify the amount of TPN solution the client is receiving every 4 hr. C. Use clean technique when changing the catheter dressing. D. Prepare the client for a chest x-ray to verify catheter placement.

Correct Answer is D

Explanation

Choice A reason: Sims’ position is for rectal exams, not central catheter insertion. Trendelenburg or supine is used, so this is incorrect for TPN prep.

Choice B reason: Verifying TPN amount is ongoing care, not insertion prep. Initial placement confirmation via x-ray takes precedence over infusion monitoring here.

Choice C reason: Clean technique risks infection in central lines; sterile is required. This compromises TPN safety, making it an incorrect preparatory step.

Choice D reason: Chest x-ray confirms catheter tip placement in the vena cava for TPN. It’s a critical prep step to ensure safe administration begins.

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A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Nursing Test Bank

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